Early assessment and in-hospital management of patients with acute myocardial infarction at increased risk for adverse outcomes: a nationwide perspective of current clinical practice. The National Registry of Myocardial Infarction (NRMI-2) Participants

Evaluation of Nonculprit Coronary Artery Lesions in Patients with Acute ST-Segment Elevation Myocardial Infarction

Background:

Multivessel coronary artery disease is a common finding during the primary percutaneous coronary intervention in patients with acute ST-segment elevation myocardial infarction (STEMI). It might be a cause for recurrent attacks. This study aimed to evaluate nonculprit lesions (NCLs) encountered in the three major epicardial coronary arteries.

Methods:

Patients with STEMI who underwent PPCI and matched the study inclusion criteria were enrolled. They were evaluated clinically, biomedically, and coronary angiographically. The coronary angiography analysis was examined by four cardiologists using the Quantitative Coronary Artery Analysis software. The data was analyzed statistically.

Results:

Of the 154 patients included in the study, 130 (84.4%) were males and 24 (15.6%) were females, with a mean age of 52.92 ± 13.14 years. Five hundred seventy-four NCLs were found in 132 (85.7%) patients. Nonobstructive lesions with stenosis less than 70% of vessel diameter were more frequent than obstructive lesions. The left circumflex coronary artery (LCX) was the first one of the three major arteries to be affected by obstructive NCLs. The obstructive NCLs were 128 in number; found in 78 (50.4%) patients; 65 (50.8%) of them were in LCX; 32 (25%) were in left anterior descending (25%); and 31 (24.2%) were in right coronary artery.

Conclusions:

NCLs are common among STEMI patients. LCX obstructive NCLs are comparable to those in the other two major epicardial coronary arteries, with respect to frequency and severity of luminal stenosis.

Investigation of the Therapeutic Potential of Organic Nitrates in Mortality Reduction Following Acute Myocardial Infarction in Hyperlipidemia Patients: A Population-Based Cohort Study

BACKGROUND

Dyslipidemia is a known risk factor for cardiac dysfunction, and lipid-lowering therapy with statins reduces symptoms and reduces hospitalization related to left ventricular heart failure. Acute myocardial infarction (AMI) is a cause of morbidity and mortality worldwide. In this study, we aimed to determine the real-world AMI treatment drug combination used in Taiwan by using the NHI database to understand the treatment outcomes of current clinical medications prescribed for hyperlipidemia patients with AMI.

METHODS

Using the NHI Research Database (NHIRD), we conducted a retrospective cohort study that compared different treatments for AMI in hyperlipidemia patients in the period from 2016 to 2018. We compared the survival outcomes between those treated with and without organic nitrates in this cohort.

RESULTS

We determined that most hyperlipidemia patients were aged 61-70 y (29.95-31.46% from 2016 to 2018), and the annual AMI risk in these patients was <1% (0.42-0.68% from 2016 to 2018). The majority of hyperlipidemia patients with AMI were women, and 25.64% were aged 61-70 y. Receiving organic nitrates was associated with lower all-cause mortality rates (HR, 95% CI, p-value = 0.714, 0.674-0.756, p < 0.0001). After multivariate analysis, the overall survival in four groups (beta-blockers, beta-blocker + diuretics, diuretics, and others) receiving an organic nitrate treatment was significantly higher than in the groups that were not treated with organic nitrates (beta-blockers HR = 0.536, beta-blocker + diuretics HR = 0.620, diuretics HR = 0.715, and others HR = 0.690).

CONCLUSIONS

The survival benefit was significantly greater in patients treated with organic nitrates than in those treated without organic nitrates, especially when combined with diuretics. A combination of organic nitrates could be a better treatment option for hyperlipidemia patients with AMI.

Neutrophil-to-Lymphocyte Ratio at Emergency Room Predicts Mechanical Complications of ST-segment Elevation Myocardial Infarction

BACKGROUND

The neutrophil-to-lymphocyte ratio (NLR) has been proven to be a reliable inflammatory marker. A recent study reported that elevated NLR is associated with adverse cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI). We investigated whether NLR at emergency room (ER) is associated with mechanical complications of STEMI undergoing primary percutaneous coronary intervention (PCI).

METHODS

A total of 744 patients with STEMI who underwent successful primary PCI from 2009 to 2018 were enrolled in this study. Total and differential leukocyte counts were measured at ER. The NLR was calculated as the ratio of neutrophil count to lymphocyte count. Patients were divided into tertiles according to NLR. Mechanical complications of STEMI were defined by STEMI combined with sudden cardiac arrest, stent thrombosis, pericardial effusion, post myocardial infarction (MI) pericarditis, and post MI ventricular septal rupture, free-wall rupture, left ventricular thrombus, and acute mitral regurgitation during hospitalization.

RESULTS

Patients in the high NLR group (> 4.90) had higher risk of mechanical complications of STEMI (P = 0.001) compared with those in the low and intermediate groups (13% vs. 13% vs. 23%). On multivariable analysis, NLR remained an independent predictor for mechanical complications of STEMI (RR = 1.947, 95% CI = 1.136-3.339, P = 0.015) along with symptom-to balloon time (P = 0.002) and left ventricular dysfunction (P < 0.001).

CONCLUSION

NLR at ER is an independent predictor of mechanical complications of STEMI undergoing primary PCI. STEMI patients with high NLR are at increased risk for complications during hospitalization, therefore, needs more intensive treatment after PCI.

The role of aspirin desensitization followed by oral aspirin therapy in managing patients with aspirin-exacerbated respiratory disease: A Work Group Report from the Rhinitis, Rhinosinusitis and Ocular Allergy Committee of the American Academy of Allergy, Asthma & Immunology

Aspirin-exacerbated respiratory disease (AERD) is characterized by the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and an intolerance to medications that inhibit the cycloxgenase-1 enzyme. Patients with AERD on average have more severe respiratory disease compared with patients with chronic rhinosinusitis with nasal polyps and/or asthma alone. Although patients with AERD traditionally develop significant upper and lower respiratory tract symptoms on ingestion of cycloxgenase-1 inhibitors, most of these same patients report clinical benefit when desensitized to aspirin and maintained on daily aspirin therapy. This Work Group Report provides a comprehensive review of aspirin challenges, aspirin desensitizations, and maintenance aspirin therapy in patients with AERD. Identification of appropriate candidates, indications and contraindications, medical and surgical optimization strategies, protocols, medical management during the desensitization, and recommendations for maintenance aspirin therapy following desensitization are reviewed. Also included is a summary of studies evaluating the clinical efficacy of aspirin therapy after desensitization as well as a discussion on the possible cellular and molecular mechanisms explaining how this therapy provides unique benefit to patients with AERD.

Predictors of In-Hospital Mortality in Patients Admitted with Acute Myocardial Infarction in a Developing Country

Background

Limited data are available on the predictors of mortality in patients hospitalized with acute myocardial infarction (AMI) in developing countries. In this study, we analyze the predictors for in­-hospital mortality in patients hospitalized with AMI (ST segment elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI)) in a large tertiary referral university hospital in Lebanon.

Methods

This was a retrospective study of 503 patients admitted to the American University of Beirut Medical Center with AMI (228 with STEMI and 275 with NSTEMI).

