Short and long term prognosis of acute myocardial infarction since introduction of thrombolysis

Short and Long-Term Survival Rates Following Myocardial Infarction and Its Predictive Factors: A Study Using National Registry Data

Background: Coronary artery disease is the most common cause of death worldwide as well as in Iran. The present study was designed to predict short and long-term survival rates after the first episode of myocardial infarction (MI).

Methods: The current research is a retrospective cohort study. The data were collected from the Myocardial Infarction Registry of Iran in a 12-month period leading to March 20, 2014. The variables analyzed included smoking status, past medical history of chronic heart disease, hypertension, diabetes, hyperlipidemia, signs and symptoms during an attack, post-MI complications during hospitalization, the occurrence of arrhythmias, the location of MI, and the place of residence. Survival rates and predictive factors were estimated by the Kaplan–Meier method, the log-rank test, and the Cox model.

Results: Totally, 21 181 patients with the first MI were studied. There were 15 328 men (72.4%), and the mean age of the study population was 62.10±13.42 years. During a 1-year period following MI, 2479 patients (11.7%) died. Overall, the survival rates at 28 days, 6 months, and 1 year were estimated to be 0.95 (95% CI: 0.95 to 0.96), 0.90 (95% CI: 0.90 to 0.91), and 0.88 (95% CI: 0.88 to 0.89). After the confounding factors were controlled, history of chronic heart disease (p<0.001), hypertension (p<0.001), and diabetes (p<0.001) had a significant relationship with an increased risk of death and history of hyperlipidemia (p<0.001) and inferior wall MI (p<0.001) had a significant relationship with a decreased risk of death.

Conclusion: The results of this study provide evidence for health policy-makers and physicians on the link between MI and its predictive factors.

The Strategy of Management Patients with non-ST Elevation Acute Coronary Syndrome

The review covers issues of epidemiology, diagnostics, management strategy, and treatment outcomes in patients with non-ST elevation acute coronary syndrome. Numerous factors affecting the choice of an invasive strategy are analyzed as well as its correspondence to existing recommendations of patient’s management. The stratification of risk of development of adverse coronary events, which is a part of the formation of a treatment strategy, is discussed.

Platelet to Lymphocyte Ratio on Admission and Prognosis in Patients with Acute Cardiogenic Pulmonary Edema

BACKGROUND

Acute heart failure is a heterogenous syndrome defined by a number of factors, such as its physiopathology, clinical picture, time of onset, and relation to acute coronary syndrome. Acute cardiogenic pulmonary edema (ACPE) constitutes approximately 10-20% of acute heart failure syndromes, and it is the most dramatic symptom of left heart failure. Platelet to lymphocyte ratio (PLR) is a relatively novel inflammatory marker that can be utilized for prognosis in various disease processes.

OBJECTIVE

In this study, we investigated the value of the PLR for the prediction of mortality in patients with ACPE.

METHODS

A total of 115 patients hospitalized with a diagnosis of ACPE were included in this study. The patients were divided into tertile groups according to their PLR values: high (PLR > 194.97), medium (98.3-194.97), and low tertile (PLR < 98.3).

RESULTS

We compared the PLR groups for in-hospital mortality and total mortality after discharge. Multivariate Cox regression analysis showed that PLR was independently associated with total mortality (hazard ratio 5.657; 95% confidence interval 2.467-12.969; p < 0.001). Survival analysis using the Kaplan-Meier curve showed that the high-PLR group had a significantly higher mortality rate than the other groups.

CONCLUSIONS

We showed an association between high PLR and mortality in patients with ACPE. PLR, together with other inflammatory markers and clinical findings, may be used as an adjunctive parameter for the stratification of mortality risk, hospitalization, or discharge criteria scoring.

Predictive factors of short-term survival from acute myocardial infarction in early and late patients in Isfahan and Najafabad, Iran

BACKGROUND

Cardiovascular disease (CVD) is the primary cause of mortality in the world and Iran. The aim of this study was to determine the prognostic factors of short-term survival from acute myocardial infarction (AMI) in early and late patients in the Najafabad and Isfahan County, Iran.

METHODS

This hospital-based cohort study was conducted using the hospital registry of 1999-2009 in Iran. All patients (n = 14426) with an AMI referred to hospitals of Isfahan and Najafabad were investigated. To determine prognostic factors of short-term (28-days) survival in early and late patients, unadjusted and adjusted hazard ratio (HR) was calculated using univariate and multivariate Cox regression.

RESULTS

The short-term (28-day) survival rate of early and late patients was 96.64% and 89.42% (P < 0.001), respectively. In 80% of early and 79.3% of late patients, mortality occurred during the first 7 days of disease occurrence. HR of death was higher in women in the two groups; it was 1.97 in early patients was (CI95%: 1.32-2.92) and 1.35 in late patients (CI95%: 1.19-1.53) compared to men. HR of death had a rising trend with the increasing of age in the two groups.

CONCLUSION

Short-term survival rate was higher in early patients than in late patients. In addition, case fatality rate (CFR) of AMI in women was higher than in men. In both groups, sex, age, an atomic location of myocardial infarction based on the International Classification of Disease, Revision 10 (ICD10), cardiac enzymes, and clinical symptoms were significant predictors of survival in early and late patients following AMI.

Prognostic factors of 28 days survival rate in patients with a first acute myocardial infarction based on gender in Isfahan, Iran (2000-2009)

BACKGROUND

Determinant prognostic factors of 28 days survival rate in patients with a first acute myocardial infarction (AMI) based on gender in teen year's period in Isfahan, Iran, was the aim of this study.

METHODS

This study is a prospective hospital-based study that consisted, all patients with AMI admitted to all hospitals (private and universal hospitals) in Isfahan and Najafabad (Iran) during 2000-2009. To determinant the prognostic factors of 28 days survival rate in patients based on gender, analysis conducted separately for male and female. In analysis, we use of t-test, log Rank tests, Kaplan-Meier method, and univariate and multivariate Cox regression model.

RESULTS

Short-term (28 days) survival rate was 92.5% in male and 86.7% in female (P < 0.001). The adjusted hazard ratio (HR) of death for age group 80 years and older was 12.7 [95% confidence interval (CI): 5.14-31.3] in male and 8.78 (95% CI: 1.2-63.1) in female. HR for acute transmural MI of the unspecified site in male was 8.9 (95% CI: 4.68-16.97) and in female 9.33 (95% CI: 4.42-19.7). HR for receive of streptokinase in male was 1.11 (95% CI: 0.94-1.31) and in female was 0.69 (95% CI: 0.56-0.84).

CONCLUSION

Short-term survival rate in male was a higher than female. In male age, anatomic location of MI and hospital status and in female streptokinase use and anatomic location of MI was the most important prognostic factors of survival in-patient with AMI in Isfahan.

Elevated admission microalbuminuria predicts poor myocardial blood flow and 6-month mortality in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

BACKGROUND

Microalbuminuria (MA) is considered a major risk factor predisposing to cardiovascular morbidity and mortality. Outcomes after percutaneous coronary intervention (PCI) for patients with acute myocardial infarction (AMI) complicated by MA have been well described. However, data regarding admission MA and coronary and myocardial flow are scant. The aims of this study were to evaluate the effects of admission MA on coronary blood flow and prognosis in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary PCI.

HYPOTHESIS

Did elevated admission microalbuminuria predict poor myocardial blood flow and 6-month mortality in ST-segment elevation myocardial infarction patients undergoing primary percutaneous coronary intervention?

METHODS

A total of 247 patients undergoing primary PCI for STEMI within 12 hours after symptom onset were studied. Patients were divided into 2 groups according to admission urinary albumin extraction rate (UAER): (1) an MA group (UAER 20-200 µg/min), and (2) a normoalbuminuria (NA) group (UAER < 20 µg/min).

