Episode Of Acute Myocardial Infarction Research Articles

Acute myocardial infarction: psychosocial and cardiovascular risk factors in men.

Controversy still exists over the independent role of psychosocial factors in acute myocardial infarction (AMI). This study aimed to compare psychometric indices in Portuguese patients surviving a first episode of AMI and a community sample free of AMI. A community-based, case-control study. The study sample included 153 male patients with a first episode of AMI and 156 male controls randomly selected from the community. Information on demographic, social, medical and behavioural characteristics was obtained using a structured questionnaire; anthropometric, blood pressure, and serum measurements were performed, and the psychometric evaluation was obtained using a self-evaluation questionnaires (Bortner scale, Beck Depression Inventory, SCL-90-R, Psychological General Well-Being and the Nottingham Health Profile). Cases of AMI more often exhibited type A behaviour (15.4 +/- 3.0 versus 14.7 +/- 2.7, P = 0.041), had more depressive symptoms (10.8 +/- 8.0 versus 8.6 +/- 8.0, P = 0.005) and showed worse scores on general well-being (68.4 +/- 17.7 versus 76.6 +/- 16.2, P < 0.001) than controls. Cases were significantly different from controls in terms of years of education (6.7 +/- 4.4 versus 9.0 +/- 4.7 years, P < 0.001), hypertension (43.1% versus 30.1%, P = 0.024), dislipidaemia (43.8% versus 34.0%, P = 0.038), type I obesity (53.6% versus 42.3%, P = 0.045), smoking (54.1% versus 26.5%, P < 0.001), no practise of exercise (68.5% versus 50.3%, P = 0.002) and presence of non-insulin-dependent diabetics (16.3% versus 6.4%, P = 0.010). After adjusting for such factors a similar set of significant psychometric results was found. Type A behaviour, depression and lower levels of well-being and quality of life, independent of other cardiovascular risk factors, were significant features of AMI cases.

League tables and acute myocardial infarction

Comparison of the outcomes of care provided by hospitals is a growing trend. Outcomes need to be distinguished into those attributable to the practice of hospitals and those that arise from differences in the characteristics of patients and the underlying morbidity of the populations for whom hospitals provide care. We explored these issues for deaths in hospital or within 30 days of discharge after acute myocardial infarction in Scotland, UK. We used records from December, 1992, to November, 1993, for 14,359 episodes of acute myocardial infarction, the death records of those who died, and 9391 death records for individuals who died after acute myocardial infarction but who had not been in hospital in the 30 days before death. Hospital discharge records were taken from the Scottish Morbidity Records. The outcomes we investigated were all-cause mortality within 30 days of discharge from hospital, and death from acute myocardial infarction at any time during the study period. We estimated separately effects attributable to patients' characteristics, hospitals, and areas of residence with multilevel modelling. We found significant differences between hospitals by age, sex, and medical history. The odds ratios for death ranged from 0.62 (95% CI 0.50-0.80) to 1.28 (1.07-1.59), relative to the average performance for Scotland as a whole. Analysis including area of residence, deaths occurring out of hospital, and more detailed information about patients showed no significant differences between hospitals for patients aged 70 years. By postcode area, there was a strong association between out-of-hospital deaths and deaths in hospital or shortly after discharge. Hospital outcomes may vary from one subgroup of patients to another and should be assessed independently of patients' areas of residence. Measures of performance that do not provide valid comparisons could diminish public confidence in hospital services.

Comprehensive Reliability Assessment and Comparison of Quality Indicators and Their Components

To test whether conventional data reliability assessment overestimates reliability, an assessment and a comparison of the reliability of complex quality indicators and their simpler components were conducted. Medical records of 1078 Medicare cases with principal diagnoses of initial episodes of acute myocardial infarction (AMI) were independently reabstracted at two national Clinical Data Abstraction Centers (CDACs). The inter-rater agreement beyond chance (kappa) of reabstracted and original quality indicators and key components were computed and compared. Results showed excellent agreement (kappas ranging from 0.88 to 0.95) for simple determinations of whether standard medical therapies were provided. Repeatability of eligibility status and the more complex determinations of whether “ideal” candidates were not treated showed moderate to excellent kappa values ranging from 0.41 to 0.79. A planned comparison of five similar quality indicators and their key components showed that the simpler treatment components, as a group, had significantly higher kappas than the more complexly derived eligibility components and composite indicators (Fisher's exact, p < 0.02). Reliability assessment of quality indicators should be based upon the repeatability of the whole indicator, accounting for both data and logic, and not just one simple element.

