Acute Coronary Attack Research Articles

Abstract 10497: Predictors of Poor Prognosis in Stable Coronary Artery Disease with and without N-Terminal Probnp Elevation

Background: Mineral Metabolism (MM) system and N-terminal probrain natriuretic peptide (NT-ProBNP) have been shown to add prognostic value in stable coronary artery disease (SCAD). However, the influence of NT-ProBNP on the prognostic role of MM in SCAD has not been shown yet Methods: We analyzed the prognostic value of MM markers (parathormone [PTH], klotho, phosphate, calcidiol [25-hydroxyvitamin D3], and fibroblast growth factor-23) in 964 pts. with SCAD and NT-ProBNP>125 pg/ml vs pts. with NT-ProBNP≤125 pg/ml included in five hospitals of Spain. The main outcome was the combination of death, heart failure, and ischemic events (any acute coronary syndrome, ischemic stroke, or transient ischemic attack). Results: 622 pts. had NT-proBNP>125 pg/ml and 342 pts. had NT-ProBNP≤125 pg/ml. Median follow-up was 5.1 years. In the group of NT-proBNP>125 pg/ml patients were older, and there were more females and smokers than in pts. with normal NT-proBNP.In high NT-proBNP pts., the predictors of poor prognosis were PTH [HR=1.00 (1.00-1.00) p<0.001] and NT-proBNP [HR=1.006 (1.00-1.01) p=0.011], along with age [HR=1.039 (1.02-1.06) p<0.001], prior coronary artery by-pass graft [HR=1.624 (1.02-2.59) p=0.041], treatment with statins [HR= 0.315 (0.19-0.53) p<0.001], insulin [HR=2.490 (1.59-4.09) p<0.001], angiotensin receptor blockers [HR= 1.726 (1.16-2.56) p=0.007], nitrates [HR= 1.645 (1.10-2.45) p=0.014], and proton pump inhbitors [HR= 2.754 (1.74-4.36) p<0.001]. In the NT-proBNP≤125 pg/ml subgroup, poor prognosis predictors were plasma levels of non-high-density lipoprotein (non-HDL) cholesterol [HR=1.01 (1.00-1.02) p=0.014] and calcidiol [HR= 0.96 (0.92-0.99) p=0.045], as well as treatment with verapamil [HR=11.28 (2.54-50.00) p=0.001], and dihydropyridines [HR= 3.16 (1.63-6.13) p=0.001], Conclusion: In pts. with SCAD and NT-ProBNP>125 pg/ml, PTH and NT-ProBNP, that are markers related with ventricular damage, are predictors of poor outcome. In the subgroup of pts. with NT-ProBNP≤125 pgm/l, calcidiol and non-HDL cholesterol, more related to vascular damage, are the independent predictors of poor outcome. Then, in pts. with SCAD, baseline NT-ProBNP may influence the type of biomarker that should be used for risk prediction.

Acute coronary syndrome in a patient with transient ischemic attack: challenges of antithrombotic therapy (a clinical case)

The paper presents experience with antithrombotic therapy in a critically ill patient with acute coronary syndrome and transient ischemic attack. It characterizes problems in triple antithrombotic therapy in a very ill patient with comorbidity. The paper demonstrates an incremental approach to choosing therapy according to the clinical picture of disease, an assessment of risk factors for ischemic and hemorrhagic complications over time, which is very important in the routine practice of a physician. It also shows how, based on existing recommendations, the optimal anticoagulant is chosen as part of triple and double antithrombotic therapy in terms of its potential risks and possible complications.

Evaluation of vascular events in patients with myeloproliferative syndromes and mutations of either the januskinase-2 or calreticulin gene at the university hospital Krems from 2008 to 2015

Myeloproliferative neoplasms (MPN), classified as polycythemia vera (PV), essential thrombocytosis (ET) and myelofibrosis (MF) are stem-cell derived disorders. Mutations in either the januskinase-2 (JAK-2) or the calreticulin (CALR) gene are characteristic for MPN and may result in enhanced proliferation of red blood cells, white blood cells and platelets, and thus increase the risk for vascular events.This study is a retrospective and descriptive analysis of records of patients, who underwent treatment for myeloproliferative syndromes at the Department of Hemato-Oncology of the University hospital Krems from 2008 to the end of 2015. Out of 250 patients, who were suspected for MPN, 51 patients displayed a JAK-2 V617F mutation. These were analyzed with regard to their blood values, gender, age at diagnosis, therapy and vascular events before and after diagnosis (during therapy). Of the 51 patients diagnosed with MPN and a JAK-2 V617F mutation, 33 suffered from PV, 15 from ET and 3 from MF. More men than women were diagnosed with MPN and the median age at diagnosis was 72 years. Acetylsalicylic acid, phlebotomy and Hydroxyurea were the most frequent therapies applied. In our study cohort, the most common vascular events were acute coronary syndrome and transitory ischemic attack. Thromboembolic events were effectively reduced by MPN therapy while no elevation in bleeding events could be observed.

