non-Q Wave Acute Myocardial Infarction Research Articles

PS-099 Pharmaceutical intervention: enoxaparin use recommendations in patients with renal impairment

BackgroundEnoxaparin is a low molecular weight heparin used in the treatment and prophylaxis of thromboembolic disease. It is metabolised in the liver and its elimination is mainly renal. Renal impairment...

Very Late Recurrence of Takotsubo Syndrome

Recurrence of the Takotsubo syndrome is possible, and in the majority of cases it occurs within 4 years. The present report is focused on a case of the Takotsubo syndrome recurrence after 10 years. The patient had been admitted for the first time in 1999 with a diagnosis of "non-q wave acute anterolateral myocardial infarction." Ten years later, she was readmitted for suspected acute myocardial infarction; coronary arteries, however, were normal, and the left ventricular angiogram demonstrated apical ballooning typical for the Takotsubo syndrome. It is worth noting that the clinical presentation and the ECG were the same on both occasions; in addition, both events were triggered by an emotional stress.

Impact of European Society of Cardiology/American College of Cardiology guidelines on diagnostic classification of patients with suspected acute coronary syndromes.

Assessment of the relative diagnostic accuracy of investigation strategies for patients with suspected acute coronary syndromes (ACS). A prospective observational study followed two groups of patients over a 3-month period in a UK district general hospital. Group one: all admissions with suspected ACS (n = 576); group two: non-cardiac in-patients who were suspected of developing ACS (n = 87). Both were investigated by full clinical history, examination and serial electrocardiographs (ECGs). Conventional World Health Organization (WHO) criteria for myocardial damage were compared with diagnosis based on cardiac troponin T (cTnT). Clinical discharge diagnosis based on conventional WHO criteria was compared with the review diagnosis based on measurement of cTnT. Diagnosis based on WHO criteria missed 58 patients (8.7%) admitted with suspected ACS who had high risk unstable angina. Thirty-three patients (5% of all admissions) who were diagnosed as non-Q wave acute myocardial infarction (AMI) were found to have normal troponin values and to have been incorrectly classified as AMI. Diagnostic strategies based on WHO criteria are inaccurate. The measurement of cTnT in all patients with suspected ACS would have increased the number of those with a diagnosis of AMI by 58 (8.7%), while avoiding inaccurate diagnosis in 33 (5%), therefore producing an absolute increase of 25/663 (3.8%) but a relative increase of 58/138 (42%). In patients with a primary diagnosis of suspected ACS, the overall increase in patients with a diagnosis of AMI will be 55 (9.5%), a relative increase of 55/118 (46.6%) but an absolute increase of 36/576 (6.3%).

Perfil clínico, tratamiento y pronóstico de los pacientes con infarto agudo de miocardio no ingresados en una unidad coronaria: utilidad de una unidad de cuidados intermedios como lugar de ingreso inicial

There is little information about the management and prognosis of patients with acute myocardial infarction (AMI) who are not admitted to coronary care units (CCU) because of the lack of available beds. The aim of this study was to evaluate the characteristics and prognosis of the patients who were admitted to the intermediate care unit (INTCU) of a cardiology department. We compared the clinical profile, management, and 12-month prognosis of the patients admitted to the INTCU or general ward (Ward) instead of the CCU. Out of 242 patients with AMI, 62 (23%) were not admitted to the CCU due to the lack of available beds. Of these, 29 (12%) were admitted to the INTCU and 26 (11%) to the Ward after being monitored for at least 24 h in the emergency room. Patients admitted to the CCU arrived at the hospital early, were younger, less frequently female, and had a lower prevalence of diabetes. ST-segment elevation AMI was more frequent in patients admitted to the CCU than in patients admitted to the INTCU or Ward (67 vs 17 and 23%, respectively; p < 0.0001), and non-Q wave AMI was less frequent (30 vs 76 and 81%; p < 0.0001). No differences were found between groups in the number of stress tests or revascularization procedures performed after the first 24 h, the duration of the hospital stay (median 8 days), or in-hospital mortality. The 12-month survival was 82, 80, and 64% in the patients admitted to the CCU, INTCU, or Ward (p < 0.05), respectively. These differences ceased to be significant after adjusting for the patients' baseline clinical profile and treatment received at admission. Compared to patients with AMI admitted to the CCU, patients admitted to the INTCU or Ward after being monitored at least 24 h had non-ST elevation and non-Q wave AMI more frequently, but a less favorable risk profile for long-term mortality. The different types of AMI were managed similarly and had a similar 12-month prognosis. Intermediate care units may be useful for palliating the lack of CCU beds and care for some patients with AMI.

