Prognosis of patients > or = 70 years of age with non-Q-wave acute myocardial infarction compared with younger patients with similar infarcts and with patients > or = 70 years of age with Q-wave acute myocardial infarction

Age-related differences in the effect of psychological distress on mortality: Type D personality in younger versus older patients with cardiac arrhythmias

Background. Mixed findings in biobehavioral research on heart disease may partly be attributed to age-related differences in the prognostic value of psychological distress. This study sought to test the hypothesis that Type D (distressed) personality contributes to an increased mortality risk following implantable cardioverter defibrillator (ICD) treatment in younger patients but not in older patients. Methods. The Type D Scale (DS14) was used to assess general psychological distress in 455 younger (≤70 y, m = 59.1) and 134 older (>70 y, m = 74.3) ICD patients. End points were all-cause mortality and cardiac death after a median follow-up of 3.2 years. Results. Older patients had more advanced heart failure and a higher mortality rate (n = 34/25%) than younger patients (n = 60/13%), P = 0.001. Cardiac resynchronization therapy (CRT), but not Type D personality, was associated with increased mortality in older patients. Among younger patients, however, Type D personality was associated with an adjusted hazard ratio = 1.91 (95% CI 1.09–3.34) and 2.26 (95% CI 1.16–4.41) for all-cause and cardiac mortality; other predictors were increasing age, CRT, appropriate shocks, ACE-inhibitors, and smoking. Conclusion. Type D personality was independently associated with all-cause and cardiac mortality in younger ICD patients but not in older patients. Cardiovascular research needs to further explore age-related differences in psychosocial risk.

Assessing the appropriateness of coronary revascularization: the University of Maryland Revascularization Appropriateness Score (RAS) and its comparison to RAND expert panel ratings and American College of Cardiology/American Heart Association guidelines with regard to assigned appropriateness rating and ability to predict outcome

BACKGROUND

Significant regional variation in procedural frequencies has led to the development of the RAND and American College of Cardiology/American Heart Association (ACC/AHA) guidelines; however, they may be difficult to apply in clinical practice. The University of Maryland Revascularization Appropriateness Score (RAS) was created to address the need for a simplified point scoring system.

HYPOTHESIS

The study was undertaken to compare revascularization appropriateness ratings yielded by the RAND Expert Panel Ratings, ACC/AHA guidelines, and the University of Maryland RAS.

METHODS

We applied these three revascularization appropriateness scoring systems to 153 catheterization laboratory patients with a variety of cardiac diagnoses and treatments. For each patient, appropriateness scores assigned by each of the three systems were compared with each other and with the actual treatment delivered. Concordance of care with appropriateness score was then correlated with outcome.

RESULTS

There were significant differences among all three scoring systems in their ratings and in the concordance of treatment with appropriateness rating. When treatment provided was concordant with RAND ratings, there was a lower occurrence of subsequent coronary artery bypass grafting (CABG), the composite end point of either CABG or percutaneous transluminal coronary angioplasty (PTCA), and the composite end point of death, myocardial infarction (MI), or revascularization. When treatment was concordant with the ACC/AHA guidelines, there was lower occurrence of all-cause mortality, PTCA, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization. When treatment provided was concordant with the RAS, there was lower occurrence of cardiac death, all-cause death, CABG, the composite end point of either CABG or PTCA, and the composite end point of death, MI, or revascularization.

CONCLUSIONS

The RAS is a simple scoring system to assess revascularization appropriateness. When the RAND, ACC/AHA, and RAS systems are compared in a catheterization laboratory population, they rate the same patient differently and vary in their correlation of appropriateness rating with outcome.

The effect of age on functional and mortality outcomes after acute myocardial infarction

OBJECTIVES

To determine the prevalence of post-myocardial infarction (MI) functional decline and to describe its association with chronological age in survivors of MI.

DESIGN

Prospective observational registry.

SETTING

Nineteen U.S. hospitals.

PARTICIPANTS

Two thousand four hundred eighty-one patients with acute MI.

MEASUREMENTS

Baseline and 1-year interviews identified subjects with functional decline, defined as a more than 5-point decline in Medical Outcomes Study 12-item Short Form Questionnaire (SF-12) Physical Component score or being "too ill" to provide a follow-up interview at 1 year. The relationship between age and functional decline was evaluated using logistic regression models adjusted for baseline SF-12 score, comorbidities, sociodemographics, and treatment characteristics. One-year mortality and a combined endpoint of death or decline were also compared across age.