Acute coronary syndrome due to high aortocoronary junction of the right coronary artery: The value of multislice CT

High aortocoronary junction of the right coronary artery (RCA) above the sinus of Valsalva is not rare. There is controversy whether it is a benign finding or a life threatening condition. A 47-year-old male, who had recurrent acute coronary syndrome underwent coronary arteriogram twice showing only an aberrant origin of the RCA ostium from the left coronary cuspid. Sixty-four cut multislice computed tomogram (MSCT) of the coronary arteries showed the RCA ostium taking off above the right sinus of Valsalva. The RCA then shifted leftward and coursed between the great vessels. Compression of its proximal segment as it passed between the aorta and pulmonary artery explained the recurrent coronary attack. High take-off of the RCA ostium above its cuspid should be considered a risk factor for acute coronary attack under certain conditions. MSCT is valuable in providing better spatial images compared to the more invasive conventional coronary arteriography.

Fatality outside hospital from acute coronary events in three British health districts, 1994-5

Objectives: To provide a contemporary account of the treatment and outcomes of acute coronary attacks in England and Wales and to identify strategies that might improve the outcome.Design: Two year...

Does stopping smoking delay onset of angina after infarction?

This study was designed to determine the relation between stopping smoking and angina after infarction in survivors of an acute coronary attack. The study population comprised 408 men aged under 60 who survived a first attack of unstable angina or myocardial infarction by 28 days and were smoking cigarettes at the time of their attack. These patients were followed up for an average of nine years. Three hundred and eighty four were alive at the one year follow up examination, when the presence or absence of angina together with habits of smoking were recorded. The prevalence of angina at one year was 19.5% in the 241 who had stopped smoking cigarettes compared with 32.2% in those who had continued (p less than 0.01). Six years later, however, the prevalence of angina after infarction was the same in the two groups. It is concluded that the onset of angina after infarction can be delayed by stopping smoking cigarettes but that this effect is not maintained in the long term.

Prognostic significance of an ST segment depression of patients with an acute coronary attack

An ST-segment depression was studied in the ECGs recorded on the first and third day after admission of 580 patients with an acute heart attack. An acute myocardial infarction was found in 86% of the 115 patients in whose ECG the J-point was depressed 2 mm. or more and the ST-segment was horizontal or sloping downwards in at least one lead (a definite ST-segment depression). The degree of the J-point depression was deemed of prognostic significance. During the first four weeks, the mortality rate was lowest (4.7%) in patients with a J-point depression less than one millimeter or no depression. The corresponding figure for patients with a definite ST-segment depression was three times (21.7%) that of the patients without the pattern (7.3%). The definite ST-segment depression in an acute coronary attack seemed to be accompanied by a severe degree of coronary heart disease. Significant differences between the patients with a definite ST-segment depression and those without the pattern were found in the C T ratio, in the degree of pulmonary congestion, in the ECG signs of LVH, and in the digitalis treatment. It is concluded that the definite ST-segment depression has an important clinical and prognostic significance in cases of acute coronary attacks.

The Acute Coronary Attack

The Acute Coronary Attack

Book Reviews

Book reviewed in this article:Primary pulmonary hypertension. Report on a WHO meeting. Edited by S. Hatano and T. StrasserThe Acute Coronary Attack. By J. F. Pantridge, A. A. J. Adgey, J. S. Geddes and S. W. Webb

Life support stations

A life support station (LSS), either mobile or fixed, may be established in areas of population density where patients with acute coronary attack or acute myocardial infarction can receive prompt medical care. The mobile LSS are represented by mobile coronary or intensive care unit. The fixed LSS are ideally established in the Emergency Departments of different hospitals. They may also be considered for the following locations: factories, large office buildings, metropolitan airports, large railroad stations, stadiums, and convention halls. The functions and potential advantages of a LSS include the following: initiation of early care with monitoring of the vital signs and electrocardiogram, prevention and management of serious cardiac arrhythmias, institution of cardiopulmonary resuscitation including defibrillation, stabilization of the patients' condition before transfer, and reduction of the incidence of cardiogenic shock and overall mortality.