Plasma and erythrocyte manganese concentrations. Influence of age and acute myocardial infarction.

This study was carried out to assess manganese (Mn) status after an acute episode of myocardial infarction. Plasma and erythrocyte Mn concentrations were measured from admission to hospital to day 15 postadmission in 21 patients suffering from acute myocardial infarction and in three control groups. The determination of Mn in these biological fluids was performed by electrothermal atomic absorption spectrometry. Plasma Mn was higher (p < 0.01) and erythrocyte Mn was similar in the acute myocardial infarction group compared to healthy age-matched control group. Plasma and erythrocyte Mn remained unchanged during the 2 wk after acute myocardial infarction and were not correlated to enzyme activities. A decrease of erythrocyte Mn with age, expressed in nmol/L, was noted (p < 0.02). These results suggest that plasma and erythrocyte Mn do not provide an indication of myocardial damage. Nonetheless, Mn status in elderly merits further attention.

Twenty-five—year mortality rate decrease in patients in Israel with a first episode of acute myocardial infarction

The aim of our study was to compare the outcome of patients with a first acute myocardial infarction (AMI) among three large cohorts of patients hospitalized between 1966 and 1992 in Israel, in view of changes in treatment facilities and investigation methods. Patients with a first AMI constituted 71% of all myocardial infarctions in 1966, 74% in 1981–1983, and 71% in 1992. The male—female ratio and the distribution of the site of infarction also remained stable from 1966 to 1992. The mean age of patients increased over time. Thrombolytic therapy was not available in 1966 and 1981–1983, whereas 53% of patients were treated with a thrombolytic agent and 22% examined with coronary angiography in 1992. The 21-day mortality rate decreased markedly, from 22% in 1966 to 14% in 1981–1983 and to 8% in 1992. The decrease was similar in both genders and among 10-year age groups. The 1-year postdischarge mortality rate (not evaluated in 1966) decreased from 7% in 1981–1983 to 6% in 1992. We conclude that a significant reduction in mortality rate after a first AMI took place over the 25-year period. Changes in treatment modality and management of the acute phase may explain this decrease in mortality rate over time.

Studies of the coronary circulation in Chagas' heart disease.

Pathogenesis of chronic Chagas' heart disease may include various disturbances in the coronary circulation, that could be responsible for the myocardial lesions seen in human hearts and in experimental models of the disease. In this paper we critically reviewed the anatomical and functional abnormalities described in chronic chagasic patients, pertaining to the so-called vascular pathogenetic theory of Chagas' disease. The epicardial coronary arteries are usually free of significant obstructive disease in nonselected groups of chagasic patients examined at autopsy or by coronary angiography. However, chagasic patients who were studied after an episode of acute myocardial infarction, show the same patterns of atherosclerotic coronary artery disease seen in the general nonchagasic population. Studies of chagasic patients with angiographically normal coronary arteries, by several scintigraphy methods, revealed myocardial perfusion abnormalities which may be caused by the microcirculatory derangements described in animals experimentally infected with the T. cruzi. Since hypoperfusion has been detected in regions with normal or mildly impaired wall motion, it is likely that the microvascular disturbances precede and may be causative mechanism for the subsequent myocardial damage. We speculate that hibernating ventricular areas may occur in chagasic patients, on the basis of the evidence gathered from these studies. Recent investigations of chronic patients with Chagas' disease and chest pain showed attenuation of the vasomotor responses to physiological and pharmacological stimuli, in the epicardial coronary arteries.

Lifestyle and the risk of acute myocardial infarction in a Gulf Arab population.

