Showing papers on "Myocardial infarction complications published in 1996"
TL;DR: The prophylactic use of a specific potassium-channel blocker does not reduce mortality, and may be associated with increased mortality in high-risk patients after myocardial infarction.
1,303 citations
TL;DR: Although plasma ANP appears to be a better predictor of left ventricular dysfunction, plasma BNP may have greater potential to complement standard prognostic indicators used in risk stratification after AMI because of its strong, independent association with long-term survival, enhanced in vitro stability, and simplicity of analysis.
Abstract: Background Elevated plasma levels of atrial natriuretic peptide (ANP) and the N-terminal fragment of the ANP prohormone (N-ANP) are associated with decreased left ventricular function and decreased long-term survival after acute myocardial infarction (AMI). Previous data suggest that plasma brain natriuretic peptide (BNP) may increase proportionally more than plasma ANP after AMI and in chronic heart failure. The diagnostic and prognostic value of plasma BNP as an indicator of left ventricular dysfunction and long-term survival after AMI, relative to that of ANP and N-ANP, remain to be established. Methods and Results Venous blood samples for analysis of ANP, N-ANP, and BNP were obtained on day 3 after symptom onset from 131 patients with documented AMI. Left ventricular ejection fraction was determined by echocardiography in a subsample of 79 patients. Twenty-eight cardiovascular and 3 noncardiovascular deaths occurred during the follow-up period (median, 1293 days). All three peptides proved to be power...
756 citations
TL;DR: A clinical prediction rule based on a set of electrocardiographic criteria, which are based on simple ST-segment changes, may help identify patients with acute myocardial infarction, who can then receive appropriate treatment.
Abstract: Background The presence of left bundle-branch block on the electrocardiogram may conceal the changes of acute myocardial infarction, which can delay both its recognition and treatment. We tested electrocardiographic criteria for the diagnosis of acute infarction in the presence of left bundle-branch block. Methods The base-line electrocardiograms of patients enrolled in the GUSTO-1 (Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries) trial who had left bundle-branch block and acute myocardial infarction confirmed by enzyme studies were blindly compared with the electrocardiograms of control patients who had chronic coronary artery disease and left bundle-branch block. The electrocardiographic criteria for the diagnosis of infarction were then tested in an independent sample of patients presenting with acute chest pain and left bundle-branch block. Results Of 26,003 North American patients, 131 (0.5 percent) with acute myocardial infarction had left bundle-b...
573 citations
Journal Article•
TL;DR: The data suggest that heart failure subsequent to myocardial infarction may be associated with an antioxidant deficit as well as increasedMyocardial oxidative stress.
Abstract: Antioxidant enzyme activities and oxidative stress were evaluated in the myocardium in relation to hemodynamic function subsequent to myocardial infarction in rats. One week after the coronary ligation, the left ventricular peak systolic pressure, left ventricular end-diastolic pressure, and aortic pressures remained near control values and there were no differences in lung and liver wet/dry weight ratios between experimental and control animals. In the 4-, 8-, and 16-week experimental animals, there was a progressive drop in left ventricular peak systolic pressure and an increase in left ventricular end-diastolic pressure. Aortic systolic pressure was depressed at 8 and 16 weeks. In myocardial infarct rats, there was a significant increase in wet/dry weight ratio of lungs at 8 weeks and at 16 weeks; this ratio was increased for lungs as well as liver. Based on the hemodynamic data as well as other observations, animals in the 1-, 4-, 8-, and 16-week groups were arbitrarily categorized into nonfailure and mild, moderate, and severe failure stages, respectively. In the nonfailure stage, there was a marginal increase in superoxide dismutase, glutathione peroxidase, and catalase activities as well as vitamin E levels. The redox state in these hearts, assessed by the reduced/oxidized glutathione ratio, was significantly increased. Superoxide dismutase activity was unchanged in mild and moderate failure stages but significantly depressed at 16 weeks. Glutathione peroxidase and catalase activities showed progressive decreases through mild, moderate, and severe failure stages. Vitamin E levels were significantly depressed at moderate and severe failure stages. There was a progressive increase in lipid peroxidation at mild, moderate, and severe stages of heart failure and the redox ratio was significantly depressed in the severe failure stage. These data suggest that heart failure subsequent to myocardial infarction may be associated with an antioxidant deficit as well as increased myocardial oxidative stress.