RESULTS

Microalbuminuria was observed in 108 patients. Univariate analyses showed statistical differences between the NA and MA groups in serum creatine level, plasma glucose level, and peak creatine kinase level on presentation. Thrombolysis In Myocardial Infarction (TIMI) flow grades (TFGs) 0-2 in the MA group were more frequent (9.4% vs 21.2%, P < 0.05) than in the NA group, and corrected TIMI frame count was higher (23.9 ± 18.5 vs 29.8 ± 23.5, P < 0.05). Admission MA was an independent predictor of poor myocardial perfusion (adjusted relative risk: 3.14, 95% confidence interval: 0.99-6.78) and a higher rate of 6-month mortality in STEMI patients undergoing primary PCI (adjusted relative risk: 1.58, 95% confidence interval: 0.74-3.39).

CONCLUSIONS

Admission MA levels are associated with impaired myocardial flow and poor prognosis in STEMI patients undergoing primary PCI.

Heart failure prognostic model

Heart failure (HF) is a common, costly, disabling and deadly syndrome. Heart failure is a progressive disease characterized by high prevalence in society, significantly reducing physical and mental health, frequent hospitalization and high mortality (50% of the patients survive up to 4 years after the diagnosis, the annual mortality varying from 5% to 75%). The purpose of this study is to develop a prognostic model with easily obtainable variables for patients with heart failure. METHODS AND RESULTS. Our lot included 101 non-consecutive hospitalized patients with heart failure diagnosis. It included 49.5% women having the average age of 71.23 years (starting from 40 up to 91 years old) and the roughly estimated period for monitoring was 35.1 months (5-65 months). Survival data were available for all patients and the median survival duration was of 44.0 months. A large number of variables (demographic, etiologic, co morbidity, clinical, echocardiograph, ECG, laboratory and medication) were evaluated. We performed a complex statistical analysis, studying: survival curve, cumulative hazard, hazard function, lifetime distribution and density function, meaning residual life time, Ln S (t) vs. t and Ln(H) t vs. Ln (t). The Cox multiple regression model was used in order to determine the major factors that allow the forecasting survival and their regression coefficients: age (0.0369), systolic blood pressure (-0.0219), potassium (0.0570), sex (-0.3124) and the acute myocardial infarction (0.2662). DISCUSSION. Our model easily incorporates obtainable variables that may be available in any hospital, accurately predicting survival of the heart failure patients and enables risk stratification in a few hours after the patients' presentation. Our model is derived from a sample of patients hospitalized in an emergency department of cardiology, some with major life-altering co morbidities. The benefit of being aware of the prognosis of these patients with high risk is extremely beneficial. The use of this model may ease the estimation of the vital prognosis, to improve the compliance and increase in the use of life-saving medical or surgical therapy (pacemakers, implantable defibrillators or transplantation).

Heart failure--concepts and significance. Birth of a prognostic model

Heart failure (HF) is a syndrome characterized by high prevalence in society, frequent hospitalization, reduced quality of life and high mortality (overall, 50% of patients are dead at an interval of 4 years, annual mortality varying from 5% to 75%). Outcomes in heart failure are highly variable, prognosis of individual patients differs considerably and trial data, though valuable, does not often give an adequate direction. Taking into account the high prevalence of heart failure in society and its complexity physicians need a model to predict the risk of death, to estimate the survival of heart failure patients. A key element of interest in this area is the survival function, usually noted by S and defined as S(t) = exp(-H0(t)e(a)Tx) = e(-H)0(t)e(a)Tx.

Effects of dehydroepiandrosterone (DHEA) on cardiovascular risk factors in older women with frailty characteristics

OBJECTIVE

this analysis was to investigate the effects of dehydroepiandrosterone (DHEA) on cardiovascular risk factors in older women with frailty characteristics.

DESIGN, SETTING AND PARTICIPANTS

the study was a double-blind, randomised, placebo-controlled trial of 99 women (mean 76.6 +/- 6.0 year) with the low DHEA-S level and frailty.

INTERVENTION

participants received 50 mg/day DHEA or placebo for 6 months; all received calcium (1,000-1,200 mg/day diet) and supplement (combined) and cholecalciferol (1,000 IU/day). Women participated in 90-min twice weekly exercise regimens, either chair aerobics or yoga.

MAIN OUTCOME MEASURES

assessment of outcome variables included hormone levels (DHEA-S, oestradiol, oestrone, testosterone and sex hormone-binding globulin (SHBG)), lipid profiles (total cholesterol, high density lipoprotein (HDL) cholesterol, low density lipoprotein (LDL) cholesterol and triglycerides), body composition measured by dual energy absorptiometry, glucose levels and blood pressure (BP).

RESULTS

eighty-seven women (88%) completed 6 months of study; 88% were pre-frail demonstrating 1-2 frailty characteristics and 12% were frail with > or =3 characteristics. There were significant changes in all hormone levels including DHEA-S, oestradiol, oestrone and testosterone and a decline in SHBG levels in those taking DHEA supplements. In spite of changes in hormone levels, there were no significant changes in cardiovascular risk factors including lipid profiles, body or abdominal fat, fasting glucose or BP.

CONCLUSION

research to date has not shown consistent effects of DHEA on cardiovascular risk, and this study adds to the literature that short-term therapy with DHEA is safe for older women in relation to cardiovascular risk factors. This study is novel in that we recruited women with evidence of physical frailty.

Treatment with ramipril improves systolic function even in patients with mild systolic dysfunction and symptoms of heart failure after acute myocardial infarction

BACKGROUND

Clinical signs of heart failure such as pulmonary rales and dyspnea, ventricular dysfunction, and ventricular arrhythmia are independent predictors of a poor prognosis after acute myocardial infarction (AMI).

HYPOTHESIS

The study aimed to assess the effect of ramipril treatment on mildly depressed left ventricular (LV) systolic function, assessed by atrioventricular (AV) plane displacement in patients with congestive heart failure after AMI.

METHODS

The study was a substudy in the Acute Infarction Ramipril Efficacy Study, a double-blind, randomized, place-bo-controlled trial of ramipril versus placebo in patients with symptoms of heart failure after AMI. In all, 56 patients were included in the main study, 4 refused to participate in the substudy, and 4 were excluded for logistical reasons. Echocardiography was performed at entry and after 6 months. Patients who underwent coronary artery bypass grafting during the follow-up period were excluded.

RESULTS

At baseline, the patients had modest LV dysfunction, and mean AV plane displacement of 9.7 mm. During follow-up, AV plane displacement increased in ramipril-treated patients from 9.5 to 10.9 mm (p < 0.01). No statistically significant changes were seen in the placebo group.

CONCLUSIONS

Ramipril improves LV systolic function in patients with clinical signs of heart failure and only modest systolic dysfunction after AMI. Measurement of AV plane displacement is a simple and reproducible method for detection of small changes in systolic function and may be used instead of ejection fraction in patients with poor image quality.

Grades of recommendation for antithrombotic agents: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition)

This chapter describes the system used by the American College of Chest Physicians to grade recommendations for antithrombotic and thrombolytic therapy as part of the Antithrombotic and Thrombolytic Therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Clinicians need to know if a recommendation is strong or weak, and the methodologic quality of the evidence underlying that recommendation. We determine the strength of a recommendation by considering the balance between the desirable effects of an intervention and the undesirable effects (incremental harms, burdens, and for select recommendations, costs). If the desirable effects outweigh the undesirable effects, we recommend that clinicians offer an intervention to typical patients. The uncertainty associated with the balance between the desirable and undesirable effects will determine the strength of recommendations. If we are confident that benefits do or do not outweigh harms, burden, and costs, we make a strong recommendation in our formulation, Grade 1. If we are less certain of the magnitude of the benefits and risks, burden, and costs, and thus their relative impact, we make a weaker Grade 2 recommendation. For grading methodologic quality, randomized controlled trials (RCTs) begin as high-quality evidence (designated by "A"), but quality can decrease to moderate ("B"), or low ("C") as a result of poor design and conduct of RCTs, imprecision, inconsistency of results, indirectness, or a high likelihood for reporting bias. Observational studies begin as low quality of evidence (C) but can increase in quality on the basis of very large treatment effects. Strong (Grade 1) recommendations can be applied uniformly to most patients. Weak (Grade 2) suggestions require more judicious application, particularly considering patient values and preferences and, when resource limitations play an important role, issues of cost.