Recent statistics indicate that acute myocardial infarction (AMI) is becoming very common in the State of Bahrain. A population-based case-control study was carried out to explore the importance of lifestyle in the occurrence of AMI in Bahrain among those aged 30-79 years. Seventy consecutive cases with a first episode of AMI were identified from a register, which included all hospital admissions, during the period 1 February 1992 to 31 July 1992, and compared with 516 subjects obtained from a random sample of the same community. Multiple logistic regression was used to control for demographic variables as well as for the mutual confounding effects of the investigated risk factors. Of the patients with first-time AMI, 64% did not walk regularly for exercise compared with 34% of community controls (adjusted odds ratio [OR] = 3.06, 95% confidence interval [CI]: 1.24-5.15). In all, 12% of community controls has a history of hypertension and 9% had diabetes. The comparative figures for AMI patients were 44% for hypertension (adjusted OR = 5.04, 95% CI: 2.82-9.00) and 22% for diabetes (adjusted OR = 3.28, CI: 1.73-6.20). Cigarette smoking and infrequent consumption of fruits and vegetables also appeared to be associated with an increased risk of AMI. There is scope for lifestyle change in reducing AMI risk, by changes in physical activity, smoking and dietary habits. In addition, measures to control hypertension and diabetes should be given a high priority in any national health policy to prevent AMI.

The relationship between impaired fibrinolysis and coronary heart disease: a role for PAI-1

Several studies have evaluated the possible relationship between deficient fibrinolysis and ischaemic heart disease. Case-control and cross-sectional studies in patients with angiographically proved coronary disease have shown a significant increase of PAI-1 levels as compared with a control group. A significant increase of PAI-1 activity and antigen has also been demonstrated in patients with acute myocardial infarction (AMI) either during the acute event (3 h-3 days) or longer than one month after the acute event. It was suggested that the impairment of fibrinolytic activity in patients studied few days after the acute event is the consequence rather than the cause of AMI. Furthermore, the high PAI-1 levels would be non specific since they may reflect an acute phase reactant behaviour. It is, therefore, difficult to establish whether reduced fibrinolytic activity plays a role in the pathogenesis of AMI, although the fact that PAI-1 is still elevated months after the acute episode seems to support this hypothesis. In order to clarify this point the analysis of reports evaluating the predictive role of impaired fibrinolysis in the appearance of a first AMI episode is important, as well as in the recurrence of infarction. Two cohort studies explored the relationship between fibrinolytic activity and the incidence of cardiovascular disease and found similar baseline fibrinolytic activity among subjects dying from cardiovascular diseases and those who survived during the follow-up period. However, only global fibrinolytic activity was measured, so there is a possibility that levels of specific components of the fibrinolytic system might be predictors of AMI. Several studies have explored the fibrinolytic activity as a predictor of the recurrent AMI and various others have shown that elevated PAI-1 levels are associated with a higher incidence of recurrent infarction. The role of the fibrinolytic system in the pathogenesis of restenosis after percutaneous transluminal coronary angioplasty and the possible association between preoperative hypofibrinolysis and postoperative graft occlusion in patients undergoing coronary revascularization procedures has also been investigated. It has been known for considerable time that several of the well-established risk factors for coronary heart disease (CHD) such as obesity, smoking, hypertension and hyperlipoproteinemia are associated with decreased fibrinolytic activity. The positive relationship between serum triglycerides and PAI-1 levels in plasma is of particular interest, since it raises the possibility that hypertriglyceridemia confers predisposition to coronary thrombosis. Patients with diabetes mellitus, mainly of the non insulin-dependent type, show an increase of PAI-1 levels and a high incidence of atherosclerosis and CHD. Finally, some authors have found increased expression of PAI-1 mRNA in segments of human arteries from atherosclerotic patients compared with normal arteries. It can be concluded that high PAI-1 would induce hypofibrinolysis contributing to the fibrin deposition and subsequent atheroma plaque growth as well as to thrombus formation on atheroma plaque. The results of interventional studies on the modulation of endogenous fibrinolysis will convincingly establish the definitive role of fibrinolysis in the pathogenesis of atherosclerosis and CHD.