364 citations
TL;DR: Predicting the site of infarction based on severity of underlying stenosis would have been unsuccessful in more than half the patients in both perioperative and nonoperative MI groups, and the severity of preexisting underlying stenotic did not predict the resulting infarct territory.
357 citations
TL;DR: It is found that anxiety early after myocardial infarction onset is associated with increased risk of ischemic and arrhythmic complications, and this finding suggests that anxiety should be considered among the conventional risk factors for in-hospital acuteMyocardial Infarction complications.
Abstract: Objective Acute myocardial infarction is often accompanied by anxiety, but the effect of this emotion on recovery is unclear. The purpose of this study was to determine the association between patient anxiety early after acute myocardial infarction and the incidence of subsequent in-hospital complications. Methods We assessed anxiety level within 48 hours of patient arrival at the hospital in 86 confirmed myocardial infarction patients. Anxiety was measured using the Brief Symptom Inventory. Myocardial infarction complications were defined as reinfarction, new onset ischemia, ventricular fibrillation, sustained ventricular tachycardia, or in-hospital death. Results More complications were seen in patients with higher versus lower levels of anxiety (19.6% vs 6%; p=.001). Multiple logistic regression was used to control for those clinical and sociodemographic factors that can influence the incidence of complications and demonstrated that higher anxiety level was independently predictive of complications. Patients with higher anxiety levels were 4.9 times (p=.001) more likely to have subsequent complications. Conclusions Anxiety early after myocardial infarction onset is associated with increased risk of ischemic and arrhythmic complications. This finding suggests that anxiety should be considered among the conventional risk factors for in-hospital acute myocardial infarction complications.
321 citations
TL;DR: Early (90-min) infarct-related artery patency as well as regional and global ventricular function do not differ between patients with and without diabetes after thrombolytic therapy, except for reduced compensatory hyperkinesia in the noninfarct zone among patients with diabetes.
278 citations
TL;DR: The clinical aspects of acute myocardial infarction in the gestational and early postpartum period in 125 well-documented cases are reviewed and recommendations for the management of this condition are established.
Abstract: Acute myocardial infarction (AMI) during pregnancy or the early post-partum period is rare but has been shown to be associated with poor maternal as well as fetal outcome. Major changes in both diagnosis and treatment of AMI in the nonpregnant patient have lead to improved outcome which may also affect pregnant patients. The purpose of this paper is to review available information related to the pathophysiology and clinical profile and provide recommendations for the diagnosis and management of AMI occuring during pregnancy and the early post-partum period. (J Am Coll Cardiol 2008;52:171‐80) © 2008 by the American College of Cardiology Foundation Acute myocardial infarction (AMI) in women during childbearing age is rare. Pregnancy, however, has been shown to increase the risk of AMI 3- to 4-fold (1–5). With the continuing trend of childbearing at older ages and advances in reproductive technology enabling many older women to conceive (6), it may be expected that its occurrence will increase. Our previous review more than a decade ago indicated high maternal mortality and fetal loss associated with pregnancy-related AMI (1). The last decade has witnessed a major change in both the diagnostic and therapeutic approaches to patients with AMI, which has led to improvement in outcome; these changes may have affected pregnant patients as well. The purpose of this article is to review new information on AMI related to pregnancy and provide recommendations for the diagnosis and management of this condition. Methods
248 citations
TL;DR: Heart rate variability, the signal-averaged electrocardiogram (ECG), ventricular arrhythmias and left ventricular ejection fraction predict the mechanism of cardiac death after myocardial infarction and a combination of risk factors identified patient groups in which a majority of deaths were either arrhythmic or nonarrhythmmic.