El dolor torácico en la práctica clínica hospitalaria: repercusión clínica y asistencial del uso rutinario de troponinas

INTRODUCTION AND OBJECTIVES. To study the significance of chest pain in the clinical practice of a Spanish hospital and to evaluate the impact of routine troponin determination. In our institution, routine serial measurements of troponins I and T were made in the evaluation of chest pain in 2000. We compared the results obtained in 1999 for all patients who visited the emergency room for chest pain and the patients who were hospitalized. We recorded the diagnosis at discharge, duration of the hospital stay, and associated costs. In 2000, 1,820 patients with chest pain visited the emergency department, which was equivalent to 1.9% of visits and 7.5 cases per 1,000 people and year: 43% of these patients were hospitalized for suspected acute coronary syndrome as compared to 49% in 1999 (-12%; p > 0.001). Among the patients admitted, 28% were discharged with a diagnosis of non-ischemic chest pain. Troponin determinations were associated with a lower probability of admission due to unstable angina (11.5 vs 16.0%; -28%; p < 0.001) and non-ischemic chest pain (12.1 vs 14.5%; -16%; p < 0.05), and an increase in diagnoses of non-Q wave acute myocardial infarction (3.4% vs 1.8%; +89%; p < 0.01). Non-ST elevation acute coronary syndrome ACS required 3,751 days of hospitalization and 1,003,420 euros of cost, and troponin determinations were associated with a reduction in hospital stays of 832 days (-18.2%) and 185,100 euros (-15.6%). Chest pain had a high incidence, 7.5, and generates high costs in hospital admissions. The routine use of serial troponin determinations was associated with a reduction in hospital admissions due to unstable angina and non-ischemic chest pain, and costs.

Stents in Acute Non-Q Wave Myocardial Infarction.

El tratamiento de la hiperplasia benigna de próstata (HBP) está cambiando debido a un mayor conocimiento de la enfermedad y al desarrollo del concepto funcional de los síntomas del tracto urinario inferior (STUI).Exponer la situación actual en el ámbito de la HBP incluyendo el diagnóstico y tratamiento de los STUI.Se resumen los temas presentados y debatidos por un grupo de urólogos expertos durante el i Congreso UROVI, auspiciado por la Asociación Española de Urología.Los STUI engloban síntomas de llenado, de vaciado y posmiccionales que afectan a la calidad de vida de los pacientes. El diagnóstico etiológico es importante para poder iniciar el tratamiento más idóneo. Por este motivo, se hacen necesarias alternativas terapéuticas nuevas, tanto farmacológicas como quirúrgicas, que permitan abordar de manera individualizada la sintomatología en los diferentes perfiles de pacientes. Se dispone de una nueva combinación de fármacos, solifenacina 6 mg y TOCAS 0,4 mg, para el tratamiento de los síntomas de llenado de moderados a graves y de los síntomas de vaciado asociados a HBP en pacientes que no responden al tratamiento en monoterapia. Asimismo, las nuevas técnicas quirúrgicas, cada vez menos invasivas, permiten intervenir a pacientes de mayor edad y con elevada comorbilidad.La disponibilidad de agentes farmacológicos capaces de actuar sobre los diferentes STUI permite integrar el paradigma anatomofisiopatológico con el funcional para proporcionar el tratamiento más adecuado a nuestros pacientes.The treatment of benign prostatic hyperplasia (BPH) is changing due to a greater understanding of the disease and the development of the functional concept of lower urinary tract symptoms (LUTS).To describe the current state of BPH and the diagnosis and treatment of LUTS.We summarise the issues presented and debated by a group of expert urologists during the First UROVI Congress, sponsored by the Spanish Urological Association.LUTS encompasses filling, voiding and postvoiding symptoms that affect patients’ quality of life. The aetiological diagnosis is an important element in starting the most ideal treatment. For this reason, new alternative therapies (both pharmacological and surgical) are needed to help individually address the symptoms in the various patient profiles. There is now a new combination of drugs (6 mg of solifenacin and 0.4 mg of the tamsulosin oral controlled absorption system) for treating moderate to severe filling symptoms and emptying symptoms associated with BPH in patients who do not respond to monotherapy. Furthermore, new surgical techniques that are increasingly less invasive help provide surgical options for older patients and those with high comorbidity.The availability of drugs that can act on the various LUTS helps integrate the pathophysiological paradigm into the functional one, providing more appropriate treatment for our patients.