IPO-V2: A prospective, multicenter, randomized, comparative clinical investigation of the effects of sulodexide in preventing cardiovascular accidents in the first year after acute myocardial infarction

Objectives. This study was conducted to assess the efficacy of sulodexide, a glycosaminoglycan compound with antithrombotic properties, in preventing death and thromboembotic events after acute myocardial infarction.Background. Antithrombotic therapy has been found to play an important role in the prevention of cardiovascular events and death after acute myocardial infarction. Glycosaminoglycan-containing compounds, including sulodexide, show profibrinolytic and antithrombotic properties that render them suitable for use in patients after infarction.Methods. A total of 3,986 patients who had recovered from acute myocardial infarction were randomized to receive either the standard therapy routinely administered at each study center, excluding antiplatelet and anticoagulant drugs (control group, 1,970 patients), or the standard therapy plus sulodexide (treated group, 2,016 patients). Between 7 and 10 days after the episode of acute myocardial infarction, sulodexide was administered as a single daily 600-lipoprotein-lipase-releasing unit (LRU) intramuscular injection for the 1st month, followed by oral capsules of 500 LRU twice daily. Patients were evaluated for ≥12 months.Results. At the end of the study, 140 (7.1%) were recorded in the control group and 97 (4.8%) in the sulodexide group (32% risk reduction, p = 0.0022, chi-square test). A total of 90 patients (4.6%) in the control group had a further infarction, compared with 66 (33%) in the sulodexide group (28% risk reduction, p = 0.035). Furthermore, a reduction in left ventricular thrombus formation (evaluated by echocardiography) was observed in the sulodeside group (n = 12; 0.6%), compared with values in the control group (n = 25; 1.3%) (53% risk reduction, p = 0.027). Sulodexide was well tolerated and devoid of significant adverse events. All significant results were confirmed by “actual treatment” analyses.Conclusions. The study provides evidence that long-term therapy with sulodexide started early after an episode of acute myocardial infarction is associated with reductions in total mortality, rate of reinfarction and mural thrombus formation.

Relationship between Plasma Level of Brain Natriuretic Peptide and Myocardial Infarct Size

To investigate the clinical significance of plasma brain natriuretic peptide (BNP) measurement in patients with acute myocardial infarction (MI), circulating levels of BNP, atrial natriuretic peptide, creatine kinase (CK), and hemodynamic parameters were serially determined in 24 patients with a first episode of acute MI. Plasma BNP (mean +/- SEM) gradually increased and peaked 21 h after the onset (from 13.7 +/- 2.2 to 23.0 +/- 3.3 fmol/ml; p < 0.001). A significant correlation was found between the increase in plasma BNP level and both the peak CK level (r = 0.83; p < 0.05) and the MI size (r = 0.74; p < 0.05). The increase in plasma BNP in the acute phase was found to be a significant predictor of left ventricular (LV) function evaluated in the convalescent phase (LV ejection fraction, r = -0.63; p < 0.05, LV end-diastolic pressure, r = 0.56; p < 0.05). In conclusion, in patients with acute MI, increases in plasma BNP concentration during the early phase reflect MI size, and thereby may predict later LV function.

Depression of factor XII-dependent fibrinolytic activity in survivors of acute myocardial infarction at risk of reinfarction.

Defective fibrinolysis may constitute a risk for the development of myocardial infarction in patients with ischaemic heart disease. We studied prospectively the factor XII-dependent plasminogen proactivator system in 49 survivors of an acute myocardial infarction. Blood samples were collected 8 weeks after hospital discharge. The factor XII-dependent fibrinolytic activity in the specimens was determined on fibrin plates after complete immuno-inhibition of the urokinase-like and the t-PA related fibrinolytic systems. During the subsequent follow-up period of 2.4 years, 10 patients developed recurrent myocardial infarction, whereas the remaining 39 patients did not. The reinfarction group of patients had a significantly lower median factor XII-dependent fibrinolytic activity (24.9 blood activating units (BAU).ml-1) than the patients without a relapse (41.9 BAU.ml-1, P < 0.02). Plasma concentrations of factor XII did not deviate significantly between the groups (P > 0.05), whereas the median plasma concentrations of prekallikrein was slightly lower in the reinfarction group (90%) than in the non-reinfarction group of patients (105%, P < 0.02). These observations point to an association between a depressed factor XII-dependent fibrinolytic activity and an enhanced risk of reinfarction in patients with a previous episode of acute myocardial infarction.