RESULTS

Of 2,009 patients who survived to 1 year, 582 (29%) experienced a functional decline. In survivors, age was not associated with functional decline in unadjusted (odds ratio (OR)=0.95/decade, 95% confidence interval (CI)=0.88-1.03) or multivariable (OR=0.94, 95% CI=0.85-1.05) models. Although age was strongly associated with 1-year mortality (adjusted hazard ratio=1.42, 95% CI=1.21-1.66), there was no association between age and the combined endpoint of death or functional decline (adjusted OR=1.02, 95% CI=0.92-1.12).

CONCLUSION

More than one in four survivors of MI experiences a significant decline in physical function by 1 year. Although age is strongly associated with mortality, it had no association with functional decline. Because older patients have the same potential for favorable functional outcomes after an MI, age alone should not preclude aggressive treatment after an MI.

Treatment and short-term outcome in women and men with acute coronary syndromes

OBJECTIVE

To study differences in treatment and early morbidity and mortality in relation to gender, type of acute coronary syndrome (ACS) and age in patients under 80 years of age.

METHODS

We studied 1744 consecutive patients with ACS with assumed decreasing order of severity [ST-elevation myocardial infarction (MI), non-ST-elevation MI and unstable angina of high- and low-risk types] admitted to the coronary care unit at Sahlgrenska University Hospital.

RESULTS

The use of thrombolysis and percutaneous coronary interventions (PCI) did not differ significantly between gender groups and women did not suffer from more severe complications than men. Treatment with beta-blockers, ACE inhibitors and aspirin was used on a similar scale among women and men. In-hospital complications and use of intravenous drugs were strongly associated with severity of disease in a similar way among women and men. The mortality rates at 30 days were 12.4% and 7.4% in MI with and without ST-segment elevation, but only 1.3% and 1.0% in unstable angina of high- and low-risk types. The use of primary PCI decreased with age, as did coronary angiography and PCI in the subacute phase, irrespective of gender.

CONCLUSION

Among patients <80 years with ACS admitted to a coronary care unit, the suspicion that women are treated less aggressively than men could not be verified. Nor did women suffer from more complications or have a significantly higher 30-day mortality than men. Elderly patients were significantly less likely to undergo invasive procedures than those of a younger age, irrespective of gender.

Safety and Efficacy of Surgical Ventricular Restoration in Unstable Patients With Recent Anterior Myocardial Infarction

BACKGROUND

The effects and efficacy of surgical ventricular restoration (SVR) in ischemic cardiomiopathy caused by chronic anterior myocardial infarction (MI) are well established. Normally, SVR is delayed at least 3 months after MI to allow the healing of infarcted tissue. Some patients have instability <30 days after anterior MI, with increased risk for morbidity and mortality.Objectives- This study tests the safety and efficacy of SVR in the setting of subacute complicated anterior MI, in terms of early and late outcome.

METHODS AND RESULTS

74 patients (62+/-10 years) were submitted to SVR at < or =30 days after anterior MI for clinical instability and were retrospectively selected from a series of 430 patients undergoing SVR at our center, between 1998 and 2001. The surgical indications included: angina (60%); New York Heart Association class 4 (62%); clinical signs of heart failure (18%); life-threatening arrhythmias (12%); and cardiogenic shock in 4% (or 3) patients. Follow-up is available for 93% of patients. All patients had coronary artery bypass grafting (CABG) (3.1+/-1.2) with internal mammary artery (IMA) utilization. An endoventricular patch was used in 17 patients (23%); direct ventriculotomy closure was used in the remaining patients. Operative mortality was 5.4% (4/74). Hemodynamic parameters improved significantly in patients with dilated hearts and reduced ejection fraction. Mitral regurgitation that resulted was significantly reduced. Survival at 3 years was 87% in the overall population and 85% in patients 70 years or older.

CONCLUSIONS

This study reports the largest series of patients with complicated, recent anterior MI treated with SVR. The results show that SVR is feasible, has acceptable in-hospital mortality, and has good early and late outcome. Further experience is needed to establish whether SVR, which excludes the infarcted region, can prevent the long-term adverse remodeling of LV dilated hearts after anterior infarction.