232 citations
TL;DR: A nearly equal risk of stroke was associated with both CEA andCarotid arteriography, and patients with asymptomatic internal carotid artery stenosis exceeding 60% reduction in diameter who are acceptable candidates for elective operation may be considered for CEA if the combined arteriographic and surgical complication rates are 3% or less.
Abstract: Background and purpose Our aim was to determine the perioperative morbidity and mortality rates of patients in the surgical arm of the multi-institutional, prospective, randomized Asymptomatic Carotid Atherosclerosis Study (ACAS). Methods Of 828 patients with carotid stenosis of 60% or more randomized to the surgical arm of ACAS, 721 underwent carotid endarterectomy (CEA). To qualify for participation, surgeons were required to have performed at least 12 CEAs per year with a combined neurological morbidity and mortality rate no greater than 3% for asymptomatic patients and 5% for symptomatic patients. Clinical centers had to demonstrate arteriographic morbidity less than 1% and mortality less than 0.1% per year. Primary events were stroke and death in the period between randomization and 30 days after surgery; secondary events were transient ischemic attack and myocardial infarction occurring in the same period. Results Of the 721 patients who underwent CEA, 1 died and 10 others had strokes within 30 days (1.5%). Of the 415 who underwent arteriography after randomization but before CEA, 5 (1.2%) suffered transient ischemic attack or stroke caused by arteriography. Thus, a nearly equal risk of stroke was associated with both CEA and carotid arteriography. In addition, 6 transient ischemic attacks and 3 myocardial infarctions could be directly linked to CEA, for a total CEA event rate of 2.6%. Conclusions Patients with asymptomatic internal carotid artery stenosis exceeding 60% reduction in diameter who are acceptable candidates for elective operation may be considered for CEA if the combined arteriographic and surgical complication rates are 3% or less.
178 citations
TL;DR: About 40% of initial survivors of resuscitation out of hospital are discharged home without major neurological disability, suggesting patients at high risk of subsequent cardiac death can be identified and may benefit from further cardiological evaluation.
Abstract: Objectives: To determine the short and long term outcome of patients admitted to hospital after initially successful resuscitation from cardiac arrest out of hospital. Design: Review of ambulance and hospital records. Follow up of mortality by “flagging” with the registrar general. Cox proportional hazards analysis of predictors of mortality in patients discharged alive from hospital. Setting: Scottish Ambulance Service and acute hospitals throughout Scotland. Subjects: 1476 patients admitted to a hospital ward, of whom 680 (46%) were discharged alive. Main outcome measures: Survival to hospital discharge, neurological status at discharge, time to death, and cause of death after discharge. Results: The median duration of hospital stay was 10 days (interquartile range 8-15) in patients discharged alive and 1 (1-4) day in those dying in hospital. Neurological status at discharge in survivors was normal or mildly impaired in 605 (89%), moderately impaired in 58 (8.5%), and severely impaired in 13 (2%); one patient was comatose. Direct discharge to home occurred in 622 (91%) cases. The 680 discharged survivors were followed up for a median of 25 (range 0-68) months. There were 176 deaths, of which 81 were sudden cardiac deaths, 55 were non-sudden cardiac deaths, and 40 were due to other causes. The product limit estimate of 4 year survival after discharge was 68%. The independent predictors of mortality on follow up were increased age, treatment for heart failure, and cardiac arrest not due to definite myocardial infarction. Conclusion: About 40% of initial survivors of resuscitation out of hospital are discharged home without major neurological disability. Patients at high risk of subsequent cardiac death can be identified and may benefit from further cardiological evaluation. Key messages Nearly 70% of patients discharged after cardiac arrest are alive four years after the event Patients whose cardiac arrest is not due to definite myocardial infarction require further cardiological assessment
TL;DR: Using multiple logistic regression, it was found that no diagnostic test performed after myocardial infarction provided additional prognostic information beyond that provided by the standard clinical variables used to predict the risk of death.