Noninvasive ventilation in acute cardiogenic pulmonary edema

BACKGROUND

Noninvasive ventilation (continuous positive airway pressure [CPAP] or noninvasive intermittent positive-pressure ventilation [NIPPV]) appears to be of benefit in the immediate treatment of patients with acute cardiogenic pulmonary edema and may reduce mortality. We conducted a study to determine whether noninvasive ventilation reduces mortality and whether there are important differences in outcome associated with the method of treatment (CPAP or NIPPV).

METHODS

In a multicenter, open, prospective, randomized, controlled trial, patients were assigned to standard oxygen therapy, CPAP (5 to 15 cm of water), or NIPPV (inspiratory pressure, 8 to 20 cm of water; expiratory pressure, 4 to 10 cm of water). The primary end point for the comparison between noninvasive ventilation and standard oxygen therapy was death within 7 days after the initiation of treatment, and the primary end point for the comparison between NIPPV and CPAP was death or intubation within 7 days.

RESULTS

A total of 1069 patients (mean [+/-SD] age, 77.7+/-9.7 years; female sex, 56.9%) were assigned to standard oxygen therapy (367 patients), CPAP (346 patients), or NIPPV (356 patients). There was no significant difference in 7-day mortality between patients receiving standard oxygen therapy (9.8%) and those undergoing noninvasive ventilation (9.5%, P=0.87). There was no significant difference in the combined end point of death or intubation within 7 days between the two groups of patients undergoing noninvasive ventilation (11.7% for CPAP and 11.1% for NIPPV, P=0.81). As compared with standard oxygen therapy, noninvasive ventilation was associated with greater mean improvements at 1 hour after the beginning of treatment in patient-reported dyspnea (treatment difference, 0.7 on a visual-analogue scale ranging from 1 to 10; 95% confidence interval [CI], 0.2 to 1.3; P=0.008), heart rate (treatment difference, 4 beats per minute; 95% CI, 1 to 6; P=0.004), acidosis (treatment difference, pH 0.03; 95% CI, 0.02 to 0.04; P<0.001), and hypercapnia (treatment difference, 0.7 kPa [5.2 mm Hg]; 95% CI, 0.4 to 0.9; P<0.001). There were no treatment-related adverse events.

CONCLUSIONS

In patients with acute cardiogenic pulmonary edema, noninvasive ventilation induces a more rapid improvement in respiratory distress and metabolic disturbance than does standard oxygen therapy but has no effect on short-term mortality. (Current Controlled Trials number, ISRCTN07448447.)

Cytokines and acute heart failure

In patients with chronic heart failure, ongoing myocardial injury partially results from activation of the inflammatory system, with production and release of proinflammatory cytokines, activation of the complement system, production of autoantibodies, overexpression of major histocompatibility complex molecules, and expression of adhesion molecules that may perpetuate the inflammatory state. Acute decompensated heart failure modifies the course of chronic heart failure and worsens outcomes via a combination of potential mechanisms, including neurohormonal activation, apoptosis, and the inflammatory cascade. Proinflammatory cytokines, including tumor necrosis factor-alpha and interleukin-6, play a pathogenetic role in chronic heart failure, and anti-inflammatory immune therapy is currently under investigation. In acute decompensation of chronic heart failure, the change in the inflammatory cytokine activation cascade is less clear. Larger investigational studies are needed to assess the exact roles of circulating and intracardiac cytokines in this particular patient population.

Potential demographic and baselines variables for risk stratification of high-risk post-myocardial infarction patients in the era of implantable cardioverter-defibrillator--a prognostic indicator

BACKGROUND

Risk stratification after myocardial infarction (MI) remains expensive and disappointing. We designed a prognostic indicator using demographic information to select patients at risk of dying after MI.

METHOD AND RESULTS

We combined individual patient data from the placebo arms of EMIAT, CAMIAT, TRACE and DIAMOND-MI with LVEF <or=40% or ventricular arrhythmias (i.e. >10 ventricular premature beats/hour or a run of ventricular tachycardia). Risk factors for mortality beginning at day 45 post-MI up to 2 years were examined using Cox regression analysis. Risk scores were derived from the equation of a Cox regression model containing only significant variables. The prognostic index was the sum of the individual contribution from the risk factors. 2707 patients were pooled (age: 66 (23-92) years, 78.8% M) with 480 deaths at 2-years (44% arrhythmic and 35.6% non-arrhythmic cardiac deaths). Variables predicting mortality were age, sex, previous MI or angina, hypertension, diabetes, systolic blood pressure, heart rate, NYHA functional class and non-Q wave infarct on electrocardiogram. Distinct survival curves were obtained for 3 risk groups based on the median and inter-quartile range for the prognostic index. In the high-risk group, up to 40% of patients died (all-cause mortality), 19.1% died of arrhythmic and 18.2% died of non-arrhythmic cardiac causes at 2-years.

CONCLUSION

In post-MI patients with LVEF <or=40% or frequent ventricular premature beats, the additional use of a simple prognostic indicator based on demographic information was able to provide clinically meaningful risk stratification on patients that were at high risk of dying and may be used to identify patients for prophylactic implantable cardioverter-defibrillator therapy.

Age, outcomes, and treatment effects of fibrinolytic and antithrombotic combinations: findings from Assessment of the Safety and Efficacy of a New Thrombolytic (ASSENT)-3 and ASSENT-3 PLUS

BACKGROUND

Elderly patients with acute myocardial infarction are at particularly high risk for death and bleeding complications. The efficacy and safety of antithrombotic strategies in these patients remain unclear.

METHODS

To provide more insight into the risk and benefit of antithrombotic strategies in the elderly, we examined patients from the ASSENT-3 and ASSENT-3 PLUS trials with STEMI who were treated with tenecteplase (TNK) and unfractionated heparin (UFH) or enoxaparin, or half-dose TNK with abciximab and reduced-dose UFH.

RESULTS

Older patients had a higher risk profile, and lower use of concomitant therapies and revascularization procedures. We found an interaction between age and treatment effect for the efficacy end point (P = .0007) and the efficacy plus safety end point (P < .0001). Younger patients (<65 years) had a lower risk of the composite efficacy plus safety end point with enoxaparin (relative risk [RR] 0.84, 95% CI 0.74-0.94) or abciximab (RR 0.79, 95% CI 0.69-0.90) compared with UFH. In patients >65 years of age, the benefit of enoxaparin appeared to be offset by an increased risk of bleeding complications. The risk of the efficacy plus safety end point tended to be higher in elderly patients receiving abciximab and half-dose TNK (RR 1.18, 95% CI 0.91-1.51 for 76-85 years of age and RR 1.48, 95% CI 0.88-2.49 for >85 years of age).

CONCLUSIONS

Although TNK with either enoxaparin or abciximab appeared to be more effective than with standard UHF in younger patients, these combinations tended to be less effective and even may be unsafe in the elderly. Development of new combination strategies and dosing schemes of fibrinolytics and antithrombotics with improved efficacy and safety in the elderly remains a high priority.

Prognostic impact of demographic factors and clinical features on the mode of death in high-risk patients after myocardial infarction--a combined analysis from multicenter trials

BACKGROUND

Contemporary information is lacking on the effect of demographic features and clinical features on the specific mode of mortality after myocardial infarction (MI) in the thrombolytic era.