Impact of anemia in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

OBJECTIVES

We sought to investigate the impact of anemia in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI).

BACKGROUND

The prognostic importance of anemia on primary PCI outcomes is unknown.

METHODS

In the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial, 2,082 patients of any age with AMI within 12 h onset undergoing primary PCI were randomized to balloon angioplasty versus stenting, each +/- abciximab. Outcomes were stratified by the presence of anemia at baseline, as defined by World Health Organization criteria (hematocrit <39% for men and <36% for women).

RESULTS

Anemia was present in 260 (12.8%) of 2,027 randomized patients with baseline laboratory values. Patients with versus without baseline anemia more frequently developed in-hospital hemorrhagic complications (6.2% vs. 2.4%, p = 0.002), had higher rates of blood product transfusions (13.1% vs. 3.1%, p < 0.0001), and had a prolonged (median 4.1 vs. 3.5 days, p < 0.0001) and more expensive (median costs $12,434 vs. $11,603, p = 0.002) index hospitalization. Patients with versus without anemia had strikingly higher mortality during hospitalization (4.6% vs. 1.1%, p = 0.0003), at 30 days (5.8% vs. 1.5%, p < 0.0001), and at 1 year (9.4% vs. 3.5%, p < 0.0001). The rates of disabling stroke at 30 days (0.8% vs. 0.1%, p = 0.005) and at 1 year (2.1% vs. 0.4%, p = 0.0007) were also significantly higher in patients with anemia. By multivariate analysis, anemia was an independent predictor of in-hospital mortality (hazard ratio, 3.26; p = 0.048) and one-year mortality (hazard ratio, 2.38; p = 0.016).

CONCLUSIONS

Anemia at baseline in patients with AMI undergoing primary PCI is common, and is strongly associated with adverse outcomes and increased mortality.

Unstable angina pectoris and non-Q-wave myocardial infarction

Unstable angina pectoris and non-Q-wave myocardial infarction are clinical syndromes that share many pathophysiologic and clinical features. In the spectrum of coronary artery disease, these syndromes lie between chronic stable angina and Q-wave myocardial infarction. Although both conditions are associated with significant morbidity and mortality, patients presenting with these syndromes can be further risk stratified into higher and lower risk based on a number of readily available clinical features and biochemical parameters. Such risk stratification can allow for more tailored treatment and better resource allocation. Although routine early coronary angiography and revascularization has not been shown to be superior to conservative management, certain high-risk patients may benefit from a more aggressive strategy. Medical therapy with the use of antiplatelet, anticoagulant, and antiischemic agents remains the cornerstone of emergent treatment for patients presenting with these syndromes. The recent demonstration of a reduction in both morbidity and mortality with the glycoprotein IIb/IIIa antagonists has further expanded the armamentarium of available agents. Following initial stabilization, risk stratification with stress testing can help identify patients with a large residual ischemic burden who may benefit from coronary angiography with revascularization if feasible.

Predictors of mortality and mortality from cardiac causes in the bypass angioplasty revascularization investigation (BARI) randomized trial and registry. For the BARI Investigators

BACKGROUND

The impact of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) on long-term mortality rates in the presence of various demographic, clinical, and angiographic factors is uncertain in the population of patients suitable for both procedures.

METHODS AND RESULTS

In the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial and registry, 3610 patients who were eligible to receive PTCA and CABG were revascularized between 1989 and 1992. Multivariate Cox models were used to identify factors associated with 5-year mortality and cardiac mortality, with particular attention to factors that interact with treatment. Diabetic patients receiving insulin had higher mortality and cardiac mortality rates with PTCA compared with CABG (relative risk [RR] 1.78 and 2.63, respectively, P<0.001), and patients with ST elevation had higher cardiac mortality rates with CABG than with PTCA (RR 4.08, P<0.001). Factors most strongly associated with high overall mortality rates were insulin-treated diabetes, congestive heart failure, kidney failure, and older age. Black race was also associated with higher mortality rates (RR 1.49, P=0.019).

CONCLUSIONS

A set of variables was identified that could be used to help select a revascularization procedure and to evaluate risk of long-term mortality in the population of patients considering revascularization.