Stent in acute non-Q wave myocardial infarction

Dear Editor, This is in reference to the case report “Stents in non-Q wave myocardial infarction” along with very informative discussion by Lt Col JS Duggal et al. Some important aspects though need to be highlighted. 1. Patients presenting with non-Q wave Myocardial Infarction (NQWMI) have a long term outcome, which is similar to that with a Q wave MI (QWMI), including the subset of patients who undergo coronary revascularisation (Fig 1). Thus, there has been extensive use of coronary arteriography (CAG) and revascularisation following NQWMI in an attempt to reduce subsequent morbidity and mortality. Fig. 1 The outcome alter angioplasty for recurrent ischemia after a Q wave or non-Q wave myocardial infarction is similar. Angioplasty was performed because of recurrent ischemia after a Q wave myocardial infarction (175 patients) or a non-Q wave infarction ... 2. Patients with mechanical complications, recurrent angina, electrical instability or congestive heart failure following NQWMI, have a very high risk of reinfarction and death. As a result, CAG followed by revascularisation is used extensively in these patients with complicated NQWMI. In uncomplicated NQWMI cases, routine CAG followed by PTCA of the culprit lesion performed days to weeks after acute NQWMI has become a standard practice at many centres. Only one trial, VANQWISH trial [1], which compared early and late coronary interventions in patients with NQWMI only, reveals that there is no evidence of benefit from an early invasive strategy in patients with uncomplicated NQWMI (Fig 2). Patients who do not have left ventricular (LV) dysfunction or inducible ischemia are at low risk of recurrent events and may well be harmed by unnecessary invasive procedures (Fig 3). Fig. 2 Conservative therapy is better after NQWMI Kaplan-Meier analysis demonstrates that, for patients with a non-Q wave myocardial infarction (NQWMI), a conservative strategy (catheterization and revascularization only for evidence of ischemia) results in ... Fig. 3 A conservatice management approach is effective for a non-Q wave myocardial infarction. Two studies have compared a conservative approach (medical therapy with catheterization and reascularization when clinically indicated) with an invasive approach (catheterization ... 3. Thus recommended approach to CAG and revascularization in patients of NQWMI based on those published by the ACC/AHA task force on practice guidelines (committee on coronary arteriography) [2] is as follows: Patients with cardiogenic shock should undergo immediate coronary angiography followed by PTCA or CABG if anatomy is suitable. Patients with mechanical complications, recurrent angina, electrical instability or CHF following NQWMI should also undergo prompt CAG followed by PTCA or CABG based upon anatomical considerations. Patients with uncomplicated NQWMI should have a non-invasive assessment of LV function and a physiologic evaluation for ischemia prior to discharge. Those with significant LV dysfunction or evidence of inducible ischemia should undergo CAG followed by revascularisation based upon anatomic considerations. There is no apparent benefit from an early invasive approach. The remaining patients are at low risk for recurrent events and should be treated medically. 4. As per recent ACC/AHA guidelines for treatment of patients with NQWMI, Diltiazem is recommended in patients only if there is no LV dysfunction or pulmonary congestion [2]. Also, short-term therapy with ACE inhibitors appears to be beneficial in NQWMI patients with anterior infarction and long-term treatment appears to be effective in those with reduced LV function [3]. 5. Stents in acute MI have come a long way. A large number of case reports and small series support a potential role for intra-coronary stents for acute Ml with success rate reported from 81 to 98%. Although primary stenting improves the short-term outcome of patients, long-term data are sparse. The American College of Cardiology experts consensus documents state that stenting is a promising approach to optimize the results of primary angioplasty for acute Ml and to treat complications [4]. Whether stenting should be used only to treat sub-optimal results or should be recommended as a primary therapy, is still uncertain.