HYPOTHESIS

The aims of this study were (1) to examine the risk and trend of a different mode of mortality (i.e., all-cause, arrhythmic, and nonarrhythmic cardiac mortality) in high-risk patients post MI with reduced left ventricular ejection fraction (LVEF) or ventricular arrhythmias; and (2) to assess the predictive value of demographic and clinical variables in the prediction of specific modes of death in high-risk patients post MI in the thrombolytic era.

METHODS

In all, 3,431 patients receiving placebo (2,700 men, median age 64 +/- 11 years) from the EMIAT, CAMIAT, SWORD, TRACE, and DIAMOND-MI studies, with LVEF < 40% or ventricular arrhythmia were pooled. Risk factors for mortality among patients surviving > or = 45 days after MI up to 2 years were examined using Cox regression. Short-term survival (from onset of MI to Day 44 after MI) was also examined for TRACE and DIAMOND-MI, in which patients were recruited within 2 weeks of MI.

RESULTS

After adjustment for treatment and study effects, age, previous MI/angina, increased heart rate, and higher New York Heart Association functional class increased the risk of all-cause, arrhythmic, and cardiac mortality. Male gender, history of hypertension, low baseline systolic blood pressure, and Q wave were predictive of all-cause and arrhythmic mortality, whereas diabetes was only predictive of all-cause mortality. Smoking habit and atrial fibrillation had no prognostic value. Similar parameters were also predictive of short-term mortality, but not identical.

CONCLUSIONS

Our study has shown that in high-risk patients post MI, who have been preselected using LVEF or frequent ventricular premature beats, demographic and clinical features are powerful predictors of mortality in the thrombolytic era. We propose that demographic and clinical factors should be considered when designing risk stratification or survival studies, or when identifying high-risk patients for prophylactic implantable cardiodefibrillator therapy.

Carvedilol in chronic heart failure: past, present and future

Large randomized clinical trials of bisoprolol, carvedilol and metoprolol have conclusively demonstrated the efficacy and confirmed safety of β-blockers in patients with chronic heart failure. Recently, the beneficial effects of carvedilol in patients with heart failure soon after an acute myocardial infarction have also been shown. Despite this, β-blockers remain under-prescribed in this condition. This is of particular importance as heart failure is common and increasing in prevalence. In this article, when to start β-blockade and which β-blocker to use is considered. Since carvedilol is the most studied β-blocker in heart failure and has a broad range of activities that extend beyond β-blockade, whether it has possible advantages over other β-blockers is discussed. Also, how the use of β-blockade might evolve with the introduction of device-related therapy in heart failure is considered.

Impact of the National Service Framework for coronary heart disease on treatment and outcome of patients with acute coronary syndromes

OBJECTIVES

To evaluate the impact the National Service Framework (NSF) for coronary heart disease has had on emergency treatment and outcomes in patients presenting with acute coronary syndromes.

DESIGN

Retrospective cohort study.

SETTING

Coronary care units of two district general hospitals.

RESULTS

Data from 3371 patients were recorded, 1993 patients in the 27 months before the introduction of the NSF and 1378 patients in the 24 months afterwards. After the introduction of the NSF in-hospital mortality was significantly reduced (95 patients (4.8%) v 43 (3.2%), p = 0.02). This was associated with a reduction in the development of Q wave myocardial infarction (40.6% v 33.3%, p < 0.0001) and in the incidence of left ventricular failure (15.9% v 12.3%, p = 0.003). The proportion of patients receiving thrombolysis increased (69.4% v 84.7%, p < 0.0001) with a decrease in the time taken to receive it (proportion thrombolysed within 20 minutes 12.1% v 26.6%, p < 0.0001). The prescription of beta blockers (51.9% v 65.8%, p < 0.0001), angiotensin converting enzyme inhibitors (37% v 66.4%, p < 0.0001), and statins (55.2% v 72.7%, p < 0.0001) improved and the proportion of patients referred for invasive investigation increased (18.3% v 27.0%, p < 0.0001). Trend analysis showed that improvements in mortality and thrombolysis were directly associated with publication of the NSF, whereas the improvements seen in prescription of beta blockers and statins were the continuation of pre-existing trends.

CONCLUSIONS

In the two years that followed publication of the NSF the initial treatment and outcome of patients presenting with acute coronary syndromes improved. Some of the improvements can be attributed to the NSF but others are continuations of pre-existing trends.

The cost-effectiveness of aspirin versus cyclooxygenase-2-selective inhibitors for colorectal carcinoma chemoprevention in healthy individuals

BACKGROUND

Aspirin therapy is accepted widely for secondary prevention in patients with documented cardiovascular disease, but there is a growing trend among healthy individuals to use aspirin as primary chemoprevention for both cardiovascular and oncologic diseases. Accruing evidence suggests that cyclooxygenase-2-selective inhibitors (coxibs) may be effective for colorectal carcinoma (CRC) chemoprevention but would not provide the primary cardiac benefit of aspirin.

METHODS

A computer-based Markov model simulated hypothetical cohorts of healthy men age 50 years who took either 325 mg of enteric-coated aspirin daily or celecoxib at a dose of 400 mg twice a day. Patients in both cohorts could develop drug-related complications that would lead to its discontinuation. The aspirin group also was modeled to have a decreased rate of coronary ischemic events; however, decreased CRC mortality was not modeled in either group based on the assumption that the two treatments were effective equally in this regard. Data sources included published literature and the Centers for Medicare and Medicaid Services. Endpoints used to compare the two strategies included quality-adjusted life years (QALYs), mortality and complication rates, and cost. The analysis was from a societal perspective with a time horizon of 10 years from age 50 years. Extensive sensitivity analyses were performed.

RESULTS

Aspirin therapy resulted in 0.03 more QALYs and cost $23,000 less than coxib therapy over a 10-year period. Compared with the aspirin group, the coxib group had 3.877% more complications and 0.17% more deaths. Alternatively stated, coxib therapy resulted in 1 patient complication or death for every 26 or 588 patients treated with coxibs, respectively.

CONCLUSIONS

Assuming equal efficacy in CRC prevention over a 10-year period, aspirin was both more effective and less costly than coxib therapy when used for primary chemoprevention of CRC.

Insurance status and the treatment of myocardial infarction at academic centers

Numerous studies have documented treatment disparities in patients with acute coronary syndromes based on race and gender. Other causes for treatment disparities may exist.

OBJECTIVES

To determine if insurance status affects quality of care in patients with acute myocardial infarction (AMI) presenting to academic health centers.

METHODS

The Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospective multicenter registry of patients with chest pain presenting to the emergency department who receive an electrocardiogram, was used as the database (N = 17,737). A subset of patients who were diagnosed as having AMI were selected from the database (n = 936). Patients were classified as having either ST-segment elevation MI (n = 178) or non-ST-segment elevation MI (n = 758). Insurance status, age, race, and gender were extracted as predictor variables. The influence of predictor variables on treatment modality was investigated using logistic regression, adjusted for clustering within sites.

RESULTS

The odds of a self-pay patient with ST-segment elevation MI receiving fibrinolytics were 3.23 (95% CI = 1.56 to 6.69) times higher than for other patients. Patients with Medicare coverage were less likely to receive fibrinolytics (odds ratio [OR] 0.35, 95% CI = 0.19 to 0.65) and tended to undergo percutaneous coronary intervention less often (OR 0.60, 95% CI = 0.36 to 1.01). The odds of a privately insured patient's receiving coronary artery bypass grafting (OR 2.76, 95% CI = 1.62 to 4.72) or percutaneous coronary intervention (OR 1.47, 95% CI = 1.03 to 2.11) were higher than for other patients.

CONCLUSIONS

Insurance coverage appears to affect treatment in patients with AMI, with self-pay patients more likely to receive less-expensive therapies and insured patients more likely to receive invasive treatments.

C-reactive protein in acute myocardial infarction: association with heart failure

BACKGROUND

High C-reactive protein (CRP) levels have been associated with higher mortality rate in patients with acute myocardial infarction (AMI). However, it is not known whether inflammation plays a role in the time-course of heart failure (HF) in this clinical setting. Our aim was to study the nature of the relationship between CRP and HF during AMI.