Management and outcome of acute myocardial infarction in older patients in the thrombolytic era

OBJECTIVE

Acute myocardial infarction (AMI) is an important cause of mortality and morbidity in older patients. The aim of this study was to determine the proportion of unselected admissions with AMI that is older than 75 years and to examine management and outcomes in this group.

DESIGN

An historical cohort study of consecutive unselected admissions with AMI identified using the Hospital In Patient Enquiry (HIPE) database and validated according to MONICA criteria for definite or probable AMI.

SETTING

An acute cardiac unit in a university teaching hospital/cardiac tertiary referral center.

RESULTS

Of 1059 patients, 606 (57%) were older than 65 years and 309 (29.2%) were older than 75 years. Mean age in this group was 80.5 years. Hospital mortality was almost twice as high as in patients younger than 75 years (28% vs 15%, P < .001), and age was an independent predictor of short- and long-term mortality following AMI. Women constituted a significantly higher proportion of older patients. Family history of AMI and cigarette smoking were less prevalent in older patients. Mean cholesterol was lower and comorbidities were higher. Other baseline characteristics, including previous AMI, did not differ. However older patients were less likely to receive thrombolysis (13% vs 36%, P < .001), aspirin (76% vs 86%, P < .01), or beta-blockers (25% vs 51%, P < .001) and were less likely to undergo cardiac catheterization or revascularization. Only 53% were admitted to coronary care.

CONCLUSION

Patients more than age 75 comprise almost one-third of patients with AMI and have a poor prognosis. Although age is an independent predictor of mortality following AMI, suboptimal management may contribute to the high mortality in these patients.

Coronary heart disease. Stable and unstable syndromes

CHD in the elderly population will continue to be a source of major concern because of the increasing costs entailed and uncertainties about how the widespread array of diagnostic and therapeutic interventions, often expensive and sometimes hazardous, should be applied. Financial, political, and health policy decisions will continue to occupy much attention, but it is likely that philosophic considerations about aging and death, both from the individual and the societal perspective, will be of paramount importance of deciding how the substantial resources available to the elderly will be used. Randomized, controlled trials are unlikely to play a major role in resolution of management dilemmas in the elderly because of the extraordinary heterogeneity in this population. Registries (databases) involving carefully prospectively collected key variables are likely to be a more effective approach. Critical characterization of complications of procedures, adverse drug reactions, and collection of follow-up data on functional status are among the critical questions, and these can be answered by registry studies. Algorithms and clinical rules developed in younger cohorts are not directly transferable to the elderly cardiovascular patients, further emphasizing the need for prospectively collected, syndrome-specific data. Treatments convincingly demonstrated to reduce mortality in absolute terms more in the elderly than in the young are underused. The heterogeneity of aging emphasizes the wide variability in patients' ability to withstand the stress of procedures and complications of disease and makes clear the need to consider physiologic reserve and biologic age rather than chronology. With better characterization of biologic age and physiologic reserve, more precise estimates of outcomes of therapies and interventions can be made, and patients can be given better information and with their families have more realistic expectations. Better-informed decisions will result. Biologic age will be multifactorial, involving cognitive, emotional, physical, and nutritional attributes as well as specific organ function (lung, kidney, liver) because no single feature can characterize the total elderly patient. The concept of competing risks among the cardiovascular disease being treated, comorbidity, risks of study, and life expectancy will evolve because even the most successful therapy will have limited effect on longevity in the very old. Although important research at the cellular and molecular level will characterize and provide better understanding of the aging process, it is not likely that this basic information will be immediately useful in the management of the large number of elderly patients with major cardiovascular disease. Preventive measures, including physical exercise, mental stimulation, avoidance of depression, good nutrition, and abstinence from tobacco use, are useful approaches to postpone or ameliorate the consequences of aging and allow patients to tolerate cardiovascular diseases better when they become manifest.