Results

The in-hospital mortality rate was 7.8%. The multivariate predictors of mortality in the overall population were similar to what has been reported in large registries in the USA and Europe. They included older age (> 65 years) (OR = 2.99, 95% CI = 1.22 - 7.36, P = 0.02), systolic blood pressure < 100 mm Hg (OR = 2.75, 95% CI = 1.12 - 6.76, P = 0.03), history of stroke (OR = 4.28, 95% CI = 1.29 - 14.17, P = 0.02), history of coronary artery bypass graft (CABG) (OR = 2.68, 95% CI = 1.15 - 6.23, P = 0.02), heart failure (OR = 3.92, CI = 1.62 - 9.49, P = 0.002) and ejection fraction (EF) < 35% (OR = 2.32, 95% CI = 1.05 - 5.14, P = 0.04). In a separate analysis of STEMI and NSTEMI patients, age, heart failure and a low EF continued to be multivariate predictors of mortality in both subgroups. In addition, prior stroke was an added predictor in STEMI patients, and prior CABG was an added predictor in NSTEMI.

Conclusion

Predictors of in-hospital mortality in patients hospitalized with AMI in a tertiary referral university hospital in the Middle East are similar to what has been reported in large registries in the USA and Europe.

Rad GTPase deletion attenuates post-ischemic cardiac dysfunction and remodeling

•

Rad-GTPase is an LTCC component that functions to govern calcium current in the myocardium.

•

Deletion of Rad increases myocardial contractility secondary to increased trigger calcium entry.

•

AMI induces heart failure, including reduced calcium homeostasis, but deletion of Rad prevents AMI myocardial calcium alterations.

•

Rad deletion prevents post-MI scar spread by attenuating the inflammatory response.

•

Future studies will explore whether Rad deletion is an effective therapeutic direction for providing combined safe, stable inotropic support to the failing heart in concert with protection against inflammatory signaling.

The protein Rad interacts with the L-type calcium channel complex to modulate trigger Ca²⁺ and hence to govern contractility. Reducing Rad levels increases cardiac output. Ablation of Rad also attenuated the inflammatory response following acute myocardial infarction. Future studies to target deletion of Rad in the heart could be conducted to establish a novel treatment paradigm whereby pathologically stressed hearts would be given safe, stable positive inotropic support without arrhythmias and without pathological structural remodeling. Future investigations will also focus on establishing inhibitors of Rad and testing the efficacy of Rad deletion in cardioprotection relative to the time of onset of acute myocardial infarction.

Impact of Killip classification on acute myocardial infarction: data from the SAIKUMA registry

Therapeutic devices for acute myocardial infarction (AMI) have evolved dramatically in recent years. However, the impact of the Killip classification of AMI outcomes in patients undergoing aggressive percutaneous coronary intervention remains unclear. We performed a 10-year retrospective review of 2062 patients diagnosed with AMI, and divided the data into two 5-year intervals: 2005-2009 (n = 1071), and 2010-2014 (n = 991). No difference was observed in in-hospital mortality rate between the two periods (first period, 11.5% vs second period, 9.7%; P = 0.19). The incidence of stent thrombosis was not significantly different between the two periods, and very few thrombi occurred in patients who received second-generation drug-eluting stents (DES) (0.98%: 5/511). In-hospital mortality due to stent thrombosis was high in the full cohort (15%). During the second period, in-hospital mortality was lower in Killip class 4 patients, although the difference was not significant (59.1 vs 47.5%, P = 0.07). Multivariable logistic regression identified several factors that significantly affected in-hospital mortality, including age [odds ratio (OR) 1.07], left main trunk (OR 2.47), peak CPK value above 5000 IU/L (OR 3.18), and Killip class 4 (OR 15.63). We evaluated trends in in-hospital mortality among patients with AMI over a 10-year period. New DES and the frequent use of mechanical support in patients with hemodynamic compromise tended to improve in-hospital mortality, but the effect was not significant. Notably, Killip class 4 on admission was associated with an estimated 16-fold increased risk of in-hospital death.

Comparison of the risk of left ventricular free wall rupture in Taiwanese patients with ST-elevation acute myocardial infarction undergoing different reperfusion strategies: A medical record review study

Ventricular free wall rupture (VFWR) is the second most common cause of death in patients with acute ST-elevation myocardial infarction (STEMI). Nevertheless, few reports have investigated the factors, including different treatment strategies, associated with VFWR in Taiwanese patients. Therefore, the aim of this study was to compare the risk of VFWR in Taiwanese patients with acute STEMI who had received primary percutaneous coronary intervention (PCI), rescue PCI, scheduled PCI, thrombolytic therapy, and pharmacologic treatment. In this medical records review study, records of patients with acute STEMI admitted to a regional hospital in south Taiwan between March 1999 and October 2013 were screened. Multivariate stepwise logistic regression analysis was used to evaluate the association between the risk of VFWR and its independent factors. The overall incidence of VFWR among the 1545 patients with acute STEMI in this study was 1.6%. Compared with primary PCI, the risk of VFWR was significantly higher in patients who had received thrombolysis (adjusted odds ratio = 6.83, P = 0.003) or pharmacologic treatment alone (adjusted odds ratio = 3.68, P = 0.014). The risk of VFWR in patients receiving rescue PCI or scheduled PCI was not significantly different from that in patients receiving primary PCI. In addition, older age and Killip class >I were associated with an increased risk of VFWR in patients with acute STEMI, whereas the use of angiotensin-converting enzyme inhibitors was associated with a lower risk of VFWR. In conclusion, findings from this medical record review study provide support for the use of primary PCI, rescue PCI, and scheduled PCI over thrombolytic therapy and pharmacologic treatment in reducing the risk of VFWR in Taiwanese patients with acute STEMI.

The association of left ventricular ejection fraction with clinical outcomes after myocardial infarction: Findings from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines (GWTG) Medicare-linked database

BACKGROUND

Little is known about the relationship between ejection fraction (EF) and clinical outcomes among older patients with myocardial infarction in contemporary clinical practice.

METHODS

Data on 82,558 patients 65 years or older with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction who survived to hospital discharge in the ACTION Registry-GWTG (2007-2011) were linked to Medicare data. Multivariable Cox proportional hazard modeling was used to assess the association between EF reported during hospitalization and 1-year mortality, using EF as a categorical variable (≤35%, >35% and ≤45%, >45% and <55%, and ≥55%) and as a continuous variable. Secondary outcomes of interest were 1-year all-cause, cardiovascular, and heart failure readmissions.

RESULTS

The risk of 1-year mortality was 29.0% in patients with EF ≤ 35%, compared with 13.0% in patients in the reference group, EF ≥ 55% (adjusted hazard ratio [HR] 1.58, 95% CI 1.51-1.66). Relative to patients with EF ≥ 55%, patients with EF ≤ 35% had an increased risk of 1-year all-cause readmission (adjusted HR 1.20, 95% CI 1.17-1.24), cardiovascular readmission (adjusted HR 1.36, 95% CI 1.31-1.41), and heart failure readmission (adjusted HR 2.43, 95% CI 2.28-2.60). For patients with EF ≤ 40%, the hazard of mortality increased by 26% for every 5% decrease in EF, a finding that remained after risk adjustment (adjusted HR 1.11, 95% CI 1.09-1.12).