Abstract: Background After an acute myocardial infarction, it is important to determine the risk of a subsequent coronary event. We studied the prognostic value of myocardial ischemia detected by ambulatory electrocardiographic (ECG) monitoring in patients who had recently had an acute myocardial infarction. Methods Five to seven days after acute myocardial infarction, 406 patients underwent 48-hour ambulatory ECG monitoring, with submaximal exercise testing before discharge and measurement of the left ventricular ejection fraction within 28 days after infarction. Death, nonfatal myocardial infarction, and admission to the hospital because of unstable angina were the principal end points recorded during the one-year follow-up period. Results The overall incidence of myocardial ischemia detected by ambulatory ECG monitoring was 23.4 percent. The mortality rates at one year were 11.6 percent among the patients with ischemia and 3.9 percent among those without ischemia (P = 0.009); 3.9 percent among the patients with ...
TL;DR: In this paper, the authors examined the influence of thrombolytic strategies, myocardial infarction location, left ventricular function, ST-segment shift, and infarct-related artery patency on heart rate variability.
Abstract: Background Diminished heart rate variability is associated with less favorable prognosis after myocardial infarction. However, the prognostic value of early (first 48 hours) measurement and the influence of thrombolytic strategies, myocardial infarction location, left ventricular function, ST-segment shift, and infarct-related artery patency on heart rate variability have not been examined comprehensively. Methods and Results Heart rate variability and ST-segment analysis of 48-hour Holter tapes were performed with the use of a commercial system in 204 patients who were part of an ST-monitoring substudy of the Global Utilization of Streptokinase and TPA for Occluded Arteries (GUSTO-I) trial. Both time-domain measures (SD of the average normal RR interval for all 5-minute segments of a 24-hour ECG recording [SDANN] and percent difference between adjacent normal RR intervals >50 ms computed over the entire 24-hour ECG recording [pNN50]) and frequency-domain measures (low frequency [LF], high frequency [HF],...
TL;DR: The presence of ACLA is a marker for increased risk of subsequent myocardial reinfarction and thromboembolic events after acute MI.
TL;DR: Left ventricular mural thrombus is a well‐recognized complication of acute myocardial infarction that occurs commonly in those with large anterior Q‐wave infarctions, particularly in the presence of a left ventricular aneurysm.
Abstract: Left ventricular mural thrombus is a well-recognized complication of acute myocardial infarction. In survivors of infarction, the incidence with which mural thrombus occurs is influenced by the location and magnitude of infarction, so that it occurs commonly in those with large anterior Q-wave infarctions, particularly in the presence of a left ventricular aneurysm. Echocardiography, radionuclide imaging with indium-111 labeled platelets, computerized tomography, and magnetic resonance imaging may be used to identify a left ventricular mural thrombus. Acute and chronic anticoagulation with heparin and warfarin, respectively, is given to prevent further thrombus formation and to reduce the incidence of systemic embolization.
TL;DR: Assessment of the magnitude of precordial ST segment depression is useful for acute risk stratification in patients with an inferior myocardial infarction and added significant independent prognostic information after adjustment for clinical risk factors.
TL;DR: Patients with persistently high serum CRP levels, particularly above 20 mg/dl, might have high probability of occurrence of sub-acute cardiac rupture after acute myocardial infarction.
Journal Article•
TL;DR: The findings suggest that ischemic heart disease may be present in a significant number of patients with sickle cell disease and should be considered in all patients who complain of chest pain, whether or not the patient is in crisis.
Abstract: Gross and microscopic findings consistent with acute (three patients) and healed (four patients) myocardial infarction were found in seven (9.7%) of 72 consecutive hearts from patients with sickle cell disease studied after autopsy between 1950 and 1982. Gross obstructive and atherosclerotic lesions were absent in all seven patients, while microthrombi were present in the arterioles of infarcted tissue in two patients. Pathophysiological mechanisms responsible for the infarction are unclear, but anemia, platelet thrombi, coronary vasospasm, and abnormal rheology related to sickle cells may all be important. Chest pain occurred clinically in six of the seven patients and ECG findings typical of infarction were found in two patients. One patient died suddenly. These findings suggest that ischemic heart disease may be present in a significant number of patients with sickle cell disease and should be considered in all patients who complain of chest pain, whether or not the patient is in crisis.