Ventricular arrhythmias induced by programmed ventricular stimulation after uncomplicated myocardial infarction.

The aim of this study was to correlate the occurrence of ventricular dysrhythmias induced by programmed ventricular stimulation and sudden cardiac death (SCD) after a first episode of acute myocardial infarction (AMI). Twenty-seven consecutive male patients aged fifty-four +/- six (forty-seven to seventy) years were studied prospectively. Thirty days after AMI, patients were submitted to coronary arteriography and programmed ventricular stimulation with the S2-S3-S4 protocol. Noninvasive assessments, including Holter monitoring, ECG stress test, and radionuclide ejection fraction, were also repeated six and twelve months after AMI. Ventricular dysrhythmias were induced in all patients. According to such response, patients were divided into three groups: (1) repetitive ventricular response (n = 9); (2) nonsustained ventricular tachycardia (n = 8); and (3) sustained ventricular tachycardia (n = 10). All patients consistently developed complex ventricular dysrhythmias at Holter monitoring and ECG stress test. One patient from group 2 suffered SCD and another presented a syncope. Similarly, in group 3, 2 patients suffered SCD, 1 during a documented episode of recurrent AMI. Except for 1 patient, radionuclide ejection fraction remained unchanged throughout the study in all cases. SCD was also unrelated to the presence and type of dysrhythmias at noninvasive evaluation. Therefore, the type of ventricular dysrhythmia induced by the S2-S3-S4 protocol has no correlation with late SCD in patients with a first AMI and preserved ejection fraction.

Fibroelastic papilloma: A not-so-benign cardiac tumor

Six fibroelastic papillomas, ranging in size from 2 to 17 mm, were diagnosed among 106 benign cardiac tumors observed at our institute since 1970. Two were incidental autopsy findings, and involved the pulmonary and aortic semilunar valves, respectively; four were surgically removed specimens from the left side of the heart. Clinical diagnosis was achieved in two young subjects, aged 25 and 31 years, by 2D-echo examination, following an episode of acute myocardial infarction precipitated during a soccer game; the tumor was related to the mitral valve apparatus in both cases, and a coronary embolism, either neoplastic or thrombotic, was the most likely cause of myocardial infarction. Thus, cardiac left-side fibroelastic papilloma should be considered a potentially lifethreatening tumor in hemodynamic terms. Like myxoma, this tumor entails the risk of systemic embolism that may also occur in the coronary arterial tree, precipitating myocardial infarction and sudden cardiac arrest.

Demonstration of the formation of hydroxyl radicals in acute myocardial infarction in man using salicylate as probe.

Dihydroxybenzoic acid (DHBA) derivatives of acetylsalicylic acid (ASA) are formed in vivo by the action of the hydroxyl radical (OH.). In order to evaluate the possible formation of OH(.) in acute myocardial infarction (AMI) in man, 9 consecutive patients with a first episode of AMI (8 males, 1 female, mean age 50.3 years), treated with rt-PA, and 8 healthy volunteers (7 males, 1 female, mean age 29.8 years) were studied. All subjects received 100 mg ASA p.o. daily; venous blood samples were taken 30 min after the first dose (time 0) and then at 3-, 6-, 12-, 24- and 48 h and 5 days. Serum was analyzed by HPLC and electrochemical detection for 2,3- and 2,5-DHBA contents. 2,3-DHBA was present in all subjects with AMI and undetectable in healthy volunteers at all time points studied. Serum levels of 2,5-DHBA did not show statistically significant differences between AMI patients and healthy volunteers. These data support the hypothesis that hydroxyl radicals are formed during AMI in man.

Serum magnesium, copper, and zinc concentrations in acute myocardial infarction.