Full recovery of contraction late after acute myocardial infarction: determinants and early predictors

OBJECTIVESTo assess the relative value of electrocardiographic, echocardiographic, angiographic, and in-hospital therapeutic indices for predicting late functional recovery after acute myocardial infarction, and to determine the variables associated with absence of recovery, partial recovery, and full recovery.DESIGNProspective observational follow up study.SETTINGTeaching hospital.PATIENTS74 consecutive patients with a first uncomplicated acute myocardial infarct.INTERVENTIONSDobutamine–atropine stress echocardiography was performed mean (SD) 5 (2) days after the acute event. Quantitative angiography was available in all patients before hospital discharge. A follow up resting echocardiogram was obtained 12 (2) months later.RESULTSFunctional recovery (partial, n = 18; full, n = 27) was observed in 45 of the 74 patients. Recovery was associated with earlier thrombolytic treatment (p = 0.008), earlier peak concentration of creatine kinase (p = 0.009), greater contractile reserve (p = 0.0001), non-Q wave acute myocardial infarction (p = 0.002), and more frequent elective angioplasty of the infarct related vessel (p = 0.0004). Three independent variables were selected stepwise from multivariate analysis for predicting late recovery: contractile reserve (χ2 = 24.2, p &lt; 0.0001); non-Q wave infarction (χ2 = 15.7, p = 0.0001); and the time from symptom onset to thrombolysis (χ2 = 4.94, p = 0.026). Three independent variables predicted full recovery: contractile reserve (χ2 = 17.2, p = 0.0001); non-Q wave infarction (χ2 = 10.1, p = 0.0016); and elective angioplasty of the infarct related artery (χ2 = 4.53, p = 0.033). Only contractile reserve (χ2 = 17.0, p &lt; 0.001) was selected from the multivariate analysis for its ability to distinguish between partial recovery and absence of recovery.CONCLUSIONSLate recovery of contraction relates to earlier treatment, which is associated with lower infarct size unmasked by a non-Q wave event and the presence of contractile reserve. Elective coronary angioplasty of the infarct related artery before hospital discharge is associated with full recovery.

Comprehensive analysis of death and nonfatal myocardial infarction during the first twelve months following acute nonq-wave myocardial infarction: Comparison of invasive versus conservative strategies in the VA non Q-wave infarction strategies in-hospital (VANQWISH) trial Arun K. Kolli, Michael J. Wade, Robert A. O'Rourke, Alvin S. Blaustein, William E. Boden. Veterans Affairs Medical Center, Syracuse, NY, Hartford Hospital, Hartford, CT

Comprehensive analysis of death and nonfatal myocardial infarction during the first twelve months following acute nonq-wave myocardial infarction: Comparison of invasive versus conservative strategies in the VA non Q-wave infarction strategies in-hospital (VANQWISH) trial Arun K. Kolli, Michael J. Wade, Robert A. O'Rourke, Alvin S. Blaustein, William E. Boden. Veterans Affairs Medical Center, Syracuse, NY, Hartford Hospital, Hartford, CT

El infarto sin onda Q en cirugía cardíaca valvular convencional. Diagnóstico mediante la troponina I cardíaca