CONCLUSIONS

Low EF after MI remains an important risk factor for postdischarge mortality and hospital readmission, even after adjustment for patient and hospital characteristics.

Combined impact of chronic kidney disease and contrast-induced nephropathy on long-term outcomes in patients with ST-segment elevation acute myocardial infarction who undergo primary percutaneous coronary intervention

Contrast-induced nephropathy (CIN) and chronic kidney disease (CKD) are associated with poor outcomes after primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI); however, its combined prognostic significance remains unclear. We enrolled 577 patients with AMI undergoing primary PCI within 12 h after symptom onset and measured serum creatinine on admission and the next 3 days. CKD was defined as admission estimated glomerular filtration rate <60 ml/min/1.73 m², and CIN was defined as creatinine increase ≥0.5 mg/dl or ≥25 % from baseline within the first 72 h. Patients were stratified according to the presence or absence of CKD and CIN. In patients with no CKD and no CIN (n = 244), no CKD but CIN (n = 152), CKD but no CIN (n = 127), and both CKD and CIN (n = 54), the 3-year major adverse cardiovascular events (MACE: a combination of all-cause mortality, nonfatal reinfarction, or heart failure requiring rehospitalization) were 8, 9, 13, and 35 %, respectively (p < 0.001). Multivariate analysis showed that as compared with no CKD and no CIN, hazard ratios (95 % CI) for MACE associated with no CKD but CIN, CKD but no CIN, and both CKD and CIN were 0.91 (0.44-1.84; p = 0.79), 1.11 (0.5-2.23; p = 0.77), and 2.98 (1.48-6.04; p = 0.002), respectively. In patients with AMI undergoing primary PCI, the combination of CKD and CIN is significantly associated with adverse long-term outcomes.

The relationship between neutrophil to lymphocyte ratio, platelet to lymphocyte ratio and thrombolysis in myocardial infarction risk score in patients with ST elevation acute myocardial infarction before primary coronary intervention

INTRODUCTION

The thrombolysis in myocardial infarction (TIMI) risk score is calculated as the sum of independent predictors of mortality and ischemic events in ST elevation acute myocardial infarction (STEMI). Several studies show that the neutrophil to lymphocyte ratio (NLR) is a prognostic inflammatory marker. In preliminary studies, platelet to lymphocyte ratio (PLR) has been proposed as a pro-thrombotic marker. The relationship between NLR, PLR and TIMI risk score for STEMI has never been studied.

AIM

To evaluate the association between TIMI-STEMI risk score and NLR, PLR and other biochemical indices in STEMI.

MATERIAL AND METHODS

In this retrospective study, we evaluated 390 patients who presented with STEMI within 12 h of symptom onset. Patients were grouped according to low and high TIMI risk scores.

RESULTS

We enrolled 390 patients (mean age 61.9 ±13.6 years; 73% were men). The NLR, platelet distribution width (PDW) and uric acid level (UA) were significantly associated with a high TIMI-STEMI risk score (p = 0.016, p = 0.008, p = 0.030, respectively), but PLR was not associated with a high TIMI-STEMI risk score. Left ventricular ejection fraction was an independent predictor of TIMI-STEMI risk score. A cut-off point of TIMI-STEMI score of > 4 predicted in-hospital mortality (sensitivity 75%, specificity 70%, p < 0.001). We found that NLR, PDW, and UA level were associated with TIMI-STEMI risk score.

CONCLUSIONS

Neutrophil to lymphocyte ratio, PDW and UA level are convenient, inexpensive and reproducible biomarkers for STEMI prognosis before primary angioplasty when these indicators are combined with the TIMI-STEMI risk score. We believe that these significant findings can guide further clinical practice.

Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Atherosclerosis is an inflammatory process, and inflammatory biomarkers have been identified as useful predictors of clinical outcomes. The prognostic value of leukocyte count in patients with ST-segment elevation myocardial infarctions who undergo primary percutaneous coronary intervention is not clearly defined. In 325 patients with STEMIs treated with primary percutaneous coronary intervention, total and differential leukocyte counts, once at admission and 24 hours thereafter, were measured. The neutrophil/lymphocyte ratio (NLR) was calculated as the ratio of neutrophil count to lymphocyte count. The primary end point was all-cause death. Twenty-five patients (7.7%) died during follow-up (median 1,092 days, interquartile range 632 to 1,464). The total leukocyte count decreased (from 11,853 ± 3,946/μl to 11,245 ± 3,979/μl, p = 0.004) from baseline to 24 hours after admission. Patients who died had higher neutrophil counts (9,887 ± 5,417/μl vs 8,399 ± 3,639/μl, p = 0.061), lower lymphocyte counts (1,566 ± 786/μl vs 1,899 ± 770/μl, p = 0.039), and higher NLRs (8.58 ± 7.41 vs 5.51 ± 4.20, p = 0.001) at 24 hours after admission. Baseline leukocyte profile was not associated with outcomes. The best cut-off value of 24-hour NLR to predict mortality was 5.44 (area under the curve 0.72, 95% confidence interval [CI] 0.52 to 0.82). In multivariate analysis, a 24-hour NLR ≥5.44 was an independent predictor of mortality (hazard ratio 3.12, 95% CI 1.14 to 8.55), along with chronic kidney disease (hazard ratio 4.23, 95% CI 1.62 to 11.1) and the left ventricular ejection fraction (hazard ratio 0.94 for a 3% increase, 95% CI 0.76 to 0.93). In conclusion, NLR at 24 hours after admission can be used for risk stratification in patients with STEMIs who undergo primary PCI. Patients with STEMIs with 24-hour NLRs ≥5.44 are at increased risk for mortality and should receive more intensive treatment.

Dynamic TIMI risk score for STEMI

Background

Although there are multiple methods of risk stratification for ST‐elevation myocardial infarction (STEMI), this study presents a prospectively validated method for reclassification of patients based on in‐hospital events. A dynamic risk score provides an initial risk stratification and reassessment at discharge.

Methods and Results

The dynamic TIMI risk score for STEMI was derived in ExTRACT‐TIMI 25 and validated in TRITON‐TIMI 38. Baseline variables were from the original TIMI risk score for STEMI. New variables were major clinical events occurring during the index hospitalization. Each variable was tested individually in a univariate Cox proportional hazards regression. Variables with P<0.05 were incorporated into a full multivariable Cox model to assess the risk of death at 1 year. Each variable was assigned an integer value based on the odds ratio, and the final score was the sum of these values. The dynamic score included the development of in‐hospital MI, arrhythmia, major bleed, stroke, congestive heart failure, recurrent ischemia, and renal failure. The C‐statistic produced by the dynamic score in the derivation database was 0.76, with a net reclassification improvement (NRI) of 0.33 (P<0.0001) from the inclusion of dynamic events to the original TIMI risk score. In the validation database, the C‐statistic was 0.81, with a NRI of 0.35 (P=0.01).

Conclusions

This score is a prospectively derived, validated means of estimating 1‐year mortality of STEMI at hospital discharge and can serve as a clinically useful tool. By incorporating events during the index hospitalization, it can better define risk and help to guide treatment decisions.