TL;DR: The short‐term infusion of milrinone may have a role in the management of CHF following AMI, especially when the aim is the rapid reduction of pulmonary congestion.
Abstract: The purpose of this study was to compare the hemodynamic and clinical effects of milrinone, a vasodilating and positive inotropic agent, with those of dobutamine in patients with congestive heart failure (CHF) following acute myocardial infarction (AMI). Thirty-three patients in Killip classification II or III within 12 h to 5 days after AMI were randomized in a multicenter, open-label clinical trial to receive a 24-h infusion of milrinone or dobutamine. Drugs were titrated to achieve at least a 30% increase in cardiac index (CI) from mean baseline or at least a 25% decrease in mean pulmonary capillary wedge pressure (MPCWP) from baseline. Both drugs improved CI, MPCWP, and other hemodynamic parameters. Criteria for decrease in MPCWP were met by 94% (15/16) of the milrinone-treated patients and 57% (8/14) of dobutamine-treated patients (p = 0.03). Both groups met the minimum efficacy criterion for CI. Maximal reduction in MPCWP over 0-3 h was greater in the milrinone group (-53.2%) than in the dobutamine group (-31.0%; p < or = 0.01); reductions were sustained over 24 h. Both drugs improved echocardiographic global ejection fraction and were generally well tolerated. The short-term infusion of milrinone may have a role in the management of CHF following AMI, especially when the aim is the rapid reduction of pulmonary congestion.
TL;DR: Specific high diagnostic threshold values for MB-CK and troponin T are needed to optimise diagnostic accuracy in out-of-hospital cardiac arrest survivors without electrocardiographic evidence of myocardial infarction.
TL;DR: The interim analysis suggests that N‐acetylcysteine has a beneficial effect, reducing the functional and structural impacts of myocardial infarction.
Abstract: Our previous experimental research and initial clinical observations regarding the use of N-acetylcysteine in the treatment of ischemic and reperfusion injury in acute myocardial infarction gave rise to a study entitled the Infarct Size Limitation: Acute N-acetylcysteine Defense (ISLAND) trial. Today, this randomized, echocardiographically and angiographically controlled study includes the first 30 patients with a first anterior wall myocardial infarction: Group A (n = 10) consisting of patients with successful recanalization of the infarct-related left anterior descending artery by streptokinase without any further treatment, Group B (n = 10) consisting of patients with failed infarct-related artery recanalization, and Group C (n = 10) comprising patients who had successful streptokinase-induced recanalization of the left anterior descending artery plus N-acetylcysteine administration at a dose of 100 mg/kg body weight. The parameters monitored in our study include changes in global and regional left ventricular ejection fraction of the infarct-related segment using echocardiography and, using electrocardiograms and the Wagner QRS scoring system, the amounts of acutely jeopardized and finally infarcted myocardium. In Group A, global left ventricular ejection fraction rose nonsignificantly within 2 weeks from 37.5 +/- 9.6% to 38.5 +/- 13.8%; it declined significantly in Group B from 36.2 +/- 6.1% to 30.1 +/- 6.7% (p < 0.05), while it considerably improved in Group C from 41.7 +/- 4.1% to 59.6 +/- 8.1% (p < 0.001). Regional left ventricular ejection fraction changed significantly only in Group C: from -4.5 +/- 27.3 to 45.6 +/- 16.3 (p < 0.001). In Group A, in which the amount of acutely jeopardized myocardium was 21.7 +/- 7.2, infarction actually occurred in 20.4 +/- 9.7% (practically no myocardial salvage). In Group B, risk area was 18.1 +/- 4.3%, but infarct size rose to a resulting 29.1 +/- 6.0%. Significant myocardial salvage was accomplished only in Group C: of 26.2 +/- 8.1% of jeopardized myocardium, infarct size was reduced to 10.8 +/- 7.1% (salvage by 58.8%). Also, basic division of patients by therapy showed that, although those with nonidentical findings on their coronary arteries were included into the same groups, patients treated with streptokinase plus N-acetylcysteine had significantly more favorable values of the monitored parameters than those treated with streptokinase alone. We conclude our interim analysis suggests that N-acetylcysteine has a beneficial effect, reducing the functional and structural impacts of myocardial infarction.