Morbidity and mortality in elective valve surgery is still significant. The main cause of death in these patients is cardiogenic shock, of which the most frequent etiology is acute myocardial infarction (AMI) with Q wave in the ECG. However, there are patients with cardiogenic shock without Q wave in the ECG and with rises in CK-MB enzyme that makes us suspect non-Q wave AMI.To analyze the use of the determination of cardiac troponin-I, a more specific marker of AMI than CK-MB after cardiac surgery, to detect perioperative non-Q wave AMI, and to establish its clinical significance.A total of 147 patients without coronary artery disease scheduled for elective valve surgery were included. We used, based in anterior publications, ECG (presence or not of new Q wave) and cardiac troponin I to define perioperative AMI. Levels of cardiac troponin-I were analysed before surgery and 14 hours after. Non-Q wave AMI was diagnosed when troponin I was superior to 38.85 ng/ml and there was not a phatologic Q wave in ECG.One hundred twenty-three (83.67%) of patients did not have AMI, 9 (6.12%) suffered perioperative AMI with Q wave, and 15 (10.27%) carried out criteria of non-Q wave perioperative AMI. Morbidity and mortality in this last group was similar to that in the group with Q wave AMI. Morbidity and mortality were minimum in patients without AMI.This study suggest the possibility of in vivo identification of non-Q wave perioperative AMI, an entity with important morbidity and mortality in our series, with a simple determination of cardiac troponin I 14 hours after surgery.

The outcome of patients with a first non-Q wave acute myocardial infarction presenting with ST segment depression, ST segment elevation, or no ST deviations on the admission electrocardiogram

We evaluated the prognosis of patients with a first non-Q wave myocardial infarction according to their admission electrocardiogram. Hospital and 1-year mortality rates in patients with ST elevation (15%, and 21% respectively) and ST depression (17%, and 27% respectively) were similar and significantly higher than in patients with no ST changes (3%, and 10% respectively). Likewise, the adjusted hospital and 1-year mortality risks of patients with ST elevation or depression were comparable but higher than the corresponding mortality risk of patients with no ST deviations. The cumulative 5-year mortality rate was highest among patients with ST segment depression (51%) compared to patients with ST elevation (34%) or no ST deviation (21%), ( p<0.001 for both comparisons). The adjusted 5-year mortality risk of patients with ST depression was higher (HR: 1.83, 95% C.I., 1.17–2.83) compared to patients with baseline ST elevation (HR–1.33, 95% C.I., 0.83–2.12) or patients with no ST changes (reference group). Patients with baseline ST segment elevation and coexistent ST segment depression in other electrocardiogram leads, had a higher in-hospital mortality rate (19%) compared to counterparts without concomitant ST depression (10%) and a tendency for higher in-hospital mortality risk but not for subsequent 1- and 5-year mortality risks. Conclusions: Patients with a first non-Q wave MI with ST elevation or depression on admission have similar hospital and 1-year mortality risk, but the long-term mortality risk is higher among patients with ST segment depression. Patients with ST elevation and concomitant ST segment depression are at increased risk for mortality during the index hospitalization.

The Relation of the Admission Electrocardiogram to Outcome, in Patients With a First Non-Q Wave Acute Myocardial Infarction

The Relation of the Admission Electrocardiogram to Outcome, in Patients With a First Non-Q Wave Acute Myocardial Infarction

The relation of the admission electrocardiogram to outcome, in patients with a first non-Q wave acute myocardial infarction

The relation of the admission electrocardiogram to outcome, in patients with a first non-Q wave acute myocardial infarction

Third and fourth operations for myocardial ischaemia: Short-term results and long-term survival