Immediate and one-year outcome of patients presenting with acute coronary syndrome complicated by stroke: findings from the 2nd Gulf Registry of Acute Coronary Events (Gulf RACE-2)

Background

Stroke is a potential complication of acute coronary syndrome (ACS). The aim of this study was to identify the prevalence, risk factors predisposing to stroke, in-hospital and 1-year mortality among patients presenting with ACS in the Middle East.

Methods

For a period of 9 months in 2008 to 2009, 7,930 consecutive ACS patients were enrolled from 65 hospitals in 6 Middle East countries.

Results

The prevalence of in-hospital stroke following ACS was 0.70%. Most cases were ST segment elevation MI-related (STEMI) and ischemic stroke in nature. Patients with in-hospital stroke were 5 years older than patients without stroke and were more likely to have hypertension (66% vs. 47.6%, P = 0.001). There were no differences between the two groups in regards to gender, other cardiovascular risk factors, or prior cardiovascular disease. Patients with stroke were more likely to present with atypical symptoms, advanced Killip class and less likely to be treated with evidence-based therapies. Independent predictors of stroke were hypertension, advanced killip class, ACS type –STEMI and cardiogenic shock. Stroke was associated with increased risk of in-hospital (39.3% vs. 4.3%) and one-year mortality (52% vs. 12.3%).

Conclusion

There is low incidence of in-hospital stroke in Middle-Eastern patients presenting with ACS but with very high in-hospital and one-year mortality rates. Stroke patients were less likely to be appropriately treated with evidence-based therapy. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.

Combining white blood cell count and thrombosis for predicting in-hospital outcomes after acute myocardial infraction

Introduction:

Admission white blood cell (WBC) count and thrombosis in myocardial infarction (TIMI) risk score have been associated with adverse outcomes after acute myocardial infarction (AMI). This study investigated the joint effect of WBC count and TIMI risk score on predicting in-hospital outcomes in patients with AMI.

Materials and Methods:

WBC count and TIMI risk score were measured at the time of hospital admission in 70 patients with AMI. Echocardiogram was done on prior to discharge by a cardiologist and ejection fraction (EF) was determined according to the Simpson formula. Patients were stratified into tertiles (low and high) based on WBC count and TIMI risk score.

Results:

Patients with a high WBC count had a 5.0-fold increase in-hospital congestive heart failure and 2.2 increases in mortality compared with those with a low WBC count. Patients with a high TIMI risk score had a 10-fold increase in congestive heart failure presentation and mortality compared with those with a low TIMI risk score. When a combination of different strata for each variable was analyzed, a stepwise increase in mortality was seen. There were a few number of patients with a high WBC count and low TIMI risk score or with a low WBC count and high TIMI risk score. These patients had an intermediate risk, whereas those with a high WBC count and TIMI risk score had the highest risk.

Conclusion:

These findings suggested that a simple combination of WBC count and TIMI risk score might provide further information for predicting outcomes in patients with AMI.

Incremental value of echocardiographic assessment beyond clinical evaluation for prediction of death and development of heart failure after high-risk myocardial infarction

BACKGROUND

Echocardiographic measurements of left ventricular (LV) function, predominantly LV ejection fraction (LVEF), have been used to define risk in patients after myocardial infarction. However, the extent to which measures of LV structure and function provide incremental prognostic value over clinical variables in survivors of high-risk myocardial infarction has not been well defined.

METHODS

Predictors of death and development of heart failure were assessed in 603 patients from the Valsartan in Acute Myocardial Infarction (VALIANT) echocardiographic substudy. We used multivariable proportional hazards models to assess the individual predictive value of echocardiographic measures including left ventricular mass index, LVEF, LV volumes, left atrial volume index, right ventricular fractional area change, mitral regurgitation, and deceleration time. We adjusted for the 11 clinical variables found previously to be most associated with all-cause mortality in this cohort. Receiver operating characteristic curves obtained via binary response regression were used to assess the incremental predictive value of echocardiographic measures in predicting outcomes of death and hospital stay for heart failure.

RESULTS

Each echocardiographic measure was independently associated with outcome of death or development of heart failure (all P < .002). Left ventricular ejection fraction alone added minimal prognostic value to the clinical assessment, yet adding additional echocardiographic assessments to a multivariable model improved in predicting 17-month survival free of heart failure significantly, increasing the c-statistic from 0.74 to 0.84 (P < .001).

CONCLUSION

Echocardiographic measures of cardiac structure and function beyond LVEF provide important prognostic information beyond the clinical assessment.

Value of early risk stratification using hemoglobin level and neutrophil-to-lymphocyte ratio in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

Complete blood count is the most widely available laboratory datum in the early in-hospital period after ST-elevation myocardial infarction (STEMI). We assessed the clinical utility of the combined use of hemoglobin (Hb) level and neutrophil-to-lymphocyte ratio (N/L) for early risk stratification in patients with STEMI. We analyzed 801 consecutive patients with STEMI treated with primary percutaneous coronary intervention (PCI) within 12 hours of onset of symptoms. Patients with cardiogenic shock or underlying malignancy were excluded, and 739 patients (63 ± 13 years, 74% men) were included in the final analysis. Patients were categorized into 3 groups using the median value of N/L (3.86) and the presence of anemia (Hb <13 mg/dl in men and <12 mg/dl in women); group I had low N/L and no anemia (n = 272), group II had low N/L and anemia, or high N/L and no anemia (n = 331), and group III had high N/L and anemia (n = 136). There were significant differences on clinical outcomes during 6-month follow-up among the 3 groups. Prognostic discriminatory capacity of combined use of Hb level and N/L was also significant in high-risk subgroups such as patients with advanced age, diabetes mellitus, multivessel coronary disease, low ejection fraction, and even in those having higher mortality risk based on Thrombolysis In Myocardial Infarction risk score. In a Cox proportional hazards model, after adjusting for multiple covariates, group III had higher mortality at 6 months (hazard ratio 5.6, 95% confidence interval 1.1 to 27.9, p = 0.036) compared to group I. In conclusion, combined use of Hb level and N/L provides valuable timely information for early risk stratification in patients with STEMI undergoing primary PCI.

Comparison of location of "culprit lesions" in left anterior descending coronary artery among patients with anterior wall ST-segment elevation myocardial infarction having ramus intermedius coronary arteries versus patients not having such arteries

Disturbed, nonlaminar flow distal to arterial bifurcations contributes to atherosclerosis development and progression. We hypothesized that the presence of a ramus intermedius (RI) amplifies the flow disturbances in the proximal left anterior descending (LAD) artery causing more proximal LAD lesions and larger ST-segment elevation myocardial infarction (STEMI). Emory University's contribution to the National Cardiovascular Data Registry was queried for STEMIs from January 2006 to July 2008. The distance from the LAD ostium to the lesion was measured in patients with angiographically visible culprit lesions. The peak troponin-I, creatinine kinase-MB, and left ventricular ejection fraction were used as markers for infarct size. Of the 386 patients with STEMI, 150 had LAD culprit lesions. The mean lesion distance from the LAD ostium was 15.2 +/- 11.0 mm in the patients with RI (n = 44) and 29 +/- 19 mm in those without RI (n = 106; p <0.01). LAD lesions were more proximal in the patients with RI, with 43% and 63% of lesions occurring in the first 10 and 20 mm of the LAD, respectively, versus 10% and 32% in those without RI (p <0.01). Patients with RI had greater peak troponin-I (69 +/- 40 ng/ml vs 50 +/- 39 ng/ml, p = 0.01) and peak creatinine kinase-MB (277 +/- 271 ng/ml vs 174 +/- 190 ng/ml, p = 0.01). A trend was seen toward a lower left ventricular ejection fraction in patients with RI (36 +/- 10% versus 40 +/- 11%, p = 0.06). In conclusion, the presence of RI was associated with more proximal LAD lesions and larger anterior infarctions, suggesting anatomy-induced flow disturbances have important clinical implications.

