Characteristics and significance of prodromes of coronary care unit patients

Prodromal Myocardial Infarction Fatigue: A Concept Analysis

Patients' care-seeking behaviors are often based on the symptoms they experience. Prodromal myocardial infarction symptoms are those symptoms that occur prior to a myocardial infarction, and fatigue is common. However, the concept of prodromal myocardial infarction fatigue has not been explored from a multidimensional perspective using a concept analysis approach. The purpose of this concept analysis was to analyze this concept, using Walker and Avant's (2011) concept analysis methodology. A comprehensive literature search revealed 41 records for analysis. The structure and function of this concept was examined, and an operational definition of prodromal myocardial infarction fatigue was developed.

Insomnia and heart disease: a review of epidemiologic studies

Since the discovery and successful treatment of sleep apnea, researchers seem to believe that the association between sleep disturbance and coronary heart disease (CHD) has been explained. To determine whether subjective nighttime sleep complaints (trouble sleeping, trouble falling asleep, trouble staying asleep), exclusive of apnea, predicted myocardial infarction and other coronary events, a MEDLINE search was conducted for articles published between January 1976 through August 1997. Ten studies with an explicit measure of association between an insomniac complaint and CHD were identified. Reported risk ratios for various sleep complaints and CHD events ranged from 1.0 for waking too early and CHD death in an elderly North Carolina community to 8.0 for the highest versus lowest quintile of a sleep scale in Finnish men. Higher quality studies showed risk ratios of 1.47-3.90 between trouble falling asleep and coronary events after adjusting for age and various coronary risk factors (combined effect=1.7, p<0.0001). While alternative explanations such as medication use still need to be ruled out, we theorize that a subjective insomniac complaint either may be part of a larger syndrome that includes poor health and depression, or it may be related to continual stressors, reduced slow-wave sleep, and autonomic dysfunction, which increase the risk of heart problems.

Prodromal symptoms in subsets of patients hospitalized for suspected acute myocardial infarction

OBJECTIVE

To describe the occurrence of prodromal symptoms in suspected acute myocardial infarction (AMI) and to relate such symptoms to final diagnosis and previous history.

DESIGN

Prospective study.

SETTING

Coronary care unit in Sahlgrenska Hospital in Göteborg, Sweden.

PATIENTS

914 patients admitted to the coronary care unit for suspected AMI.

OUTCOME MEASURES

Chest pain within the last 48 hours or other prodromal symptoms.

RESULTS

Among patients in whom AMI developed, 57% reported prodromal chest pain and 61% reported other prodromal symptoms. Size, location, or type (Q-wave versus non-Q-wave AMI) did not influence outcome. Women reported more prodromal symptoms than men (p < 0.05), whereas age did not influence results. A similar proportion of patients with no confirmed AMI reported prodromal symptoms. Fifty-nine percent of patients with prodromal symptoms had wished to contact a physician if possible, and in fact one third did so. Two thirds of all patients were at rest, and one third reported some emotional distress before onset of the symptoms that brought them to hospital.

CONCLUSION

A large proportion of patients with suspected AMI experienced prodromal symptoms before onset of suspected AMI. Such symptoms were more common in women but were not affected by size, location, or type of AMI. The symptoms were so severe that 59% of the patients with such symptoms wished to contact a physician before arrival in hospital.

Predictors of reinfarction and sudden death in a high-risk group of acute myocardial infarction survivors

75 patients aged under 70 years who had survived acute myocardial infarction complicated by both significant arrhythmias and cardiac failure were followed-up for 1 year in an attempt to identify features which suggest the likelihood of late death or reinfarction. Patients were carefully instructed in the identification and importance of possible prodromal symptoms and the availability of a mobile intensivecare ambulance service and a 24 h hospital control centre. Horizontal ST-segment depression or anginal pain on an exercise test done within 6 weeks of infarction was a useful predictor of late death. Routine twice weekly E.C.G. recordings taken by telephone transmitter at rest and after mild exertion resulted in the identification of significant arrhythmias in only 7 patients. 13 patients (17%) died, 5 of them instantaneously. 4 of the 13 patients and 22 of the 62 survivors reported "prodromal symptoms". Unreported prodromal symptoms were elicited retrospectively in 14 of the 62 survivors and from the relatives of 4 of the 13 patients who died. Thus, 35% of prodromal symptoms were not reported despite intensive patient education and counselling. The incidence of "prodromal symptoms" was no higher in patients who died than in those who did not die.

Prodromal characteristics as indicators of cardiac events in patients hospitalized for chest pain

In an effort to determine the usefulness of prodromata for predicting a myocardial infarction, a prospective analysis was made of 211 consecutive patients with chest pain who were admitted to the Stanford University Medical Center Coronary Care Unit. In their subsequent course, 91 patients had a myocardial infarction, 102 had a myocardial infarction ruled-out, and 18 had a noncardiac etiology for their chest pain. Prodromal chest pain in the previous six months had occurred in 65% of patients and unstable angina in 61%. Infarction versus noninfarction patient groups could not be identified on the basis of prodromal ill health, chest pain, unstable angina, typical versus atypical nature of the chest pain, or activity at the onset of pain. Complaints of preceding fatigue and increased perceived stress were common in both groups. Activity at the onset of the admission chest pain was strenuous in 15% of the infarction patients and 12% of the noninfarction patients. We conclude that prodromal symptoms are common in both infarction and noninfarction patients. Although chest pain probably remains the single most frequent identifier of a new cardiac event, it is common in noninfarction patients and cannot be used alone to predict infarction or death.

Unstable angina pectoris: national cooperative study group to compare medical and surgical therapy. I. Report of protocol and patient population

A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the eithical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.

Prehospital care of acute myocardial infarction

It has been estimated recently that half of deaths among the patients with acute myocardial infarction occur before they ever reach the hospital for definitive medical care. One of the major reasons for the high incidence of death was attributed to delays in reaching medical care, involving patients themselves, physicians, transportation, and receiving areas of the hospital. In order to reduce this high mortality substantially we should focus our attention on the prehospital care of this disease, which may include several major approaches.

A. To shorten the delay in securing medical care:

1. Public education, with emphasis on the early warning symptoms and signs of acute myocardial infarction, and the need and importance of seeking early medical care, with special attention directed toward the high-risk coronary patients.

2. Professional education.

3. Mechanisms to direct and/or bring patients with suspected or proven acute myocardial infarction promptly to the system of medical care with special emphasis on the utilization of a telephone information center and provision of rapid transportation.

B. Establishment of emergency life-support stations for screening, monitoring, and early stabilization of cardiac arrhythmias:

1. Fixed.

a. Emergency department of hospitals, preferably with an attached precoronary care area.

b. Areas where many employees are working on weekdays.

c. Areas where many people move in and out from day to day.

d. Areas where there is periodic concentration of mass population.

2. Mobile.

a. Mobile coronary care unit.

b. Mobile intensive care unit.

C. Prevention of sudden death:

1. Study of mechanism and clinical environment of sudden death.

2. Development of techniques for early diagnosis and management of acute myocardial infarction prior to inception of symptoms.

3. Identification of individuals prone to sudden death.

4. Preventive measures directed toward the individuals prone to sudden death.

a. Effective control of risk factors.

b. Intermittent or periodic electrocardiographic monitoring in these individuals.

c. Long-term antiarrhythmic therapy for these individuals.

d. Possibility of implanting an automatic defibrillator in patients with previous myocardial infarction or in those recovered from ventricular fibrillation.

5. Early administration of antiarrhythmic drugs in patients with suspected or proven acute myocardial infarction.