An increasing number of patients having at least two operations for myocardial ischemia are now presenting for a third or fourth procedure. We report the Mayo Clinic experience with repeated reoperative surgery for coronary artery disease. We have evaluated 67 consecutive patients (54 men, 13 women) during a 14-year period (1978 to 1992). The mean age at the third procedure (n=63) was 63.4 years and at the fourth procedure (n=4) was 70.6 years. Clinical indications for surgery were unstable angina in 29 patients (43%), New York Heart Association class III angina in 36 (54%), non-Q wave acute myocardial infarction in 1, and acute pulmonary edema in 1. Urgent or emergency surgery was undertaken in 17 patients (25%). All patients had triple-vessel disease, and 20 (30%) had left main coronary artery stenosis >50%. The mean ejection fraction in 56 patients was 0.56+/-0.11. Occlusion or significant stenoses of preexisting saphenous grafts were thought to be the major cause of recurrent ischemia in 64 patients (96%). Only 14 patients (21%) had received previous arterial grafts. An average of 2.4 grafts was placed, and a new internal mammary artery was used on 47 occasions. Eight patients (11.9%) died. Three patients required a left ventricular assist device, and one of them survived. There were 21 late deaths: 8 were cardiac and 5 were likely to be cardiac. Five-year and 10-year survival in all patients was 75.6%+/-5.3% and 47.9%+/-7.7%, respectively. Freedom from further intervention for hospital survivors at 5 and 10 years was 88.4+/-4.5 and 72.3+/-8.5%, respectively. Of the 38 patients still alive at last follow-up, 29 (76%) were considered to be in New York Heart Association functional class I or II. On univariate analysis, use of an intra-aortic balloon pump, prolonged bypass time, left main coronary artery stenosis >50%, and a surgeon's impression of angiographic inoperability correlated with increased risk of early mortality. We conclude that in a select group of patients, repeated reoperative surgery, despite an increased mortality, can result in good long-term survival and significant improvement in clinical status.

Clinical Features of Non-Q Wave Acute Myocardial Infarction

Sung Hee Kim, M.D., Joon Woo Kim, M.D., Ju Han Kim, M.D., Young Keun Ahn, M.D., Yul Bae, M.D., Jong Cheol Park, M.D., Kwang Soo Cha, M.D., Joo Hyung Park, M.D., Myung Ho Jeong, M.D.,* Jeong Gwan Cho, M.D.,* Jong Chun Park, M.D.,* Jung Chaee Kang, M.D.* Department of Internal Medicine, Chonnam University Medical School, Chonnam, Korea Research Institute of Medical Sciences,* Chonnam National University, Chonnam, Korea

Registros de morbimortalidad en cardiología: metodología

The effectiveness of diagnostic, preventive and therapeutic procedures, whose efficacy has been assessed in clinical trials, should be tested in a real treatment scenario. The procedures used in acute myocardial infarction (AMI) management can be evaluated by means of cohort studies that include all consecutive patients admitted to one or several hospitals. Such studies are called hospital registries. They are simpler to organize and cheaper than clinical trials. On the other hand, the AMI population-based registries allow the establishment of the incidence and mortality rates, as well as case-fatality as they include those patients who die before reaching hospital facilities. In both types of registries a set of variables on co-morbidity, age, sex, severity, and the utilization of procedures along with the course of the disease are systematically recorded in each patient using standard definitions to warrant the internal validity. In hospital registries, the external validity of the results will depend on whether the sample of hospitals represents the population where it was obtained. A good registry should include patients with a wide age range, allow the analysis of specific subgroups of patients such as non-Q wave or first AMI to allow for comparison with other registries. In addition, it should also permit a mid-term follow-up, respect ethical issues, receive appropriate funding and keep a multidisciplinary team involved in its design and development.

Seasonal Pattern of Acute Myocardial Infarction in the National Registry of Myocardial Infarction

The purpose of this study was to determine whether the rate of hospital admission for acute myocardial infarction (AMI) varies seasonally in a large, prospective U.S. registry. Identification of specific patterns in the timing of the onset of AMI is of importance because it implies that there are triggers external to the atherosclerotic plaque. Using death certificate data, most investigators have noted a seasonal pattern to the death rate from AMI. However, it is unclear whether this observation is due to variation in the prevalence of AMI or to other factors that may alter the likelihood of a fatal outcome. We examined the seasonal mean number of cases of AMI (adjusted for the length of days in each season) that were submitted to the National Registry of Myocardial Infarction (NRMI) by 138 high volume core hospitals over a 3-year period (December 21, 1990 through December 20, 1993) during which the number of hospitals participating in the Registry was stable. Data were analyzed using general linear modeling and analysis of variance. High volume core hospitals reported 83,541 cases of AMI to the Registry during the study period. Approximately 10% more such cases were entered into the Registry in winter or spring than in summer (p < 0.05). The same trends were seen in both northern and southern states, men and women, patients < 70 versus > or = 70 years of age and those with Q wave versus non-Q wave AMI. We conclude that there is a seasonal pattern to the reporting rate of cases of AMI in the NRMI. This observation further supports the hypothesis that acute cardiovascular events may be triggered by events that are external to the atherosclerotic plaque.