METHODS

This prospective study was carried out in 269 subjects admitted to the hospital for suspected AMI. Of these, 220 had evidence of AMI. The other 49 subjects were studied as controls. CRP was assessed on the first, third, and seventh day after admission.

RESULTS

CRP was significantly higher in the patients with AMI than in the control patients (P =.001) and peaked on the third day. Among the patients with AMI, CRP was higher in patients with HF than in patients without HF (adjusted P =.008, P =.02 and P =.03 on 1st, 3rd, and 7th day, respectively). Prevalence of HF on admission was slightly higher in the subjects with first-day CRP >or=15 mg/L than in those with CRP <15 mg/L, and the between-group difference progressively increased from the first to the seventh day (P <.0001). At multivariable regression analysis, first-day log-CRP was shown to be a strong independent predictor of both HF progression (P <.0001) and left ventricular ejection fraction (P <.0001). One-year total mortality and HF-mortality rates turned out to be higher in the patients with CRP >or=85 mg/L than in those with CRP below that level (P <.0001), and log-third-day CRP was independently associated with 1-year mortality at multivariable analysis (P =.0001).

CONCLUSIONS

CRP on admission to hospital is suitable for predicting the time-course of HF in patients with AMI. Peak CRP value is a strong independent predictor of global and HF-mortality during the following year.

A single serum glucose measurement predicts adverse outcomes across the whole range of acute coronary syndromes

OBJECTIVES

To analyse the relation between serum glucose concentration and hospital outcome across the whole spectrum of acute coronary syndromes.

METHODS

This was a prospective cohort study of 2127 patients presenting with acute coronary syndromes. The patients were stratified into quartile groups (Q1 to Q4) defined by serum glucose concentrations of 5.8, 7.2, and 10.0 mmol/l. The relation between quartile group and major in-hospital complications was analysed.

RESULTS

The proportion of patients with acute myocardial infarction increased incrementally across the quartile groups, from 21.4% in Q1 to 47.9% in Q4 (p < 0.0001). The trend for frequency of in-hospital major complications was similar, particularly left ventricular failure (LVF) (Q1 6.4%, Q4 25.2%, p < 0.0001) and cardiac death (Q1 0.7%, Q4 6.1%, p < 0.0001). The relations were linear, each glucose quartile increment being associated with an odds ratio of 1.46 (95% confidence interval (CI) 1.27 to 1.70) for LVF and 1.52 (95% CI 1.17 to 1.97) for cardiac death. Although complication rates were higher for a discharge diagnosis of acute myocardial infarction than for unstable angina, there was no evidence that the effects of serum glucose concentration were different for the two groups, there being no significant interaction with discharge diagnosis in the associations between glucose quartile and LVF (p = 0.69) or cardiac death (p = 0.17). Similarly there was no significant interaction with diabetic status in the associations between glucose quartile and LVF (p = 0.08) or cardiac death (p = 0.09).

CONCLUSION

Admission glycaemia stratified patients with acute coronary syndromes according to their risk of in-hospital LVF and cardiac mortality. There was no detectable glycaemic threshold for these adverse effects. The prognostic correlates of admission glycaemia were unaffected by diabetic status and did not differ significantly between patients with acute myocardial infarction and those with unstable angina.

Effect of thrombolytic therapy on QT dispersion in elderly versus younger patients with acute myocardial infarction

The objective of this study was to assess the degree of QT dispersion and effect of thrombolytic therapy on QT dispersion in elderly (age > or =65 years) versus younger (age <65 years) patients with acute myocardial infarction. The QT dispersion was measured manually in 10 +/- 2 leads of 12-lead electrocardiograms on admission, at completion of thrombolytic therapy, and at day 2 after thrombolytic therapy in 36 elderly (73 +/- 5.7 years) and 36 younger (59.9 +/- 7.7 years) patients with acute myocardial infarction. Before initiation of thrombolytic therapy, elderly patients had higher absolute and corrected QT dispersion than younger patients (absolute QT dispersion: 76.3 +/- 7.3 versus 69.6 +/- 7.5 milliseconds, respectively, P < 0.0001; corrected QT dispersion: 77.9 +/- 7.6 versus 70.8 +/- 7.4 milliseconds, respectively, P < 0.001). The difference in QT dispersion between elderly and younger patients persisted at the completion of thrombolytic therapy (absolute QT dispersion: 75.1 +/- 7.2 versus 69.1 +/- 8.4 milliseconds, respectively, P = 0.001; corrected QT dispersion: 77.2 +/- 7.2 versus 70.7 +/- 8.0 milliseconds, respectively, P = 0.001) and at day 2 after thrombolytic therapy (absolute QT dispersion: 74.1 +/- 8.2 versus 69 +/- 9.1 milliseconds, respectively, P = 0.01; corrected QT dispersion: 76.0 +/- 7.9 versus 70.5 +/- 8.8 milliseconds, respectively, P = 0.006). Compared with the prethrombolytic values, there was no significant change in absolute and corrected QT dispersion at the completion of thrombolytic therapy or at day 2 after thrombolytic therapy in elderly or younger patients. Elderly patients with acute myocardial infarction have higher QT dispersion than younger patients with acute myocardial infarction, and QT dispersion does not change early after thrombolytic therapy in elderly or younger patients.

Impact of selected geographical and clinical conditions on thrombolysis rate in myocardial infarction in three departments of France

Our objective was to assess the impact of selected geographic factors and patients' characteristics on thrombolysis rates in patients resident and hospitalised for acute myocardial infarction in three departments of the Rhĵne-Alpes Region (France). We used a two-level hierarchical model to estimate and explain geographic areas' specific effects. Old subjects and women were less frequently treated than young subjects and men. Severe, non-anterior and non-Q-wave myocardial infarctions were associated with lower thrombolysis rates. It was also lower in patients with a pulmonary chronic disease, a cancer, a peripheral arterial disease, a history of cerebrovascular accident or transient ischaemia attack, and in patients with a psychiatric disorder. After adjusting for patients' characteristics, significant variations in thrombolysis rates remained between geographic areas (up to 3.2 times). These variations seem to be partly explained by distance or isolation: a longer distance to the closest hospital or a high degree of isolation seem to lower the probability of thrombolytic therapy. Several other sources of treatment variation between the studied geographic areas remain unexplored. These factors, especially those that augment the delay to treatment, are to be identified in order to augment fibrinolysis usage and reduce inter-area heterogeneity.

Interaction between arrival time and thrombolytic treatment in determining early outcome of acute myocardial infarction

BACKGROUND

Shortening prehospital delay has been identified as an important means of improving responses to reperfusion treatment. If this increases the risk profile of the population delivered to hospital, it may paradoxically cause a deterioration in hospital mortality.

OBJECTIVE

To examine the interaction between arrival time (time from onset of chest pain to arrival at hospital) and thrombolytic treatment in determining the early outcome of acute myocardial infarction.

METHODS

Prospective cohort study of 1723 patients with acute myocardial infarction who were potentially eligible for thrombolytic treatment (ST elevation on ECG; arrival time < or = 12 hours).

RESULTS

All patients were eligible for thrombolysis but only 1098 (80%) received it. Patients who did not receive thrombolytic treatment were older (66 (58-73) v 61 (53-70) years, p < 0.001), more commonly female (32.1% v 24.8%, p < 0.01), and had higher frequencies of previous infarction (28.6% v 15.6%, p < 0.001) and left ventricular failure (37.5% v 26.9%, p < 0.01) than patients who received thrombolytic treatment. For the group as a whole, 30 day mortality was 11.7% and was unaffected by arrival time, but in patients who did not receive thrombolysis an arrival time of < or = 6 hours was associated with significantly higher 30 day mortality than an arrival time of 6-12 hours (24.3% v 2.6%, p = 0.002). Conversely, in patients who did receive thrombolysis an arrival time of < or = 6 hours was associated with a lower 30 day mortality than an arrival time of 6-12 hours (8.5% v 14.5%, p < 0.02).