Coenzyme Q10 improves the tolerance of the senescent myocardium to aerobic and ischemic stress: studies in rats and in human atrial tissue

The inferior recovery of cardiac function after interventional cardiac procedures in elderly patients compared to younger patients suggests that the aged myocardium is more sensitive to stress. We report two studies that demonstrate an age-related deficit in myocardial performance after aerobic and ischemic stress and the capacity of CoQ10 treatment to correct age-specific diminished recovery of function. In Study 1 the functional recovery of young (4 mo) and senescent (35 mo) isolated working rat hearts after aerobic stress produced by rapid electrical pacing was examined. After pacing, the senescent hearts, compared to young, showed reduced recovery of pre-stress work performance. CoQ10 pretreatment (daily intraperitoneal injections of 4 mg/kg CoQ10 for 6 weeks) in senescent hearts improved their recovery to match that of young hearts. Study 2 tested whether the capacity of human atrial trabeculae (obtained during surgery) to recover contractile function, following ischemic stress in vitro (60 min), is decreased with age and whether this decrease can be reversed by CoQ10. Trabeculae from older individuals (> or = 70 yr) showed reduced recovery of developed force after simulated ischemia compared to younger counterparts (< 70 yr). Notably, this age-associated effect was prevented in trabeculae pretreated in vitro (30 min at 24 degrees C) with CoQ10 (400 MicroM). We measured significantly lower CoQ10 content in trabeculae from > or = 70 yr patients. In vitro pretreatment raised trabecular CoQ10 content to similar levels in all groups. We conclude that, compared to younger counterparts, the senescent myocardium of rats and humans has a reduced capacity to tolerate ischemic or aerobic stress and recover pre-stress contractile performance, however, this reduction is attenuated by CoQ10 pretreatment.

Myringosclerosis develops within 9h of myringotomy

The aim of the present experimental study was to elucidate the temporal development of myringosclerosis. Twenty-four Sprague-Dawley rats were myringotomized bilaterally. At 3, 6, 9, 12, 18, 24, 30, 36, 48, 60, 72 and 84 h after the myringotomy, 2 animals at each time were examined otomicroscopically and thereafter sacrificed. The pars flaccida and pars tensa were excised and prepared for light- and electron-microscopic studies. Otomicroscopically, myringosclerosis was visible in the pars tensa 24 h after myringotomy, whereas no sclerotic lesions were noted in the pars flaccida. Histologically, sclerotic lesions were present in the pars tensa and pars flaccida 9 and 12 h, respectively, after myringotomy. The pars flaccida responds promptly with an inflammatory reaction characterized by abundant macrophages. Myringosclerosis develops promptly after myringotomy and its establishment is related to an inflammatory reaction.

Coenzyme Q10 treatment improves the tolerance of the senescent myocardium to pacing stress in the rat

OBJECTIVE

In elderly patients the results of cardiac interventions are inferior to those in the young. A possible contributing factor is an age-related reduction in cellular energy transduction during the intervention which may induce aerobic or ischemic stress. To investigate whether coenzyme Q10 (CoQ10) improves the response to aerobic stress, functional recoveries of senescent and young rat hearts after rapid pacing were compared with or without CoQ10.

METHODS

Young (4.8 +/- 0.1 months) and senescent (35.3 +/- 0.2 months) rats were given daily intraperitoneal injections of CoQ10 (4 mg/kg) or vehicle for 6 weeks. Their isolated hearts were rapidly paced at 510 beats per minute for 120 min to induce aerobic stress without ischemia.

RESULTS

In senescent hearts pre-pacing cardiac work was 74% and oxygen consumption (MVO2) 66% of that in young hearts. CoQ10 treatment abolished these differences. After pacing, the untreated senescent hearts, compared to young, showed reduced recovery of pre-pacing work, (16.8 +/- 4.3 vs. 44.5 +/- 7.4%; P < 0.01). CoQ10 treatment in senescent hearts improved recovery of work, (48.1 +/- 4.1 vs. 16.8 +/- 4.3%; P < 0.0001) and MVO2 (82.1 +/- 2.8 vs. 61.3 +/- 4.0%; P < 0.01) in treated versus untreated hearts respectively. Post-pacing levels of these parameters in CoQ10 treated senescent hearts were as high as in young hearts.

CONCLUSIONS

(1) Senescent rat hearts have reduced baseline function and reduced tolerance to aerobic stress compared to young hearts. (2) Pre-treatment with CoQ10 improves baseline function of the senescent myocardium and its tolerance to aerobic stress.

Better outcome for women compared with men undergoing coronary revascularization: a report from the bypass angioplasty revascularization investigation (BARI)

BACKGROUND

Numerous studies have shown that women undergoing coronary revascularization procedures do so at a higher risk for an adverse outcome compared with men. However, the impact of advances in technology and improvements in techniques on in-hospital and long-term outcome after revascularization in women is unclear.