This study was carried out to assess the serum levels of magnesium, copper, and zinc after an acute episode of myocardial infarction. Determination of the metal concentrations were carried out on 41 patients with myocardial infarction and 41 healthy controls matched for age and sex. A slight decrease in the mean level of magnesium (P less than .05) was observed in patients (2.0 mg/dl) compared with the controls (2.1 mg/dl). The mean serum copper concentration was significantly higher (P less than .001) in patients (138 micrograms/dl) than in controls (98 micrograms/dl), while the mean serum zinc concentration was significantly lower (P less than .001) in patients (75 micrograms/dl) than in controls (100 micrograms/dl). The differences in serum copper and zinc levels between patients and controls were magnified considerably when the copper/zinc ratios were calculated for both groups (P less than .001). The mean copper/zinc value obtained for patients (1.91) was almost double that for the controls (1.02).

One-year follow-up after recombinant tissue plasminogen activator administered to patients with acute myocardial infarction

Of 106 patients seen within 4 h of chest pain with 107 episodes of acute myocardial infarction, nine died before or during hospitalization mainly from cardiogenic shock, and four died during the next year, three were sudden deaths. The 93 survivors were reviewed at a mean of 53 (range 49-70) weeks after infarction. Of these 93, 18 had had attempted angioplasty (successful in 12) and 15 had had coronary artery bypass grafting (including one patient who had coronary artery bypass grafting performed after unsuccessful angioplasty). The remaining 61 patients continued on medical therapy only. During the one-year follow-up two patients suffered reinfarction and a further 22 had one or more cardiac admissions, mostly for chest pain. At review, 22 patients had angina (16 New York Heart Association Grade I or II) and five dyspnoea (all NYHA Grade II). Forty-three patients were taking oral nitrates, 53 were receiving calcium antagonists, 54 were using betablocking agents and 73 used anti-platelet agents. However, many of these patients continued on anti-anginal therapy prophylactically after their myocardial infarction, without continuing chest pain. Thus after recombinant tissue plasminogen activator therapy and following hospital discharge the mortality rate for patients with acute myocardial infarction was four out of 97 (4.1%) and reinfarction rate among survivors was two out of 93 (2.2%). Although the incidence of cardiac symptoms was low this may be partly due to the high incidence of angioplasty and coronary artery grafting, together with the use of anti-anginal agents.

Hypertension control and the risk of myocardial infarction and stroke: a population‐based study

A population-based case-control study was performed to determine the importance of the presence of hypertension and the control of blood pressure level during treatment for hypertension on the occurrence of acute myocardial infarction (AMI) and stroke in persons aged 35-69 years in the Hunter Region community. Patients with a first episode of AMI or stroke were identified from community-based heart attack and stroke registers and compared with control subjects obtained from a random population sample from the same community. Twenty per cent of control subjects were currently receiving treatment for hypertension compared with 37% of patients with myocardial infarction (odds ratio adjusted for age, sex and several other possible confounding variables, 2.6; 95% confidence interval (CI), 1.9-3.4) and 51% of patients with stroke (adjusted odds ratio, 3.5; 95% CI, 2.3-54). Among those who had ever been told they had hypertension, 71%, 73% and 59% of patients with AMI, patients with stroke and control subjects, respectively, were receiving treatment at the time of the AMI or the stroke or at the time of the survey (control subjects). For those receiving treatment for hypertension, blood pressure levels were obtained from the records of their general practitioner. Despite similar pretreatment levels the last recorded blood pressure level (either before the survey of the development of AMI or stroke) was higher among those who developed AMI or stroke than those in the control group. Those with a treated diastolic blood pressure of less than 80 mmHg appeared to be at a higher risk of both AMI and stroke than those with a treated diastolic blood pressure level of 80-89 mmHg, but the difference was not statistically significant. Randomised controlled trials do not show a reduction in rates of AMI in response to a reduction of blood pressure. Nevertheless our findings suggest that the presence of hypertension and poor control of blood pressure levels despite treatment may be important aetiologically both for AMI and stroke occurrence.