CONCLUSIONS

Shortening prehospital delay in acute myocardial infarction will tend to increase the risk profile of patients presenting to emergency departments. The data presented here indicate that this may increase hospital mortality if underutilisation of thrombolytic treatment among high risk groups is not diminished.

Long-term trends in the incidence of and survival with heart failure

BACKGROUND

Heart failure is a major public health problem. Long-term trends in the incidence of heart failure and survival after its onset in the community have not been characterized.

METHODS

We used statistical models to assess temporal trends in the incidence of heart failure and Cox proportional-hazards regression to evaluate survival after the onset of heart failure among subjects in the Framingham Heart Study. Cases of heart failure were classified according to the date of onset: 1950 through 1969 (223 cases), 1970 through 1979 (222), 1980 through 1989 (307), and 1990 through 1999 (323). We also calculated 30-day, 1-year, and 5-year age-adjusted mortality rates for each period.

RESULTS

Heart failure occurred in 1075 subjects (51 percent of whom were women). As compared with the rate for the period from 1950 through 1969, the incidence of heart failure remained virtually unchanged among men in the three subsequent periods but declined by 31 to 40 percent among women (rate ratio for the period from 1990 through 1999, 0.69; 95 percent confidence interval, 0.51 to 0.93). The 30-day, 1-year, and 5-year age-adjusted mortality rates among men declined from 12 percent, 30 percent, and 70 percent, respectively, in the period from 1950 through 1969 to 11 percent, 28 percent, and 59 percent, respectively, in the period from 1990 through 1999. The corresponding rates among women were 18 percent, 28 percent, and 57 percent for the period from 1950 through 1969 and 10 percent, 24 percent, and 45 percent for the period from 1990 through 1999. Overall, there was an improvement in the survival rate after the onset of heart failure of 12 percent per decade (P=0.01 for men and P=0.02 for women).

CONCLUSIONS

Over the past 50 years, the incidence of heart failure has declined among women but not among men, whereas survival after the onset of heart failure has improved in both sexes. Factors contributing to these trends need further clarification.

Predictors of subsequent coronary events, stroke, and death among survivors of first hospitalized myocardial infarction

We identified predictors of prognosis among n = 2,677 health maintenance organization enrollees 30 to 79 years old who survived a first hospitalized myocardial infarction (MI) during 1986-1996 (mean follow-up 3.4 years). Independent risk factors for reinfarction/fatal coronary heart disease (CHD) (incidence = 49.0/1,000 person-years, 445 events) were age, diabetes, chronic congestive heart failure (CHF), angina, high body mass index (BMI), low diastolic blood pressure (DBP), high serum creatinine, and low/high-density lipoprotein (HDL) cholesterol. Independent risk factors for stroke (incidence = 13.0/1,000 person-years, 124 events) were age, diabetes, CHF, high DBP, and high creatinine. Independent predictors of death (incidence = 44.2/1,000 person-years, 431 events) were age, diabetes, CHF, continued smoking after MI, low DBP, high pulse rate, high creatinine, and low HDL cholesterol, while BMI had a significant U-shaped association with death (elevated risk at low and high BMI). The occurrence of study end points did not differ significantly between men and women after adjustment for other risk factors and use of preventive medical therapies, although men tended to have higher rates of reinfarction/CHD than women among older subjects. In summary, we demonstrated that the major cardiovascular risk factors age, diabetes, CHF, smoking, and dyslipidemia are important prognostic factors in the years after nonfatal MI. Elevated BMI was associated with increased risk of reinfarction/CHD and death and elevated DBP with increased risk of stroke, but we also observed high mortality among those with low BMI and high risk of recurrent coronary disease and death among those with low DBP. Finally, high creatinine was a strong, independent predictor of a variety of adverse outcomes after first MI.

Functional monitoring of anthracycline cardiotoxicity: a prospective, blinded, long-term observational study of outcome in 120 patients

BACKGROUND

With increasing doses the highly tumoricidal anthracycline drugs cause heart damage. Based on empirical drug limitations about 10-15% of patients will develop congestive heart failure (CHF) with a mortality of -50% within 2 years on digitalo-diuretic therapy alone. To avoid CHF there is a consensus recommendation that cardiac function should be monitored in close connection with anthracycline administration. As no prospective studies in a larger series have been performed, these recommendations are based on retrospective data on small numbers of patients.

PATIENTS AND METHODS

In a prospective, blinded observational study 120 patients with advanced breast cancer were followed before, during, and a median 3 years after treatment with epirubicin. They had 604 serial radionuclide measurements of left ventricular ejection fraction (LVEF) that were stored without calculations except in patients who developed a well-defined CHF.

RESULTS

Anthracycline cardiotoxicity was closely correlated with the cumulative dose, with a great variability in individual susceptibility and a dramatic increase with advancing age. With a delayed onset of 3 months or more, epirubicin induced a threatening, slowly progressive deterioration of cardiac function continuing years after treatment. An actuarial estimation of 59% of the patients experienced a 25% relative reduction in LVEF 3 years after 850-1000 mg/m2 of epirubicin and 20% had deteriorated into a CHF. The patients did not spontaneously regain cardiac function whereas continued therapy with a circadian angiotensin-converting enzyme inhibitor for more than 3 months caused a remarkably potent and long-lasting recovery.

CONCLUSIONS

Due to the displaced cardiotoxic manifestation, functional monitoring in close connection with anthracycline administration appears to be a poorly effective method while later monitoring is essential. Current monitoring recommendations should therefore be revised.

Treating atherosclerosis: local drug delivery from laboratory studies to clinical trials

Treating only the specific section of the vascular bed that is diseased appears to make sense. Giving drugs systematically to treat perhaps only a few centimetres of affected artery carries with it the risk of systemic side effects and reduced efficacy consequent on low concentrations of agent at the site of the problem. There has thus been great interest since the early 1990s in local drug delivery. Initial targets were the thrombotic response to plaque disruption but the problems arising from the incidental damage inflicted by devices used in interventional cardiology and the pathological consequences of this, namely smooth muscle cell initiated intimal hyperplasia, soon became the focus of pre-clinical studies. Problems to be overcome were the low efficiency of delivery of drugs and the low retention rates. Solutions to these problems included the development of strategies to target drugs, through the use of antibodies directed at antigens newly released at the site of damage. As it became clear that stents were becoming central to the attainment of a better clinical response to intervention by their inherent physical properties, it also became obvious that stents could be used to deliver agents. Issues such as which stent, how to load the drug onto the stent and what drug to use to inhibit the unwanted pathobiological response are ongoing issues.

[Worsening of heart failure during hospital course in myocardial infarction is a factor of poor prognosis. Apropos of a prospective cohort study of 2,507 patients hospitalized with myocardial infarction: the PRIMA study]

BACKGROUND

Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon.

AIMS

The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of heart failure worsening, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the "real world" in a region in France, using multivariate analysis.

METHODS

Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône-Alpes region in France between September 1, 1993 and January 31, 1995.

RESULTS

Among 2,507 patients, 33% were in Killip classes II-IV at admission. Four hundred and sixteen patients (17%) had worsening of Killip class during the first five days. In-hospital mortality (overall: 14%) increased dramatically with Killip class at admission (9% in class I; 62% in class IV) and with worsening of Killip class during the first five days (36% vs 8% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first five days.

CONCLUSION

This large, unselected cohort revealed that among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

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

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

Consequences of overutilization and underutilization of thrombolytic therapy in clinical practice. TRACE Study Group. TRAndolapril Cardiac Evaluation

OBJECTIVES

The aim of this study was to evaluate the consequences, measured as mortality and in-hospital stroke, of the use of thrombolytic therapy among patients with acute myocardial infarction (AMI), who do not fulfill accepted criteria or who have contraindications to thrombolytic therapy (i.e., overutilization) and among patients who are withheld thrombolytic treatment despite fulfilling indications and having no contraindications (i.e., underutilization).