Explicit risk in acute coronary syndrome management

At least implicitly, most clinical decisions represent an integration of disease and treatment-based risk assessments. Often, as is the case with acute coronary syndrome (ACS), these decisions need to be made quickly at a time when data elements are limited, and published risk models are very useful in clarifying time-dependent determinants of risk. The present review emphasizes the value of explicit risk assessment and reinforces the fact that patients at highest risk are often those most likely to benefit from newer and more invasive therapies. Suggested ways to incorporate published ACS risk models into clinical practice are included. In addition, the need to adopt a longer-term view of risk in ACS patients is stressed, with particular regard to the important role of heart failure prediction and treatment.

Improved survival after acute myocardial infarction in patients with advanced Killip class

BACKGROUND

The continuing applicability of the Killip classification system to the effective stratification of long-term and short-term outcome in patients with acute myocardial infarction (MI) and its influence on treatment strategy calls for reanalysis in the setting of today's primary reperfusion treatments.

HYPOTHESIS

Our study sought to test the hypothesis that Killip classification, established on admission in patients with acute MI, is an effective tool for early prediction of in-hospital mortality and long-term survival.

METHODS

A series of 909 consecutive Olmsted County patients admitted with acute MI to St. Marys Hospital, Mayo Clinic, between January 1988 and March 1998 was analyzed. Killip classification was the primary variable. Endpoints were in-hospital death, major in-hospital complications, and post-hospital death.

RESULTS

Patients analyzed included 714 classified as Killip I, 170 classified as Killip II/III, and 25 classified as Killip IV. Increases in in-hospital mortality and prevalence of in-hospital complications correspond significantly with advanced Killip class (p < 0.01), with in-hospital mortality 7% in class I, 17.6% in classes II/III, and 36% in class IV patients (p < 0.001). Killip classification was strongly associated with mode of therapy administered within 24 h of admission (p < 0.01). Killip IV patients underwent primary angioplasty most commonly and were less likely to receive medical therapy.

CONCLUSIONS

Killip classification remains a strong independent predictor of in-hospital mortality and complications, and of long-term survival. Early primary angioplasty has contributed to a decrease in mortality in Killip IV patients, but effective adjunctive medical therapy is underutilized.

Can ischemic stroke be caused by acute reduction of blood pressure in the acute phase of cardiovascular disease?

Acute-phase cardiovascular disease (CVD) frequently presents with markedly elevated blood pressure (BP) levels and often requires fairly rapid lowering of BP. On the other hand, aggressive lowering of systemic BP to the point that the cerebral BP decreases below a certain threshold may result in ischemic stroke. The authors retrospectively studied 192 consecutive patients with CVD who had markedly elevated BP and end-organ damage. Ischemic stroke was noted in 12 of these patients during BP-lowering therapy. The incidence of ischemic stroke did not differ significantly between a standard BP-lowering group, in which the target BP reduction was within the parameters of the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines, and a rapid BP-lowering group, in which the target BP was below these guidelines (7.1% vs 2.6%, respectively; P=.27, not significant). In stepwise multiple regression analysis, diabetes mellitus (beta=0.203, P=.008) and acute pulmonary edema (beta=0.228, P=.003) remained significant factors associated with the incidence of stroke. Thus, acute pulmonary edema and diabetes were the most important factors related to ischemic stroke during BP reduction in patients with marked elevations of BP regardless of the rapidity of BP lowering.

Comprehensive adrenergic blockade post myocardial infarction left ventricular dysfunction

Practice guidelines recommend that post myocardial infarction (MI) patients should be started and continued indefinitely on oral beta-blocker therapy unless absolutely contraindicated or not tolerated. Patients with post-MI left ventricular dysfunction (LVD) are at particularly high risk for recurrent cardiovascular events, heart failure, sudden death, and mortality and have been shown to derive substantial benefit from certain beta-blockers. Nevertheless, many of these patients are not prescribed beta-blockers, and some patients are treated with agents whose long-term use has not been shown to be effective. This article discusses the clinical trial evidence supporting the use of beta-blockers in patients post MI with LVD, provides the rationale for choosing specific beta-blockers, and presents practical approaches to implement this evidence-based therapy in the acute and chronic post-MI period.

Outcome and quality of care of patients who have acute myocardial infarction

Coronary artery disease is the number-one killer in developed countries, with lifetime prevalence of up to 50% in American men, and is the topic of much medical literature. Recently, multiple therapies have emerged to save lives after acute myocardial infarction (AMI), backed by well-conducted studies; however, appropriate implementation of therapy guidelines is less than optimal. Recent efforts have focused on improving the quality of care (QC) after AMI in order to improve outcomes. This article illustrates how outcome after AMI is related to QC, describes the underuse of evidence-based therapies, and discusses factors associated with poor guideline adherence. It also reviews current quality improvement projects, and some available means to measure and optimize the QC for patients with AMI.

Improving the management of patients after myocardial infarction, from admission to discharge

BACKGROUND

Recent developments in pharmacologic and device therapy, as well as initiatives to increase the use of standard orders and promote in-hospital communication, have improved the care of patients with myocardial infarction (MI). The increased presence of hospitalists, physicians who provide in-hospital care as a specialty, promises to provide further improvements.

OBJECTIVE

This article reviews current information on evidence-based care of the hospitalized MI patient, with a particular emphasis on identifying left ventricular dysfunction (LVD) and appropriate treatments.

METHODS

MEDLINE was searched for all large-scale clinical trials providing information on the care of post-MI patients with or without LVD and/or heart failure (HF), with no limit on time period. The search terms were post-myocardial infarction, large-scale, randomized, clinical trial, left ventricular dysfunction, and/or heart failure. All trials investigating therapies currently recommended in the American College of Cardiology/American Heart Association ST-elevation MI (ACC/AHA STEMI) guidelines and including post-MI patients with or without LVD and/or HF, as indicated by signs and symptoms of HF or Killip class, were included.

RESULTS

In the acute setting, the ACC/AHA STEMI guidelines recommend the use of aspirin, clopidogrel, beta-blockers, angiotensin-converting enzyme inhibitors, heparin (low molecular weight or unfractionated), and glycoprotein IIb/IIIa inhibitors (if the patient is undergoing a percutaneous coronary intervention). The guidelines recommend use of aldosterone antagonists and statins at discharge, in addition to continuation of all acute therapies. The ACC/AHA guidelines apply to all patients after MI and do not specify whether the recommended therapies are effective in post-MI patients with LVD or HE Reviewing the trials that included post-MI patients with LVD and/or HF, it appears that in some cases, only certain agents within a class have been evaluated (eg, post-MI beta-blocker trials often excluded patients with LVD, and the efficacy of atenolol has not been evaluated in post-MI patients with LVD or HF), and some agents have not shown as much efficacy as others in this high-risk patient population (eg, metoprolol appeared to be associated with poorer outcomes in this population than carvedilol). Rather than recommending an entire class, hospital care maps and critical-care pathway tools should incorporate the use of evidence-based agents.