METHODS AND RESULTS

We evaluated 1829 patients with symptomatic multivessel coronary disease randomized to CABG or PTCA in the Bypass Angioplasty Revascularization Investigation (BARI), of whom 27% were women. As expected, women were older (64.0 versus 60.5 years), with more congestive heart failure (14% versus 7%), hypertension (68% versus 42%), treated diabetes mellitus (31% versus 15%), and unstable angina (67% versus 61%) than men but had similar preservation of left ventricular function and extent of multivessel disease. Women assigned to surgery received the same number of total grafts but fewer internal mammary artery grafts (72% versus 85%, P<0. 01), and those assigned to angioplasty had more intended lesions (76% versus 71%, P<0.01) successfully dilated than men. At an average of 5.4 years' follow-up, crude mortality rates were similar in women (12.8%) and men (12.0%). The Cox regression model adjusting for baseline differences revealed that women had a significantly lower risk of death (relative risk, 0.60; 95% CI, 0.43 to 0.84; P=0. 003) but not a significantly lower risk of death plus myocardial infarction (relative risk, 0.84; 95% CI, 0.66 to 1.07; P=0.16) than men.

CONCLUSIONS

Although the unadjusted mortality rate suggests that women and men undergoing CABG and PTCA have a similar 5-year mortality, women have higher risk profiles; consequently, contrary to previous reports, female sex is an independent predictor of improved 5-year survival after we control for multiple risk factors.

Outcomes in patients with acute non-Q-wave myocardial infarction randomly assigned to an invasive as compared with a conservative management strategy. Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) Trial Investigators

BACKGROUND

Non-Q-wave myocardial infarction is usually managed according to an "invasive" strategy (i.e., one of routine coronary angiography followed by myocardial revascularization).

METHODS

We randomly assigned 920 patients to either "invasive" management (462 patients) or "conservative" management, defined as medical therapy and noninvasive testing, with subsequent invasive management if indicated by the development of spontaneous or inducible ischemia (458 patients), within 72 hours of the onset of a non-Q-wave infarction. Death or nonfatal infarction made up the combined primary end point.

RESULTS

During an average follow-up of 23 months, 152 events (80 deaths and 72 nonfatal infarctions) occurred in 138 patients who had been randomly assigned to the invasive strategy, and 139 events (59 deaths and 80 nonfatal infarctions) in 123 patients assigned to the conservative strategy (P=0.35). Patients assigned to the invasive strategy had worse clinical outcomes during the first year of follow-up. The number of patients with one of the components of the primary end point (death or nonfatal myocardial infarction) and the number who died were significantly higher in the invasive-strategy group at hospital discharge (36 vs. 15 patients, P=0.004, for the primary end point; 21 vs. 6, P=0.007, for death), at one month (48 vs. 26, P=0.012; 23 vs. 9, P=0.021), and at one year (111 vs. 85, P=0.05; 58 vs. 36, P= 0.025). Overall mortality during follow-up did not differ significantly between patients assigned to the conservative-strategy group and those assigned to the invasive-strategy group (hazard ratio, 0.72; 95 percent confidence interval, 0.51 to 1.01).

CONCLUSIONS

Most patients with non-Q-wave myocardial infarction do not benefit from routine, early invasive management consisting of coronary angiography and revascularization. A conservative, ischemia-guided initial approach is both safe and effective.

Management strategies for a better outcome in unstable coronary artery disease

Unstable coronary artery disease is a term encompassing both unstable angina and non-Q-wave (non-ST-segment elevation) myocardial infarction. Patients with these conditions are at risk of early progression to acute myocardial infarction and death. Thus, management of these conditions must aim to reduce long-term mortality and morbidity. Risk stratification is crucial for the identification of patients whose risk of early progression is high; they may require coronary angiography and (if suitable) either percutaneous transluminal coronary angioplasty or coronary artery bypass surgery. No single variable can accurately predict risk, but considerable data are emerging to show that biochemical markers of myocardial injury, such as troponin-T and troponin-I, are valuable in combination with electrocardiographic findings and clinical features. Routine early invasive procedures (coronary angiography with or without revascularization) have not yet been shown to have any significant advantage over conservative regimens for the majority of patients. Antiplatelet, anticoagulant, and anti-ischemic agents remain the mainstay of treatment in the acute phase. New agents, such as glycoprotein IIb/IIIa receptor inhibitors and low-molecular-weight heparins, as well as antithrombins and Factor Xa inhibitors add to the treatments currently available. Thrombolytic agents are contraindicated in the absence of ST-segment elevation. After clinical stabilization, ongoing assessment should include exercise testing for all patients who are able; other imaging techniques should be used for patients unable to exercise. A profile indicating a high risk of future events is an indication for elective angiography and consideration for revascularization.