BACKGROUND

The implementation of treatment with thrombolysis in clinical practice is not in accordance with the accepted criteria from randomized studies. The consequence has been over- and underutilization of thrombolytic therapy among patients with AMI in clinical practice. The outcome of overutilization of thrombolytic therapy has not been described previously.

METHODS

We examined 6,676 consecutive patients admitted to the hospital with an AMI and recorded characteristics, in-hospital complications and long-term mortality.

RESULTS

Overall, 41% of the patients received thrombolytic therapy. Thrombolytic therapy was underutilized in 14.3% and overutilized in 12.9% of the patients. The use of thrombolytic therapy was associated with reduced mortality in every subgroup examined, including patients without an accepted indication, with an accepted indication and in patients with prior stroke. The risk ratio of in-hospital stroke was not increased in connection with thrombolytic therapy, not even in patients with prior stroke (relative risk = 0.237, 95% confidence interval: 0.031 to 1.810, p = 0.17).

CONCLUSIONS

With the large benefit known to be associated with thrombolytic therapy and the favorable result of thrombolytic therapy in patients with contraindications observed in this study, we conclude that a formal evaluation of thrombolytic therapy in wider patient categories is warranted.

Socioeconomic differentials in recurrent ischaemia and mortality after acute myocardial infarction

OBJECTIVE

To examine the influence of socioeconomic deprivation on case fatality following acute myocardial infarction.

DESIGN

Prospective cohort observational study.

SETTING

General hospital.

PATIENTS

1417 white and south Asian patients admitted with acute myocardial infarction between January 1988 and December 1996, and classified by the Carstairs socioeconomic deprivation score of the enumeration district of residence.

MAIN OUTCOME MEASURES

30 day and one year survival.

RESULTS

There was little variation across deprivation groups in age, sex, or smoking status, though a higher proportion of patients from more deprived enumeration districts were diabetic and of south Asian origin, and a higher proportion of them developed Q wave infarction and left ventricular failure. There was no appreciable variation in clinical treatment with deprivation. Patients from more deprived enumeration districts had a higher risk of recurrent ischaemic events (death, recurrent myocardial infarction, or unstable angina) over the first 30 days: event free survival (95% confidence interval (CI)) of the most deprived quartile was 0.79 (95% CI 0.74 to 0.83) compared with 0.85 (95% CI 0.80 to 0.88) in the least deprived quartile. The unadjusted hazard ratio corresponding to an increase from the 5th to 95th centile of the deprivation distribution was 1.54 (95% CI 1.02 to 2.32), and 1.59 (95% CI 1.03 to 2.44) after adjustment for age, sex, racial group, diabetes, acute treatment with thrombolysis and aspirin, and left ventricular failure. Survival from 30 days to one year, however, did not show a socioeconomic gradient (hazard ratio adjusted for the same variables was 1.07 (95% CI 0.68 to 1.70)).

CONCLUSIONS

In patients hospitalised with acute myocardial infarction, there is a strong association between early recurrent ischaemic events and socioeconomic deprivation that is not accounted for by clinical presentation or treatment. This association appears to be attenuated over time.

Worsening of heart failure during hospital course of an unselected cohort of 2507 patients with myocardial infarction is a factor of poor prognosis: the PRIMA study. Prise en charge de l'Infarctus du Myocarde Aigu

Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon. The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of worsening heart failure, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the 'real world' in a region in France, using multivariate analysis. Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône--Alpes region in France between 1 September 1993 and 31 January 1995. Among the 2507 patients included, 33% were in Killip classes II--IV at admission. After exclusion of patients with admission Killip class IV, 416 patients (17% of the cohort, 24% of women and 14% of men) had worsening of Killip class during the first 5 days. In-hospital mortality (overall, 14%) increased dramatically with Killip class at admission (9% in class I, 62% in class IV) and with worsening of Killip class during the first 5 days (36.5 vs. 8.5% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening; Killip class >I at admission was a significant predictor of Killip-class worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first 5 days. This large, unselected cohort revealed that, among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

Diabetes

The causes of accelerated atherogenesis in diabetes are unclear but the consequences in terms of cardiovascular morbidity and mortality are profound. Thus diabetes not only increases the risk of coronary heart disease but also increases the case fatality rate, ensuring that the majority of patients die of cardiovascular causes, often before the age of 50 years. The problem is compounded by autonomic neuropathy which alters the perception of cardiac pain, attenuating symptoms which are often atypical or absent. This may delay presentation or lead to inappropriate triage decisions such that access to defibrillators and specific treatment is denied. Central to the cardiovascular management of diabetes is vigorous risk factor modification although clear evidence that this leads to extra protection against coronary heart disease beyond that achieved in non-diabetic individuals has not been forthcoming. In other respects too, the management of diabetic patients with heart disease is underpinned by the same evidence-base as applies to non-diabetic patients, and it is noteworthy that 15-20% of the patients in most of the landmark clinical trials have been diabetic. Recently, however, trials such as the United Kingdom Prospective Diabetes Study (UKPDS), the Heart Outcomes Prevention Evaluation (HOPE) study, and the Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) study have identified novel strategies for reducing cardiovascular risk in diabetes. These trials have already had a major impact on cardiological practice, emphasising the prime importance of blood pressure control and converting enzyme inhibition for reducing cardiovascular risk in diabetes as well as the value of insulin therapy for reducing mortality in diabetic myocardial infarction. Additional trials, already in progress, are expected to refine further the cardiovascular management of patients with diabetes in order to provide an effective challenge for a problem that shows no signs of going away.

The acute management of myocardial infarction

Acute myocardial infarction (AMI) is a common and potentially fatal condition. Primary prevention by reducing the risk of developing coronary atheroma disease has had an important effect on the incidence of the disease. However, for many, the first clinical presentation of their coronary atheroma is the development of acute coronary occlusion. The acute nature of such presentation is the result of the dynamic nature of the plaque event. Thus while measures such as increasing public education in areas of primary prevention are always important it needs to be recognised that real differences in outcome need to and can be made even once the event has occurred. Individuals developing chest pain need to be encouraged to present early, especially if they have a history of ischaemic heart disease. Once they have arrived at point of medical contact, rapid triage, early diagnosis and the institution of therapies designed to reduce the extent of myocardial damage are paramount.

Cardiac decompensation during an ischemic event weakens the predictive power of myocardial injury markers

Our objection was to find determinants of long-term outcome in routine data collected for differential diagnosis of suspected acute myocardial infarction. Study population consisted of 263 discharged patients who were initially hospitalized for differential diagnosis of suspected acute myocardial infarction between October 1992 and January 1993. Follow-up time for all cause and cardiac mortality was 5 years. The variables studied as predictors of outcome were computerized ECG, peak creatine kinase isoenzyme MB, peak troponin I, radiographic evidence of pulmonary congestion (cardiac decompensation), treatment for hyperlipidemia, hypertension or diabetes, smoking, previous myocardial infarction, age and gender. Total mortality was 32% at 5 years, of which 77% (64/83) was of cardiac origin. Pulmonary congestion in chest X-ray was the most powerful predictor of outcome (RR=3.3, 95% CI=2.0-5.2, P<0.001). In multivariate analysis congestion (RR=3.3, CI=2.0-5.2) was the only independent predictor of 5-year total mortality in addition to age (RR=1.06, CI=1.04-1.08). These two variables together with previous myocardial infarction (RR=1.9, CI=1.2-3.1) and hyperlipidemia (RR=2. 0, CI=1.1-3.5) were independent predictors of cardiac mortality. Radiographic evidence of cardiac decompensation during hospitalization is a strong and independent predictor of long-term outcome in unselected patients with suspected AMI. The predictive power of cardiac markers is confined to patients without pulmonary congestion.