Successful Direct PTCA on LAD after First Episode of Acute Myocardial Infarction: Does It Improve Cardiac Function?

Patients who received direct percutaneous transluminal coronary angioplasty (PTCA) after acute mycardial infarction and maintained potency but with unimproved cardiac function were studied. In 15 patients, the first episode of acute myocardial infarction was caused by a left anterior descending branch lesion; 11 had an ejection fraction of 50% or more in the left ventriculogram in the follow-up period (improved group), and 4 patients had ejection fraction of less than 50% (unimproved group). There was so significant difference between the groups in the mean time between the onset of infarction and revascularization (improved group, 259.3 +/- 76.9 min; unimproved group, 168.0 +/- 101.6 min) or in the sigma Q. which was the sum of the Q wave depth of V2, V3, and V4 at the time of admission (improved group, 12.1 +/- 15.6 mm; unimproved group 29.8 +/- 13.4 mm). The maximum creatine kinase concentration was significantly higher in the unimproved group (improved group 2670 +/- 893 IU/L; unimproved group, 7243 +/- 1928 IU/L, p less than 0.05), and the time taken from the onset to reach its peak was significantly shorter in the unimproved group (improved group, 13.0 +/- 5.1 hr; unimproved group, 6.8 +/- 1.3 hr, p less than 0.05.) These results suggest the probability of sudden deterioration of myocardium, and factors other than microcirculatory thromboembolism should be considered as the cause of unimproved cardiac function after successful direct PTCA.

The nature and evolution of ventricular arrhythmias in acute myocardial infarction

The natural evolution of ventricular arrhythmias complicating a first episode of acute myocardial infarction has been studied in a group of 56 consecutive patients, who were admitted to the Coronary Care Unit within three hours of the onset of symptoms, and in whom drug administration (digitalis, antiarrhythmics, diuretics and heparin) was limited. Ventricular arrhythmias have been evaluated by means of Holter monitoring performed during the first 24 hours, the second 24 hours, the eighth day, the 18th day and two years after discharge when antiarrhythmic drugs has been discontinued for at least five half-lives. The overall incidence and prevalence of ventricular arrhythmias showed a steady and statistically significant reduction from the first to the eighth day, and a not statistically significant increase from the eighth to the 18th day. The latter increase was still present at the two-year follow-up. The one-by-one behaviour analysis of discharged patients delineated three different patterns: patients who presented a steady reduction in ventricular arrhythmias from the first to the 18th day (44%); patients who showed an almost constant incidence of ventricular arrhythmias during all phases of acute myocardial infarction (24%); and patients who presented both a decrease and an increase in their ventricular arrhythmias (31%). The follow-up at two years showed that the majority of patients, especially those discharged in a high Lown class, had the same arrhythmias as at their follow-up on the 18th day. Correlation of ventricular arrhythmias with the extent of the infarcted area demonstrated that only the peak and mean values of lactic dehydrogenase correlated with the severity of ventricular arrhythmias. Cross-sectional echocardiography and electrocardiographic scores showed no correlation.

老年者における急性心筋梗塞後のリハビリテーションと予後

We examined the effect of rehabilitation on the prognosis of aged patients with a first episode of acute myocardial infarction. The mean age of patients was 77 years old. We divided them into two groups, one group consisted of 53 patients for whom a rehabilitation program was available, another group consisted of 84 patients for whom a rehabilitation program was not available. Of the patients with rehabilitation available, there were 20 who were unable to receive rehabilitation, 15 who were able to participate in only light rehabilitation, 27 who were able to walk and 22 who finished rehabilitation. During 3.5 years of follow-up after initial myocardial infarction, the rates of cardiac death were 51% in the group without rehabilitation and 41% in the group with rehabilitation. For 26 patients who died of cardiac events and who had received rehabilitation, there was a positive correlation (r = 0.53) between the level of rehabilitation reached and the survival in years. The incidence of angina pectoris after myocardial infarction was more frequent in the group with rehabilitation. However the exercise activity level was higher and the prognosis was better in the group with rehabilitation, although statistical significance was not found.