Relationship between diabetes mellitus and long-term survival after coronary bypass and angioplasty

BACKGROUND

Recent subgroup analyses of randomized trials have suggested that percutaneous intervention in diabetic patients with multivessel disease results in higher mortality than coronary artery bypass graft surgery (CABG). We studied the relationship between diabetes and survival after revascularization in a large prospective cohort of patients with multivessel coronary artery disease.

METHODS AND RESULTS

By analyzing data for 3220 patients (24% diabetic) with symptomatic two- or three-vessel coronary disease who were undergoing percutaneous transluminal coronary angioplasty (PTCA) or CABG at Duke University Medical Center between 1984 and 1990, we found that at 5 years, unadjusted survival in the group of patients undergoing CABG was 74% in diabetics and 86% in nondiabetics. Similarly, 5-year survival among PTCA patients was 76% in diabetics and 88% in patients without diabetes. After adjustment for baseline characteristics, diabetic patients receiving either PTCA or CABG had significantly poorer survival than nondiabetics (chi2=43.56, P<.0001). Unlike previous studies, however, there was no significant differential effect of diabetes on outcome between patients treated with PTCA and those treated with CABG (chi2=0.01, P=.91).

CONCLUSIONS

Although diabetes was associated with a worse long-term outcome after both PTCA and CABG in patients with multivessel coronary artery disease, the effect of diabetes on prognosis was similar in both treatment groups. Thus, our findings support the concept that the choice of initial revascularization strategy should not be based exclusively on a history of diabetes but rather should rely on other factors, such as angiographic suitability and clinical status.

Influence of diabetes on 5-year mortality and morbidity in a randomized trial comparing CABG and PTCA in patients with multivessel disease: the Bypass Angioplasty Revascularization Investigation (BARI)

BACKGROUND

Patients with diabetes mellitus have increased morbidity and mortality after coronary revascularization. The Bypass Angioplasty Revascularization Investigation (BARI), a trial of percutaneous transluminal coronary angioplasty (PTCA) versus coronary artery bypass graft surgery (CABG) in patients with multivessel disease, reported a 5-year survival advantage of CABG over PTCA in patients with treated diabetes mellitus (TDM). This report examines these findings in more detail.

METHODS AND RESULTS

Eighteen clinical centers randomly assigned 1829 patients with multivessel coronary disease to undergo initial CABG or PTCA. Patients were followed an average of 5.4 years. TDM was defined as a history of diabetes with use of oral hypoglycemic agents or insulin at study entry. Nineteen percent of the randomized population (353 patients) met these criteria. TDM patients had more unfavorable baseline characteristics than other patients, but among TDM patients, these characteristics were similar between the CABG and PTCA groups. Better average 5.4-year survival with CABG was due to reduced cardiac mortality (5.8% versus 20.6%, P=.0003), which was confined to those receiving at least one internal mammary artery graft.

CONCLUSIONS

Patients with TDM assigned to an initial strategy of CABG have a striking reduction in cardiac mortality compared with PTCA. Long-term internal mammary artery graft patency may contribute to this improved outcome by reducing the fatality of follow-up myocardial infarction.

[Clinical prediction of the early prognosis in acute myocardial infarct]

Several clinical factors can influence the pathophysiology, clinical course and prognosis of acute myocardial by different means. Some of them may be easily detected through the history, physical examination or ECG in an early phase. The knowledge of these factors may help the therapeutic decision making of patients with myocardial infarction. The influence for the main clinical factors (age, sex, risk factors, cardiologic antecedents and evolutive findings) on the short-term prognosis of acute myocardial infarction is reviewed. An analysis of the likely mechanisms of the influence of these factors on infarct prognosis is also performed.

