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

Sex differences in relative survival and prognostic factors in patients with a first acute myocardial infarction in Guipuzcoa, Spain

INTRODUCTION AND OBJECTIVES

To determine 28-day and 5-year survival rates in patients who have experienced a first acute myocardial infarction and to identify prognostic factors for survival.

METHODS

This study involved 1,677 patients with a first acute myocardial infarction who were treated at a hospital in Guipuzcoa, Spain between 1997 and 2000.

RESULTS

Women were approximately 10 years older than men, presented more often with diabetes and hypertension, were in a less favorable clinical condition, and consumed fewer medical resources, but were less likely to smoke. Survival rates at 28 days and 5 years were higher in men over 60 years of age. In the period from 29 days to 5 years, the relative survival rate was higher in men from all age groups. Factors associated with short- and long-term survival varied between the sexes. Disease severity in the acute phase and, later on, age were associated with survival in both men and women, whereas the effect of other variables differed between the sexes.

CONCLUSIONS

Myocardial infarction is a condition associated with high mortality in the acute phase. There is an interaction between sex and age that affects survival after an acute myocardial infarction. A number of factors are associated with poor short- and long-term prognoses in both sexes.

[Descriptive study of vascular complications secondary to antithrombotic agents and percutaneous cardiovascular interventionism in a coronary unit]

Administration of drugs in the patients diagnosed of acute coronary syndrome and treated with percutaneous transluminal coronary angioplasty (PTCA) has noticeably reduced morbidity-mortality and appearance of new ischemic events. However, these drug agents may cause bleeding problems secondary to therapeutic intervention. The objectives of this research are: to know the incidence of vascular complications developed in patients treated with antithrombotic drugs and percutaneous cardiovascular interventionism and describe variables that may be related with their appearance. A retrospective descriptive study was done on the registries of the clinical histories of 153 patients subjected to primary angioplasty and rescue treatment during the period ranging from October 1, 2001 to October 31, 2002 in the Hospital Universitario Marques de Valdecilla. Mean age of the patients was 63 years, 75% diagnosed of acute myocardial infarction and 71% subjected to primary angioplasty. Drugs used were anticoagulants, antiaggregants and fibrinolytics. Furthermore compression methods and arterial sheath duration time were analyzed. Complications appeared in 39% of the patients, the most frequent complication being the hematoma in 28%. It is concluded that when antithrombotic drugs are combined with PTCA, vascular complications appear in one third of the patients studied, the appearance of hematomas standing out in the first place and in the second place, femoral bleeding. The main study variables also contributing to their appearance are the permanence of the sheath and its removal.

[The characteristics, management and prognosis of the acute myocardial infarct patient in the Valencian Community in 1995: the results of the PRIMVAC Registry (The Registry Project of Acute Myocardial Infarct in Valencia, Alicante and Castellón). As representatives of the PRIMVAC investigators]

BACKGROUND AND OBJECTIVES

Regional registers of patients with acute myocardial infarction are scarce in Spain. The PRIMVAC register (Proyecto de Registro de Infarto agudo de Miocardio de Valencia, Alicante y Castellón) was initiated to obtain updated information on the management of these patients in the Valencia Autonomous Community. Data of the first twelve months of the register are presented.

METHODS

The 17 participating hospitals cover 2,833,938 inhabitants. Demographic, clinical, procedural and outcome data as well as predictive variables of mortality were analysed in the patients with acute myocardial infarction during their stay in the coronary care units from 1 December 1994 to 30 November 1995.

RESULTS

During 12 months, 2,377 patients were included. Mean age was 65.3 years (SD 11.9) and 23.2% were female. Left ventricular failure was present in 39.8%. Thrombolytic therapy was applied in 42.1% with a median time delay of 195 min from chest pain onset. This time was longer in the women (250 min) and in the elderly (210 min). The in-coronary-care-unit-mortality rate was 13.9%. Age, female gender, diabetes, previous myocardial infarction, Q wave and right ventricular infarction independently predicted increased early mortality.

CONCLUSION

Present data show the feasibility of an acute myocardial infarction register in the Valencia Autonomous Community. Although an acceptable level of thrombolysis has been reached, the mortality rate is still high. The long delay in initiating thrombolysis, particularly in female and elderly patients is remarkable.

[Therapy with glucose-insulin-potassium reduces the complications in the acute phase of myocardial infarct. Arguments against]

Glucose-insulin-potassium therapy has shown its efficacy in diminishing the myocardial damage under ischemia-reperfusion conditions in experimental models. This effect appears to be mainly due to the increase of anaerobic glycolysis in ischemic cells with a consequent reduction in the use of fatty acids. On the other hand, clinical studies in the acute phase of myocardial infarction are out-dated and almost non-existent in the thrombolytic era. The absence of current consistent data makes it difficult to draw conclusions concerning the real utility of this therapy in the clinical practice.

[Is the exercise test performed after myocardial infarct really useful in improving prognosis? Arguments in favor]

The evaluation of risk after myocardial infarction accomplishes two objectives: a) selecting patients with high-risk for coronary angiography and revascularization, and b) identifying low-risk patients to avoid unnecessary laboratory investigation and revascularization procedures. Currently, patients eligible for exercise test are those with no evidence of heart failure or angina, and with a preserved left ventricular function. Overall prognosis for such patients, especially if they were thrombolyzed, is very good. In this setting, in contrast to that pointed out in previous reports, the positive predictive value of exercise electrocardiography is very low (i.e., a patient with S-T depression has a probability of cardiac death in the ensuing year of only 4% vs 2% if the test is negative). This suggests that a routine postinfarction exercise test is inefficient from a prognostic point of view. However, a recent study has shown that thrombolyzed patients with a positive response to the exercise test, have a significantly lower rate of reinfarction and unstable angina when they undergo myocardial revascularization. Mortality rate, as it was low in the study population, was unchanged by the use of revascularization procedures. We conclude that, in spite of the limitations pointed out, there are at least two reasons to continue performing exercise tests in all uncomplicated infarctions: a) a negative test, due to its high negative predictive value for adverse events, reassures the patient and his family and prompts an early discharge, and b) some patients, despite an uncomplicated in-hospital evolution, have a "strong" positive response that suggests multivessel disease and a possible benefit from myocardial revascularization.