CONCLUSIONS

The use of evidence-based care in the hospital has the potential to substantially reduce morbidity and mortality in post-MI patients with LVD and/or HE The hospitalist can facilitate the best practices and best care of the post-MI patient through the use of in-hospital critical-care pathway tools.

Prognostic value of C-reactive protein and cardiac troponin I in primary percutaneous interventions for ST-elevation myocardial infarction

BACKGROUND

The rise in cardiac troponin I after ST-elevation myocardial infarction treated by primary percutaneous coronary interventions (PCIs) is predictive of infarct size and left ventricular ejection fraction (LVEF). However, the comparative value of C-reactive protein (CRP) and troponin I for infarct size evaluation and the respective relationships between these biomarkers and mortality have not been investigated.

METHODS

We studied 87 patients who underwent primary PCI for ST-elevation myocardial infarction. Concentrations of troponin I and CRP were measured before and for 72 hours after PCI. Infarct size was measured by the cumulative release of alpha-hydroxybutyrate deshydrogenase during the 72 hours after PCI (QHBDH72) and by delayed radionuclide LVEF (at 4.6 +/- 1.7 weeks).

RESULTS

Concentrations of CRP at peak and at 24, 48 and 72 hours, and of troponin I at 6 and 72 hours, correlated with QHBDH72 and LVEF. In single variable analysis, at a mean follow-up of 42 +/- 8 months, Killip score of 3 to 4, CRP at baseline and at 48 hours, and troponin I at 6 and 72 hours were related to mortality. By multiple variable analysis, Killip score (OR 9.9, CI 1.6-58.8) and troponin I at 72 hours (OR 9.43, CI 2.1-43.5) were the only independent predictors of mortality.

CONCLUSIONS

Plasma concentrations of CRP and troponin I after PCI were related to infarct size and mortality. However, Killip class and troponin I at 72 hours were the only independent predictors of mortality at long-term follow-up.

Incidence and Prevention of Ischemic Stroke following Myocardial Infarction: Review of Current Literature

Myocardial infarction is the leading cause of death today. With the fast progress in pharmacotherapy and revascularization technology, outcomes following a myocardial infarction have become very favorable. While most of the complications from a myocardial infarction can be adequately managed, thus leading to reduced mortality, stroke following a myocardial infarction remains a challenge even today, and can lead to potentially devastating complications. We discuss the incidence, pathophysiology, and management options of non-hemorrhagic stroke following a myocardial infarction.

Impact of organizational infrastructure on beta-blocker and aspirin therapy for acute myocardial infarction

BACKGROUND

Although organizational change has been advocated as a critical component of quality improvement, there is little data available on the variation and effectiveness of organizational elements in the care of acute myocardial infarction (AMI).

PURPOSE

This study was designed to examine the impact of organizational infrastructure on the use of aspirin and beta-blockers during and after AMI.

METHODS

We assessed organizational infrastructure for AMI care in 44 hospitals in Kansas and linked these data to patient-specific process of care data collected in Kansas as part of the Cooperative Cardiovascular Project. While controlling for clustering within hospitals, we examined the relationships between hospital infrastructure and use of aspirin and beta-blocker both at admission and discharge.

RESULTS

Hospitals varied widely in their inclusion of aspirin and beta-blockers in AMI pathways, protocols, and standardized order sets. Hospitals also varied in the involvement of their physicians in AMI quality improvement and in their ability to identify a physician champion for AMI care. Patients were more likely to receive aspirin on admission in hospitals that included aspirin in their emergency department order sets (odds ratio [OR] 1.57, 95% confidence interval [CI] 1.01-2.48) and were more likely to receive beta-blockers on admission and at discharge if beta-blockers were included in an emergency department protocol or pathway (OR 2.14, 95% CI 1.25-3.77 and OR 3.5, 95% CI 1.14-14.38, respectively). Use of beta-blockers at discharge was also associated with commitment of administration to AMI care and the presence of a physician champion.

CONCLUSIONS

Quality improvement efforts should include a close examination of the organization of AMI care to assure that critical elements in the care of AMI patients are not inadvertently omitted.

Therapeutic hypothermia utilization among physicians after resuscitation from cardiac arrest*

OBJECTIVE

We sought to evaluate current physician use of therapeutic hypothermia after cardiac arrest, to ascertain reasons for nonadoption of this treatment, and to determine current cooling techniques employed.

DESIGN

Web-based survey.

SETTING

International physician cohort in the United States, UK, and Finland.

SUBJECTS

Physicians (MD or DO) caring for resuscitated cardiac arrest patients.

INTERVENTIONS

An anonymous Web-based survey was distributed to physicians identified through United States-based critical care, cardiology, and emergency medicine directories and critical care networks in the UK and Finland. Recipients were queried regarding use of postresuscitation therapeutic hypothermia.

MEASUREMENTS AND MAIN RESULTS

Of the final 13,272 surveys actually distributed to physicians, 2,248 (17%) were completed. Most respondents were attending physicians (82%) at teaching hospitals (76%) who practiced critical care (35%), cardiology (20%), or emergency medicine (22%). Of all replies, 74% of United States respondents and 64% of non-United States respondents had never used therapeutic hypothermia. United States emergency medicine physician adoption of cooling was significantly less than that of United States intensivists (16% vs. 34%, p < .05). The most often cited reasons for nonuse by respondents were "not enough data," "not part of Advanced Cardiac Life Support guidelines," and "too technically difficult to use." Factors associated with increased use included non-United States residence, critical care specialty, and larger hospital size.

CONCLUSIONS

Physician utilization of cooling after cardiac arrest remains low. For improved adoption of therapeutic hypothermia, our data suggest that development of better cooling methodology and recent incorporation into resuscitation guidelines may improve use.

Beta blockade in the post-myocardial infarction setting: pharmacologic rationale and clinical evidence

The use of beta blockers reduces the risk of arrhythmias, reinfarction, and heart failure in both the immediate and long-term periods after a myocardial infarction. Every patient should be prescribed a beta blocker after a myocardial infarction unless there is a strong contraindication to therapy. Despite compelling evidence and recommendations, beta blockers remain an underutilized therapy in the post-myocardial infarction period. Evidence-based recommendations for the choice of agent and the practical implementation of beta blockers are reviewed.

The incidence of stroke after myocardial infarction: a meta-analysis

PURPOSE

While the risk of stroke after myocardial infarction (MI) is increased compared with the risk among those without MI, the magnitude of this risk remains unclear. Although numerous clinical trials have reported the incidence of stroke following MI, these are among selected populations. We reviewed cohort studies reporting the incidence of stroke after MI to better define the risk of ischemic stroke in an unselected population.