Life Support Stations

A life support station (LSS), either mobile or fixed, may be established in areas of population density where patients with acute coronary attack or acute myocardial infarction can receive prompt medical care. The mobile LSS are represented by mobile coronary or intensive care unit. The fixed LSS are ideally established in the Emergency Departments of different hospitals. They may also be considered for the following locations: factories, large office buildings, metropolitan airports, large railroad stations, stadiums, and convention halls. The functions and potential advantages of a LSS include the following: initiation of early care with monitoring of the vital signs and electrocardiogram, prevention and management of serious cardiac arrhythmias, institution of cardiopulmonary resuscitation including defibrillation, stabilization of the patients' condition before transfer, and reduction of the incidence of cardiogenic shock and overall mortality.

Current status of coronary prevention: Lessons from the Framingham study

In the past decade dramatic innovations have been made in the management of the acute coronary attack culminating in organized coronary care units and cardiac surgery. Epidemiologic studies have identified major host and environmental contributors to coronary incidence allowing both assessment of risk and identification of vulnerable persons for prophylaxis. Notwithstanding these advances there is no evidence that coronary mortality in the community has been significantly reduced. The authors believe that the only hope for a major impact on coronary mortality lies in primary prevention. Two approaches to the prevention and control of the atherosclerotic diseases are possible. First, by the development of public health measures which will favorably change environmental and host factors. Such measures would include improved regimens of both diet and exercise, elimination of cigarette smoking, and reduction of weight and blood pressure. This will entail a comprehensive and forceful program of education for the American public. It is unlikely that the public will accept the necessary controls of the entire population unless the beneficial effects thereof have been clearly demonstrated on an individual basis. Secondly, by the detection of persons at high risk of developing disease combined with an attempt on an individual basis to change the major adverse host and environmental characteristics. This will require a great deal of effort and motivation by both patient and physician. The degree of change needed and the age at which such change is undertaken are important considerations. The earlier in life positive changes in life habits are instituted, the greater will be the probability of increased longevity and a healthy active life.

Long-term prognosis and insurability in coronary heart disease

Long-term prognosis in the individual patient with coronary heart disease is unpredictable. However, there are broad patterns of survival in the various clinical syndromes which may be expressed in sufficiently quantitative terms to allow an estimate of insurability. Clinical and actuarial studies are surveyed comprising long-term follow-up of groups having: (1) acute attacks of myocardial infarction, (2) angina pectoris, (3) atypical chest pain, (4) asymptomatic electrocardiographic abnormalities, including bundle branch block and T-wave abnormalities, (5) electrocardiographic evidence of coronary insufficiency on performance of exercise or hypoxemia stress tests. Prognosis is expressed most conveniently in terms of mortality ratios (actual to expected deaths), i.e., the relative number in a group succumbing compared to the relative number in the general population of the same age and sex dying in the some period. In most clinical studies the long-term prognosis, i.e., survival after the initial period of acute coronary attacks, has been analyzed in terms of the percentage alive after five and ten years. Mortality in the first two years after a coronary attack is of the order of six to seven times normal (mortality ratio of 600 to 700 per cent). Thereafter it falls progressively, with increasing intervals of time after the attack. Other factors have significant bearing on survival after coronary attacks. The milder the acute attack, the more complete the recovery, and the older the age at which it occurs, the more favorable the long-term outlook. In such groups, life expectancy may far exceed the over-all average experience, which in most studies has been that 3 of 5 persons surviving acute infarction live a further five years, and 1 of 3 survives ten years. Conversely, in persons who have accompanying disorders predisposing to progression of coronary disease, such as diabetes, the long-term outlook is poorer than average. Mortality ratios are somewhat better in persons with angina pectoris than in those who have had known attacks of myocardial infarction, although in one very extensive study the five- and ten-year survival rates were not significantly higher. Long-term prognosis is slightly better in females than in males both in instances of angina pectoris and after coronary attacks. Asymptomatic electrocardiographic abnormalities also have an adverse effect on survival. Mortality in those with major T-wave abnormalities is approximately three and one-half times the normal, and in those with minor T-wave changes it is twice the normal. Bundle branch block, at one time considered an ominous finding, is not (in the absence of accompanying physical impairments) associated with any striking increase in mortality ratios and is prognostically less unfavorable than T-wave abnormalities. Among those who have ischemic electrocardiographic changes after exercise, mortality rates are almost threefold greater than among those with a negative response. Actuarial investigations, as well as epidemiologic studies on the rate of development of coronary heart disease, indicate that the risk of developing overt disease may be multiplied several fold in the presence of various predisposing factors, particularly when multiple factors are present concurrently. Among these are elevated serum cholesterol, obesity, hypertension, diabetes, strong family history of coronary disease, heavy smoking, sustained stressful personality pattern, and arcus senilis. There are indications that the course of coronary heart disease may be modified, and that the pattern of survival may begin to approach that of the average population by controlling some of the predisposing factors, and by application of such measures as dietary restriction of fat and prolonged anticoagulation. Persons with coronary heart disease, of whatever type, as groups, have an abbreviated life expectancy, and the great majority succumb to complications of their coronary disease, most commonly recurrent acute coronary attacks or sudden death, and, more particularly in older persons, congestive heart failure. However, clinical and actuarial experience indicates that long-term mortality ratios following attacks of myocardial infarction and in other syndromes of coronary heart disease are not prohibitive; and insurability may be considered in appropriate circumstances, e.g., at an interval after recovery from acute attack, when functional recovery is good, and when there are no accompanying adverse factors.