TL;DR: In patients with a recent MI, CFVR was significantly lower than in those without MI, both before and after PTCA, and angiographic stenosis severity was the most important determinant of CFVR in both study groups.
TL;DR: A history of hypertension is a negative independent prognostic factor after acute myocardial infarction treated with thrombolysis, and left ventricular failure and recurrent ischaemic events were also significantly more frequent in hypertensives both during their hospital stay and during follow-up study.
Abstract: ObjectiveTo assess the prognostic value of a history of hypertension in patients with acute myocardial infarction (AMI) treated with thrombolysis.DesignRetrospective adjusted analysis of outcome data of patients with AMI randomly allocated to treatment in a controlled study of alteplase versus strep
TL;DR: EMD has a highly predictive accuracy in diagnosing acute left ventricular free wall rupture in patients with a first AMI without overt heart failure and in 13 consecutive cases with a second AMIwithout heart failure, emergency surgery demonstrated LVFWR in all.
TL;DR: In this article, a dyssynergic score was calculated by analysing regional wall motion in 18 left ventricular segments, which indicated that the presence of thrombus is related to the extent of myocardial damage.
Abstract: Background Controversial evidence exists as to whether thrombolytic therapy reduces the incidence of left ventricular thrombus in acute myocardial infarction and, if so, how this relates to successful reperfusion.
Methods Four hundred and eighteen consecutive patients underwent echocardiography and coronary angiography within 3 weeks of an acute myocardial infarction. A dyssynergic score was calculated by analysing regional wall motion in 18 left ventricular segments. The infarct-related artery was considered patent if TIMI grade 2 or 3 flow and less than 90% stenosis were present. Retrograde perfusion by Rentrop's grade 2 or 3 collaterals was considered significant.
Results Large anterior myocardial infarctions were associated with the highest prevalence (39%) of left ventricular thrombosis. Thrombus was also very frequent if the left anterior descending coronary artery was occluded and no collaterals to the infarct area were seen (75%). Anticoagulant therapy reduced the prevalence of left ventricular thrombus, regardless of whether the infarct-related vessel was patent or not. Conversely, in patients undergoing thrombolysis the incidence of left ventricular thrombosis was lower when the left anterior descending coronary artery was patent, and especially when an early creatine kinase peak, suggestive of reperfusion, was recorded (7%). Finally, the presence of left ventricular thrombosis was inversely related to the asynergy score.
Conclusion These observations suggest that the presence of left ventricular thrombus is related to the extent of myocardial damage. Thrombolytic therapy reduces thrombus probably by salvaging myocardium at risk.
(Eur Heart J 1996; 17: 421–428)
TL;DR: There is an interaction between wall motion index andCHF and the interaction of CHF and LV function on long-term mortality was studied in patients with different levels of LV function.