METHODS

A computerized literature search (MEDLINE and PubMed) and manual review of reference lists of identified articles were conducted. Population-based studies published from 1978-2004 with at least 100 subjects that reported number or percent of ischemic strokes experienced by MI survivors were identified. Data were extracted using standardized forms, and study quality was assessed by 2 independent reviewers. Ischemic stroke rates were reported as number of events per 1000 MI with 95% confidence intervals (CI) calculated by Poisson distribution. A combined stroke rate was calculated for in-hospital, 30 days, and 1-year post-MI using weights of 1/variance. A random-effects model also was created to estimate in-hospital stroke rate. Variability in study designs and outcome definitions limit synthesis of available data.

RESULTS

During hospitalization for the index MI, 11.1 ischemic strokes occurred per 1000 MI compared with 12.2 at 30 days and 21.4 at 1 year. Using a random-effects model, 14.5 strokes occurred per 1000 MI. Positive predictors of stroke after MI included: advanced age, diabetes, hypertension, history of prior stroke, anterior location of index MI, prior MI, atrial fibrillation, heart failure, and nonwhite race.

CONCLUSIONS

The public health implications of stroke among MI survivors, as well as the large number of MI survivors, underscore the need to be aware of this devastating complication. Further research is needed to determine the optimal stroke prevention strategies for MI survivors.

La fréquence cardiaque, facteur pronostique majeur du risque cardiovasculaire

The prognostic value of heart rate (HR) was analysed based on the reports from the literature in the general population and in patients with coronary artery disease (CAD). Multivariate analyses showed that elevated resting HR was found to be an independent predictor of total and cardiovascular mortality. The behaviour of HR during exercise testing was predictive of sudden death. The beneficial effects of betablockers in post-infarction patients are well established. Calcium channel blockers that increase resting HR are associated with a deleterious effect on mortality. Therefore, resting HR should not be overlooked in risk stratification of CAD patients. Reduction of resting HR should be viewed as an attractive therapeutic target in CAD patients.

Which Factors Are Associated with the Application of Reperfusion Therapy in ST-Elevation Acute Coronary Syndromes?

BACKGROUND/AIMS

A large proportion of patients with a ST-elevation acute coronary syndrome do not receive reperfusion therapy. In order to contribute to a better understanding of the clinical decision making process, we analyzed which factors are associated with the application of reperfusion therapy.

METHODS

From the Euro Heart Survey of Acute Coronary Syndromes I, 4,260 patients with ST-elevation acute coronary syndrome were selected for the current analysis, of which 1,539 (36%) patients received fibrinolysis and 904 (21%) primary percutaneous coronary intervention (PCI). The analysis contained 32 variables on demographics, medical history, admission parameters and reperfusion therapy.

RESULTS

A short pre-hospital delay, arrival in a hospital with PCI facilities, severe ST-elevation, and participation in a clinical trial were the strongest predictors for receiving reperfusion therapy. Primary PCI was more likely to be performed than fibrinolysis in patients with a long pre-hospital delay, arriving in a hospital with PCI facilities, not participating in a clinical trial, and with at least one previous PCI.

CONCLUSION

Hospital facilities and culture, pre-hospital delay and infarction size play a major role in management decisions regarding reperfusion therapy in ST-elevation acute coronary syndrome. This analysis indicates which factors require special attention when implementing and reviewing the reperfusion guidelines.

Clinical characteristics and prognostic factors in patients with complicated acute coronary syndromes requiring prolonged mechanical ventilation

Patients with acute coronary syndromes (ACSs) may develop serious multiorgan complications and require prolonged intensive care. Our aim was to characterize and identify factors that are associated with outcomes in these patients. We retrospectively identified 267 consecutive patients admitted to the coronary care unit for an ACS who required >3 days of mechanical ventilation. Multiple clinical and laboratory variables were correlated with mortality. Patients' ages were 68.3 +/- 10.9 years (mean +/- SD) and 165 (62%) were men. Seventy-six patients (29%) died within 30 days of admission, and the 1 year mortality was 46%. Moderate or severe left ventricular systolic dysfunction was found in 72% of the patients. Eighty-nine patients (33.3%) required vasopressors, of whom 64 (72%) did not survive 30 days. Among 127 patients who required antibiotics (48.3%), 30-day mortality was 53% compared with 4% among patients who did not require antibiotics (p <0.001). The 30-day mortality among patients who received both antibiotics and vasopressors was 64 of 87 patients (74%), and the 1-year mortality in this subgroup was 86.2%. Parameters found to be independent predictors of 30-day mortality were (in descending order): vasopressor requirement, use of antibiotics, peripheral vascular disease, ST-elevation myocardial infarction, renal failure, obesity and Killip class on admission. In conclusion, mortality among patients who require prolonged mechanical ventilation after an ACS is substantial. The main independent predictors of with mortality are the severity of heart failure and the presence of co-morbidities.

Admission glucose concentrations independently predict early and late mortality in patients with acute myocardial infarction treated by primary or rescue percutaneous coronary intervention

BACKGROUND

In patients with acute myocardial infarction (MI), increased plasma glucose levels at hospital admission are associated with worse outcome. We aimed to assess the predictive value of admission glucose concentrations on short- and long-term mortality in patients with acute MI undergoing primary or rescue percutaneous coronary intervention (PCI).

METHODS

We analyzed the 30-day and long-term (mean follow-up 3.7 years) outcome of 978 patients prospectively included in a single-center registry of patients with acute MI treated with PCI within 24 hours after onset of symptoms. Patients were classified according to plasma glucose levels at admission: < 7.8 mmol/L (group I, n = 322), 7.8 to 11 mmol/L (group II, n = 348), and > 11.0 mmol/L (group III, n = 308).

RESULTS

Mortality at 30 days was 1.2% in group I, 6.3% in group II, and 16.6% in group III (P < .001). After multivariate adjustment for age, the presence of cardiogenic shock, and TIMI 3 flow after PCI, the association of mortality with glucose classification remained significant (P value for trend = .003). The relative risk of death at 30 days for group III versus group I was 3.9 (95% CI 1.2-13.2). During long-term follow-up, mortality was similar in groups I and II. However, in group III adjusted mortality remained significantly increased compared with group I (relative risk 1.76, CI 1.01-3.08).

CONCLUSIONS

In patients undergoing emergency PCI for acute MI, glucose levels at hospital admission are predictive for short- and long-term survival. Knowledge of admission glucose levels may improve initial bedside risk stratification.

Heart failure on admission and the risk of stroke following acute myocardial infarction: the VALIANT registry

AIMS

We sought to assess the relative contribution of heart failure (HF) on admission for an acute myocardial infarction (MI) to the subsequent in-hospital stroke risk.

METHODS AND RESULTS

The VALsartan In Acute myocardial iNfarcTion (VALIANT) registry enrolled 5573 consecutive MI patients at 84 international sites from 1999 to 2001. We calculated odds ratios (ORs) for stroke and adjusted for baseline characteristics, Killip Class, and risk factors for stroke, such as diabetes and prior HF. In-hospital stroke occurred in 81 (1.5%) patients. HF was present on admission in 38% of patients who developed a stroke and in 24% who did not (P=0.001). Older age (OR 1.03 increase/year, 95% confidence interval (CI) 1.01-1.04), Killip Class III (OR 1.66, CI 0.86-3.19) or IV (OR 4.85, CI 1.69-13.93), history of hypertension (OR 1.73, CI 1.06-2.82), and history of stroke (OR 1.89, CI 1.06-3.37) were more common in patients who had in-hospital stroke. In-hospital mortality in patients with and without stroke was 27.2 and 6.5%, respectively (P<0.001).