The problems of acute coronary attacks without classic electrocardiographic signs of acute myocardial infarction

In patients with a good history favoring the diagnosis of myocardial infarction and with slightly abnormal electrocardiograms, exploration of the upper midchest, upper lateral chest, posterior axillary line, over the ensiform and in left scapular line, will frequently reveal the typical record of infarction. Subendocardial infarction may be diagnosed from persistent S-T depression in several leads. Serial electrocardiograms are often necessary over a period of two weeks before the signs of infarction are found. Other factors producing slight electrocardiographic abnormalities must also be considered in the diagnostic significance of the record. The terminology of arteriosclerotic heart disease should include angina pectoris and myocardial infarction. The latter should be modified by the severity of the clinical signs as mild or slight, moderate or severe. A further modifying term will include the tentative electrocardiographic localization. A plea is made to drop the terms coronary insufficiency and coronary failure in clinical diagnosis.

Idiopathic recurrent pericarditis: Comparison with the postcommissurotomy syndrome; considerations of etiology and treatment

Forty-two episodes of idiopathic pericarditis occurring in twelve patients were studied. The manifestations were compared with those observed in seventy-two attacks of the postcommissurotomy syndrome in twenty-four patients. There is a striking resemblance between the clinical and laboratory features of idiopathic pericarditis and those of the postcommissurotomy syndrome. Both diseases include pericarditis, pleurisy and pneumonitis although the incidence of these components varies in the individual case. In some instances the occurrence of gallop rhythm, dilatation of the heart, transient auricular flutter-fibrillation and congestive heart failure suggests involvement of the myocardium. The outstanding clinical features are pain of the pleuropericardial type and fever. Both syndromes usually have a benign course and tend to relapse frequently. There are compelling reasons for the belief that the postcommissurotomy syndrome is a manifestation of rheumatic activity. The same etiology is suggested for some cases of “idiopathic” pericarditis by the following facts: (1) Close resemblance of idiopathic pericarditis and the postcommissurotomy syndrome; (2) presence of major and minor rheumatic manifestations in a relatively large number of cases of idiopathic pericarditis reported in the literature and in two-thirds of the cases observed by the writer; (3) salicylates and pyramidon sometimes have a beneficial, even dramatic effect in cases of idiopathic pericarditis; and (4) idiopathic pericarditis is predominantly a disease of the adult. Rheumatic fever in the adult is known to manifest itself often atypically, as a benign exudative process which may heal without residual heart disease. The finding of pleurisy and/or pneumonitis aids in the differentiation of idiopathic pericarditis from an acute coronary attack.

Factors in the onset of coronary occlusion and coronary insufficiency; effort, occupation, trauma and emotion.

Diseases of the heart, particularly those involving the coronary arteries, are the major medical problem facing us today. Estimates of the number of persons with heart disease in this country have varied up to eight million,¹and practically half of cardiac deaths are caused by coronary artery disease.²We have estimated that one-half to one million attacks of coronary occlusion occur annually.³Probably an equal number of acute coronary insufficiency occur.⁴As the span of life has lengthened, the incidence of coronary artery disease has increased, and will continue to do so. It has been estimated that in 1980 there will be 42 million persons between the ages of 50 and 74—almost double the number in 1940.⁵ The importance of coronary artery disease in industry scarcely requires emphasis, considering that over 60 million persons are employed and that, although two-thirds of acute coronary attacks occur

Coronary Occlusion and Coronary Insufficiency

Acute coronary attacks may be divided clinically, electrocardiographically, pathologically and therapeutically into (i) classical angina pectoris, (2) acute coronary insufficiency and (3) acute coronary occlusion. In 1000 consecutive cardiac consultations, 450 of 618 cases with organic heart disease had coronary artery disease. Of these 450 cases, 38 per cent had chronic coronary insufficiency (angina pectoris or congestive failure), 26 per cent had acute coronary insufficiency, and 36 per cent had acute coronary occlusion. The differentiation between coronary occlusion and insufficiency which can be made electrocardiographically in 95 per cent of cases is discussed in this paper.