Prognostic significance of angina pectoris > or = 30 days before acute myocardial infarction in patients > or = 75 years of age

We compared the prognostic significance of prior angina pectoris in 151 patients > or = 75 years of age admitted for acute myocardial infarction. There was a similar in-hospital course, but the long-term outcome was poorer in patients with prior angina.

Acute myocardial infarction: clinical characteristics, management and outcome in a metropolitan Veterans Affairs Medical Center teaching hospital

OBJECTIVES

The influence of race and age on thrombolytic therapy, invasive cardiac procedures and outcomes was assessed in a Veterans Affairs teaching hospital. The influence of Q wave evolution on the use of invasive cardiac procedures and outcome was also assessed.

BACKGROUND

It is not well known how early revascularization procedures for acute myocardial infarction are delivered or influence survival in a Veterans Affairs patient population.

METHODS

From October 1993 to October 1995, all patients with myocardial infarction were identified by elevated creatine kinase, MB fraction (CK-MB) and one of the following: chest pain or shortness of breath during the preceding 24 h or electrocardiographic (ECG) abnormalities.

RESULTS

Racial groups were similar in terms of age, time to ECG, peak CK and length of hospital stay. Mortality increased with age (odds ratio [OR] 1.93, 95% confidence interval [CI] 1.33 to 2.81). A trend toward increased mortality occurred for race other than Caucasian. Patients meeting ECG criteria were given thrombolytic agents in 49% of cases, but age, comorbidity count and Hispanic race decreased the probability of thrombolytic use. Cardiac catheterization was performed more often after thrombolytic agents (OR 1.85, 95% CI 0.97 to 3.54), but less often in African-Americans (OR 0.59, 95% CI 0.35 to 1.02), older patients (OR 0.39, 95% CI 0.24 to 0.64) or patients with heart failure (OR 0.30, 95% CI 0.17 to 0.52). Patients evolving non-Q wave infarctions were older and had increased comorbidity counts and trends toward increased mortality. Angioplasty was chosen less for patients > or = 65 years old (p = 0.02); angioplasty and coronary artery bypass graft surgery were performed less in patients > or = 70 years old (p = 0.02). Patients treated invasively had lower mortality rates than those treated medically (p < 0.02).

CONCLUSIONS

The use of thrombolytic agents and invasive treatment plans declined with age, and mortality increased with age. Trends toward increased mortality occurred with non-Q wave infarctions and race other than Caucasian.

Hirudin in acute myocardial infarction. Thrombolysis and Thrombin Inhibition in Myocardial Infarction (TIMI) 9B trial

BACKGROUND

The TIMI 9 trial evaluated whether the direct antithrombin hirudin is more effective than an indirect-acting antithrombin, heparin, as adjunctive therapy for thrombolysis in myocardial infarction.

METHODS AND RESULTS

Patients (n = 3002) with acute myocardial infarction were treated with aspirin and either accelerated-dose tissue plasminogen activator (TPA) or streptokinase. They were randomized within 12 hours of symptoms to receive either intravenous heparin (5000 U bolus followed by infusion of 1000 U/h) or hirudin (0.1 mg/kg bolus followed by infusion of 0.1 mg/ kg per hour). The infusions of both antithrombins were titrated to a target activated partial thromboplastin time (aPTT) of 55 to 85 seconds and were administered for 96 hours. Patients randomized to hirudin were significantly more likely to have an aPTT measurement in the target range (P < .0001). The primary end point (death, recurrent nonfatal myocardial infarction, or development of severe congestive heart failure or cardiogenic shock by 30 days) occurred in 11.9% of the 1491 patients in the heparin group and 12.9% of the 1511 patients in the hirudin group (P = NS). Subgroup analyses did not reveal any profile of patients who benefited more from one of the antithrombins. The rate of major hemorrhage was similar in the heparin (5.3%) and hirudin (4.6%) groups; intracranial hemorrhage occurred in 0.9% of the heparin and 0.4% of the hirudin patients.

CONCLUSIONS

Heparin and hirudin have an equal effect as adjunctive therapy to TPA and streptokinase in preventing unsatisfactory outcome in patients with acute myocardial infarction. Similar rates of major bleeding were observed for patients in the heparin and hirudin groups.