CONCLUSION

Patients with stroke after MI have a dismal prognosis. The presence of HF on admission for an acute MI increases in-hospital stroke risk. HF treatments may modify the risk of stroke.

Practical considerations of beta-blockade in the management of the post-myocardial infarction patient

Acute myocardial infarction (AMI) is a major cause of death and disability in the United States that affects an estimated total of 1.5 million men and women each year. Despite significant advances in pharmacologic and interventional therapies, 25% of men and 38% of women still die within 1 year of the acute event. Beta-blockers have been shown to significantly decrease the risk of morbidity and mortality in patients after an AMI. National guidelines recommend that all patients with AMI may be started on beta-blocker therapy and continued indefinitely, unless absolutely contraindicated or not tolerated. However, a substantial portion of eligible AMI survivors are not prescribed beta-blockers in the hospital after an acute event or upon hospital discharge. In addition, patients with AMI are often treated with agents whose long-term use has not been shown effective and for which optimal dosing has not been defined. This paper will discuss the background of beta-blocker use for the treatment of AMI, discuss the rationale for choosing specific agents, and present protocols for initiating or switching to evidence-based therapies.

Effects of treatment recommendations and specialist intervention on care provided by primary care physicians to patients with myocardial infarction or heart failure

PURPOSE

To assess the effects of an intervention involving dissemination of treatment recommendations to primary care physicians treating outpatients with acute myocardial infarction or heart failure.

METHODS

The study comprised 509 patients with myocardial infarction and 323 patients with heart failure who were discharged from hospital. The primary care physicians caring for these patients were assigned randomly to either the intervention or control group; the intervention group was mailed practice guidelines immediately after patient discharge, and patients were cited by name. During a 6-month assessment period, the records of primary care physicians (and cardiologists, if any) were reviewed to assess mean conformance with the guidelines, using seven measures of care for myocardial infarction and eight measures of care for heart failure.

RESULTS

After adjusting for demographic and clinical characteristics of patients, and the number of eligible measures per patient, we observed no effect of the intervention on care of patients with myocardial infarction (odds ratio [OR] = 0.98; 95% confidence interval [CI]: 0.81 to 1.17) or heart failure (OR = 1.25; 95% CI: 0.96 to 1.59). However, there was a higher likelihood of conformance with measures for patients with infarction (OR = 1.56; 95% CI: 1.29 to 1.87) or heart failure (OR = 1.71; 95% CI: 1.29 to 2.23) who had also been seen by a cardiologist during the 6-month assessment period.

CONCLUSION

Mailing treatment recommendations did not improve the quality of care of recently discharged patients with myocardial infarction or heart failure. However, efforts to include cardiologists in the care of these patients might be worthwhile.

Undocumented patient information: an impediment to quality of care

PURPOSE

Poor documentation in medical records might reduce the quality of care and undermine analyses based on retrospective chart reviews. We assessed the documentation of cardiac risk factors and cardiac history in the records of patients hospitalized with myocardial infarction or heart failure.

METHODS

We performed a retrospective cohort study involving direct chart audit of all consecutive hospitalizations for myocardial infarction (n = 2,109) or heart failure (n = 3,392) in Nova Scotia, Canada, from October 15, 1997, to October 14, 1998. The main outcome measures were the documentation rates for prespecified clinical items, including cardiac risk factors and history of myocardial infarction or heart failure, which were recognized as indicators of the quality of care for the conditions under study.

RESULTS

Information was not documented in a high proportion of cases, ranging from 9% (smoking) to 58% (previous history of heart failure) in charts from patients hospitalized for myocardial infarction, and from 19% (smoking) to 69% (hyperlipidemia) in charts from heart failure hospitalizations. Lack of documentation was more common in women and the elderly.

CONCLUSION

Documentation of important clinical information is poor even in the hospital charts of patients with severe conditions. This quality-of-care issue has implications for health services and outcomes research, including the development of report cards.

Effect on survival of acute myocardial infarction in Killip classes II or III patients undergoing invasive coronary procedures

The purpose of the present study was to determine whether patients with acute myocardial infarction (AMI) in Killip class II or III are likely to benefit from catheterization and coronary revascularization performed within 30 days of AMI. The study population was drawn from 2 national surveys performed during 1996 and 1998 in 26 coronary care units operating in Israel. Our analysis included 3,113 patients with AMI who were divided into 2 groups according to their admission Killip class: 2,484 patients (80%) in Killip class I, of whom 1,408 (57%) underwent cardiac catheterization and 1,076 were treated noninvasively; and 629 patients in Killip class II or III, of whom 314 (50%) underwent cardiac catheterization and 315 were managed conservatively. Patients in Killip class II or III who were treated invasively had lower mortality rates than their counterparts who were treated noninvasively at 30 days: 7.6% versus 15.6%, respectively (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.28 to 0.92), and thereafter from 30 days to 6 months, 4.3% versus 13.6%, respectively (OR 0.34, 95% CI 0.16 to 0.68). In Killip class I patients, an invasive versus noninvasive management was not associated with a better outcome at 30 days: 1.6% versus 3.2%, respectively (OR 0.58, 95% CI 0.32 to 1.05), but with similar mortality rates at 30 days to 6 months, 1.9% versus 2.0%, respectively (OR 1.46, 95% CI 0.79 to 2.74). Thus, the present study suggests that patients with AMI in Killip class II or III on admission may benefit from cardiac catheterization and revascularization performed within 30 days from admission, whereas patients with AMI in Killip class I are less likely to benefit from this approach.

[Characteristics of acute myocardial infarction patients treated with mechanical ventilation. Data from the ARIAM Registry]

INTRODUCTION

Scarce information is available about the use, clinical course and follow-up of patients with acute myocardial infarction treated with mechanical ventilation.

PATIENTS AND METHOD

Historical cohort study of patients with acute myocardial infarction, included in Spanish registry ARIAM. Differences in clinical characteristics and prognosis from patients treated with or without mechanical ventilation were compared.

RESULTS

Three hundred and thirty-three of the 4143 patients (8.1%) with acute myocardial infarction were treated with mechanical ventilation. Treated patients were older, more frequently female, and had more frequently reinfarcts, anterior infarction, Killip III and IV, and higher creatine phosphokinase peak. Diabetes and high blood pressure were more frequent in those in which the technique was applied. They had a higher mortality at the coronary care unit (65.7 vs 5.1%; p < 0.001) than the non-ventilated patients. In multivariate analysis, creatine phosphokinase peak levels higher than 1.200 units/ml, Killip III and IV, and an infarction localization different to inferior were independent predictors of mechanical ventilation application. The 220 treated patients who died were older, more frequently female, had been more frequently admitted to the coronary unit, and had Killip IV whereas Killip III was more frequent among survivors. In multivariate analysis, restricted to patients treated with mechanical ventilation, Killip III was an independent predictor of survival with an odds ratio for mortality of 0.26 (CI 95%: 0.09-0.77).

CONCLUSIONS

Mechanical ventilation is a vital support technique employed in a significant number of complicated acute myocardial infarction patients. The high mortality of these patients was related to more extended myocardial infarction and a worse clinical state.