Abstract: Left ventricular (LV) systolic function and congestive heart failure (CHF) are important predictors of long-term mortality after acute myocardial infarction. The importance of transient CHF and the interaction of CHF and LV function on prognosis has not been studied in detail previously. In the TRAndolapril Cardiac Evaluation Study, 6,676 consecutive patients with acute myocardial infarction 1 to 6 days earlier had LV systolic function quantified as wall motion index (echocardiography), which is closely correlated to LV ejection fraction. To study the interaction of CHF and wall motion index on long-term mortality, separate analyses were performed in patients with different levels of LV function. Risk ratio (95% confidence intervals [CI]) were determined from proportional hazard models subgrouped by wall motion index or CHF adjusted for age and gender. Heart failure was separated into transient or persistent. Wall motion index and CHF are correlated. Furthermore, there is an interaction between wall motion index and CHF. The prognostic importance of wall motion index depends on whether patients have CHF or not: the risk ratio associated with decreasing 1 wall motion index unit is 3.0 (2.6 to 3.4) in patients with CHF, and 2.2 (1.7 to 2.9) in patients without CHF when adjusted for age and gender. Similarly, the prognostic importance of CHF depends on the level of wall motion index: the risk ratio associated with CHF is 3.9 (1.8 to 8.3) when the wall motion index is 1.6. Transient CHF is an independent risk factor (risk ratio 1.5, confidence interval [CI] 1.3 to 1.8) although milder than persistent CHF (risk ratio 2.8, CI 2.5 to 3.2).
TL;DR: 201Tl imaging is a sensitive predictor of subsequent adverse cardiac events in patients who have received thrombolysis after acute myocardial infarction, whereas exercise electrocardiography fails to predict outcome.
Abstract: OBJECTIVE: To determine the prognostic role of thallium-201 imaging compared with that of exercise electrocardiography in patients with acute myocardial infarction treated by thrombolysis. DESIGN: Patients who remained free of adverse cardiac events six weeks after myocardial infarction had stress and rest 201TI imaging and exercise electrocardiography and were followed up for 8-32 months. Adverse cardiac events (death, reinfarction, unstable angina, and congestive heart failure) were documented. SETTING: Large district general hospital, Middlesex. SUBJECTS: 100 consecutive male and female patients who were stable six weeks after thrombolysis for myocardial infarction. MAIN OUTCOME MEASURES: Prediction of occurrence of adverse cardiac events after myocardial infarction by exercise cardiography and 201TI myocardial perfusion imaging. RESULTS: Reversible ischaemia on 201TI imaging predicted adverse cardiac events in 33 out of 37 patients with such events during follow up (hazard ratio 8.1 (95% confidence interval 2.7 to 23.8), P < 0.001). Exercise electrocardiography showed reversible ischaemia in 33 patients, of whom 13 had subsequent events, and failed to predict events in 24 patients (hazard ratio 1.1 (0.56 to 2.2), P = 0.8). CONCLUSION: 201TI imaging is a sensitive predictor of subsequent adverse cardiac events in patients who have received thrombolysis after acute myocardial infarction, whereas exercise electrocardiography fails to predict outcome.
TL;DR: In survivors of remote myocardial infarction, metoprolol enhances parasympathetic cardiac activity in the time and frequency domain domain measures of heart rate variability.
Abstract: We assessed the influence of metoprolol on heart rate variability in survivors of remote myocardial infarction. In 43 survivors of myocardial infarction 12 to 18 months previously (26 men and 17 women, aged 38 to 69 years), two 24-hour ambulatory electrocardiograms were recorded 2 weeks apart. In patients in group A (n=28), who had taken metoprolol for the previous year, the drug was discontinued for 2 weeks, after which the first recording was done. The second recording was done 2 weeks after metoprolol was resumed. In patients in group B (n=15), who had not taken metoprolol for the previous year, it continued to be withheld, and two 24-hour recordings were done 2 weeks apart. In group A, metoprolol increased the time domain variables indicative of enhanced vagal tone; root-mean-square successive difference in normal RR (NN) intervals was 20 +/- 11 ms (mean +/- SD) without and 24 +/- 9 ms with metoprolol (p 50 ms (pNN50%) was 3.6 +/- 6.0 without and 5.5 +/- 6.0 with metoprolol (p<0.05). In the frequency domain, the logarithms of the 24-hour very low frequency and the 24-hour high-frequency power (reflecting parasympathetic activity) were increased (5.12 +/- 1.03 and 4.48 +/- 1.51, respectively, without metoprolol; 5.32 +/- 0.99 and 4.83 +/- 1.24, respectively, with metoprolol, p <0.05 for both). Thus, in survivors of remote myocardial infarction, metoprolol enhances parasympathetic cardiac activity in the time and frequency domain measures of heart rate variability.