Pseudonormal and restrictive filling patterns predict left ventricular dilation and cardiac death after a first myocardial infarction: a serial color M-mode Doppler echocardiographic study

OBJECTIVES

We sought to assess the prognostic value of left ventricular (LV) filling patterns, as determined by mitral E-wave deceleration time (DT) and color M-mode flow propagation velocity (Vp), on cardiac death and serial changes in LV volumes after a first myocardial infarction (MI).

BACKGROUND

Combined assessment of DT and Vp allows separation of the effects of compliance and relaxation on LV filling, thereby allowing identification of pseudonormal filling. This may be valuable after MI, where abnormal LV filling is frequently present.

METHODS

Echocardiography was performed within 24 h, five days and one and three months after MI in 125 unselected consecutive patients. Normal filling was defined as DT 140 to 240 ms and Vp > or =45 cm/s; impaired relaxation as DT > or =240 ms; pseudonormal filling as DT 140 to 240 ms and Vp <45 cm/s; and restrictive filling as DT <140 ms.

RESULTS

Left ventricular filling was normal in 38 patients; impaired relaxation in 38; pseudonormal in 23; and restrictive in 26. End-systolic and end-diastolic volume indexes were significantly increased during the first three months after MI in patients with pseudonormal or restrictive filling (37+/-15 vs. 47+/-19 ml/m2, p<0.0005 and 71+/-20 vs. 88+/-24 ml/m2, p<0.0005, respectively). During a follow-up period of 12+/-7 months, 33 patients died. Mortality was significantly higher in patients with impaired relaxation (p = 0.02), pseudonormal filling (p<0.00005) and restrictive filling (p<0.00005), compared with patients with normal filling. On Cox analysis, restrictive filling (p = 0.003), pseudonormal filling (p = 0.006) and Killip class > or =II (p = 0.008) independently predicted cardiac death, compared with clinical and echocardiographic variables.

CONCLUSIONS

Pseudonormal or restrictive filling patterns are related to progressive LV dilation and predict cardiac death after a first MI.

Acute myocardial infarction in women: contribution of treatment variables to adverse outcome

BACKGROUND

Women have excessive mortality rates after acute myocardial infarction compared with men. The extent to which this increased risk can be attributed to differences in treatment is not well-understood.

METHODS

This was an observational follow-up study of 1737 patients admitted with acute myocardial infarction for coronary care between January 1, 1988, and December 31, 1997.

RESULTS

Compared with men, women took longer to arrive at the hospital (132.5 minutes [range 76 to 291 minutes] vs 120 minutes [range 60 to 240 minutes]; P =.006), were less likely to receive aspirin acutely (87.8% vs 91.3%; P =.03), had longer door-to-needle times (90 minutes [range 60 to 143.5 minutes] vs 78 minutes [range 50 to 131 minutes]; P =.004), and were less likely to be given beta-blockers at hospital discharge (31.6% vs 44.9%; P <.0001). Estimated survival (95% confidence interval [CI]) at 30 days was only 78.4% (range 74.4% to 81.9%) for women compared with 88.0% (range 86.1% to 89.7%) for men. Women were older and more often white, but their excess risk (hazard ratio 2.09; 95% CI, 1.59-2.75) persisted after adjustment for age, racial group, and diabetes (hazard ratio 1.52; 95% CI, 1.15-2.01). Additional adjustment for emergency thrombolytic and aspirin therapy caused a further small reduction in the excess risk for women (hazard ratio 1.46; 95% CI, 1. 09-1.98), but with adjustment for aspirin and beta-blockers prescribed at discharge, the excess risk attributable to being female disappeared as the hazard ratio fell to 0.75 (95% CI, 0.31-1. 84). Estimated 30-day survival free of reinfarction and unstable angina was also lower for women than for men (75% [range 71% to 79%] vs 86% [range 84% to 88%]); again, the excess risk for women persisted despite adjustment for age and racial group before disappearing as treatment variables were introduced into the model. The influence of treatment variables on the differential risks for women and men disappeared at 12 months.

CONCLUSIONS

This study has shown that women with acute myocardial infarction arrived later at the hospital, were less likely to be given aspirin therapy acutely, had longer door-to-needle times, and, on discharge from the hospital, were less likely to be prescribed beta-blockers for secondary prevention. The data suggest that the failure to treat women as vigorously as men made a significant contribution to their worse outcome.

Diabetes mellitus is a strong negative prognostic factor in patients with myocardial infarction treated with thrombolytic therapy

OBJECTIVES

To assess the long-term prognostic values of baseline demographic data, occurrence of vectorcardiographic signs of reperfusion, left ventricular function and coronary angiographic features.

DESIGN

Longitudinal study of morbidity and mortality.

SETTING

Coronary care unit at Danderyd Hospital, Stockholm, Sweden.

SUBJECTS

A total of 222 patients (mean age 61 years) with a suspected acute myocardial infarction treated with thrombolysis were investigated and followed for 2-5 years (mean 1216 days).

MAIN OUTCOME MEASURES

Death or a new myocardial infarction.

RESULTS

Age above 55 years (P < 0.05), a previous diagnosis of diabetes mellitus (P < 0.005), hypertension (P < 0.05), heart failure (P < 0.001) and myocardial infarction (P < 0.05), a previous use of beta-blockers (P < 0.05) and an ejection fraction below 60% (P < 0.01) were predictors for death or a new myocardial infarction in univariate analysis. Sex, a previous history of smoking or angina pectoris, vectorcardiographic signs of reperfusion or degree of coronary artery disease had no prognostic values. In multivariate analysis including age above 55 years, a previous diagnosis of diabetes mellitus, hypertension and myocardial infarction, and an ejection fraction below 60%, only age (P < 0.05), diabetes mellitus (P < 0. 01) and ejection fraction (P < 0.05) were predictors for death or a new myocardial infarction.

CONCLUSIONS

The results of the present study emphasize the importance of diabetes mellitus as a long-term prognostic risk factor in patients with myocardial infarction treated with thrombolysis. Further studies are needed to determine the mechanisms behind this increased risk.

Influence of previous aspirin treatment and smoking on the electrocardiographic manifestations of injury in acute myocardial infarction

OBJECTIVE

To examine demographic and clinical characteristics of patients with acute myocardial infarction in order to identify factors affecting the electrocardiographic evolution of injury.

METHODS

Prospective cohort study of 1399 consecutive patients with a first myocardial infarction. Baseline clinical data associated with ST elevation and Q wave development were identified and 12 month survival was estimated.

RESULTS

Smoking had complex effects on the evolution of injury, increasing the odds of ST elevation (odds ratio (OR) 1.61; 95% confidence interval (CI) 1.08 to 2.36), but reducing the odds of Q wave development (OR 0.69, 95% CI 0.49 to 0.96). The effects of previous aspirin treatment were more consistent with reductions in the odds of ST elevation (OR 0.57, 95% CI 0.35 to 0.94) and Q wave development (OR 0.53, 95% CI 0.34 to 0. 84). ST elevation and Q wave development were both associated with an adverse prognosis, with estimated 12 month survival rates of 80. 6% (95% CI 78.2% to 83.1%) and 80.0% (95% CI 77.5% to 82.5%), respectively, compared with 86.5% (95% CI 81.2% to 91.9%) and 89.9% (95% CI 86.2% to 93.7%) for patients without these ECG changes.

CONCLUSIONS

The thrombogenicity of the blood may be a major determinant of infarct severity. Smoking increases thrombogenicity and the likelihood of ST elevation, but because coronary occlusion is relatively more thrombotic in smokers, responses to both endogenous and exogenous thrombolysis are better, reducing the risk of Q wave development. Previous aspirin treatment reduces thrombogenicity, protecting against ST elevation and Q wave development.