Long-term prognosis of patients after a Q wave compared with a non-Q wave first acute myocardial infarction. Data from the SPRINT Registry.

OBJECTIVE, DESIGN AND PATIENTS: Between August 1981 and July 1983, 5839 consecutive myocardial infarction patients were hospitalized in 13 coronary care units in Israel. The present study examines 10 year survival among 4037 consecutive patients with a first myocardial infarction with either Q or non-Q waves. Demographic and medical data were collected from hospital records, and 1 year clinical follow-up was complete for 99% of hospital survivors. Mortality follow-up was extended to June 1992 (mean 10 years of follow-up). Five hundred and eighty patients (14%) had first myocardial infarctions of the non-Q wave type and 3457 of the Q wave type. Hospital mortality was significantly higher in patients with a Q wave (10%) than those with a non-Q wave myocardial infarction (7%) (P < 0.05). One year post-discharge, non-fatal reinfarction and mortality rates were comparable in patients with Q wave (4% and 7%) and non-Q wave myocardial infarctions (4% and 7% respectively). Similarly, 5 to 10 year post-discharge mortality rates were equally high in patients with a non-Q wave (26% and 44%) as in those with a first episode of a Q wave myocardial infarction (22% and 40% respectively). Patients with a first non-Q wave acute myocardial infarction exhibited relatively better in-hospital survival than counterparts with a first Q wave infarction, but the advantage did not persist after discharge. Patients with a non-Q wave infarction deserve particular attention as their post-discharge mortality risk is similar to counterparts with a first Q wave myocardial infarction.

Does Aspirin Consumption Affect the Presentation or Severity of Acute Myocardial Infarction?

While consumption of aspirin has been shown to decrease the occurrence of nonfatal cardiac events, the majority of studies have not demonstrated any impact of aspirin intake on cardiovascular mortality. The present population-based study explores the possibility that aspirin consumption affects the presentation and severity of acute myocardial infarction (AMI), and hence the likelihood of clinical detection. We monitored the use of aspirin before admission for 2114 patients with a validated diagnosis of AMI in 16 hospitals in the Worcester, Mass, metropolitan area during 1986, 1988, and 1990. The AMIs were characterized as Q wave vs non-Q wave and large (peak creatine kinase levels more than five times normal) vs small (peak creatine kinase levels less than two times normal). A total of 332 patients (16%) with validated AMI took aspirin before hospital admission. Nearly 65% of aspirin users had non-Q wave AMIs, compared with 49% of nonaspirin users. Thirty percent of aspirin users sustained small AMIs, compared with 22% of nonaspirin users. These findings persisted after stratifying for previous AMI, history of coronary disease, receipt of thrombolytic therapy, and exclusion of early hospital deaths. Using multivariable regression models to control for age, gender, previous evidence of coronary disease, and use of other medications, prior aspirin consumption remained independently associated with AMI type (non-Q-wave AMI) and smaller infarct size. Aspirin consumption appears to modify the presentation of AMI, increasing the likelihood that the infarct will be of the small, non-Q-wave variety.

Electrocardiographic Appearance of a Non-Q Wave Acute Myocardial Infarction in a Patient with Thyrotoxicosis

A patient with severe thyrotoxicosis developed the typical electrocardiographic (ECG) evolution of a non-q myocardial infarction. This occurred without evidence of myocardial necrosis and in the absence of coronary artery disease. Treatment with beta blockers resolved the ECG changes despite the persistence of the thyrotoxic state.