TL;DR: The relative importance of LV systolic dysfunction and congestive heart failure diminished with increasing age, but the absolute excess mortality was more pronounced in the elderly than in the young.
Abstract: The aim of this study was to assess the importance of congestive heart failure and left ventricular (LV) systolic dysfunction after an acute myocardial infarction (AIM) on long-term mortality in different age groups. A total of 7,001 consecutive enzyme-confirmed AMIs (6,676 patients) were screened for entry into the TRAndolapril Cardiac Evaluation (TRACE) study. Medical history, echocardiographic estimation of LV systolic function determined as wall motion index, infarct complications, and survival were documented for all patients. To study the importance of congestive heart failure and wall motion index independent of age, we performed Cox proportional-hazard models in 4 different age strata ( 75 years). Patients in these strata had 1-year mortality rates of 5%, 11%, 21%, and 32%, respectively. Three-year mortality rates were 11%, 20%, 34%, and 55%, respectively. The risk ratios (and 95% confidence limits) associated with congestive heart failure in the same 4 age strata were 1.9 (1.3 to 2.9), 2.8 (2.1 to 3.7), 1.8 (1.5 to 2.2) and 1.8 (1.5 to 2.2), respectively. The risk ratios associated with decreasing wall motion index were 6.5 (3.6 to 11.4), 3.3 (2.3 to 4.6), 2.7 (2.2 to 3.4), and 2.1 (1.7 to 2.6), respectively. In absolute percentages, there was an excess 3-year mortality associated with congestive heart failure in the 4 age strata of 14%, 24%, 25%, and 28% respectively. The absolute excess in 3-year mortality associated with LV systolic dysfunction in the 4 age strata was 15%, 19%, 25%, and 21%, respectively. Thus, the relative importance of LV systolic dysfunction and congestive heart failure diminished with increasing age. However, the absolute excess mortality associated with congestive heart failure and LV systolic dysfunction was more pronounced in the elderly than in the young.
TL;DR: It is confirmed that long‐term anticoagulant therapy substantially reduces the risk of stroke in post‐myocardial infarction patients and the increased risk of bleeding complications associated with anticoAGulant treatment is offset by a marked reduction in ischemic events.
Abstract: Myocardial infarction survivors have an increased risk of stroke, which is reduced with long-term anticoagulant therapy. However, an estimated 10-times increase in risk of bleeding during such treatment has been reported. We evaluated the risk of stroke in patients after a myocardial infarction and examined the relationship of the risk of intracranial hemorrhage or cerebral infarction and the intensity of anticoagulant therapy. The study population consisted of 3,404 post-myocardial infarction patients who took part in a randomized, double-blind, placebo-controlled trial. Patients were randomized to treatment with anticoagulants (international normalized ratio range, 2.8-4.8) or matching placebo. Mean follow-up was more than 3 years. The incidence of stroke analyzed on "intention-to-treat" was 0.7 per 100 patient-years in the anticoagulant patients against 1.2 in placebo, a hazard ratio of 0.60, with 95% confidence interval of 0.40 to 0.90. In the anticoagulation group, 15 patients had cerebral infarction and 17 an intracranial bleeding, 3 of which occurred after withdrawal of treatment. In the placebo group, the numbers were 43 and 2. Of the 14 intracranial bleeds during anticoagulation, 6 occurred at an international normalized ratio between 3.0 and 4.0 and 8 at greater than 4.0. These results confirm that long-term anticoagulant therapy substantially reduces the risk of stroke in post-myocardial infarction patients. The increased risk of bleeding complications associated with anticoagulant therapy is offset by a marked reduction in ischemic events. The risk of intracranial bleeding is directly related to the intensity of anticoagulant treatment.