History Of Previous Infarction Research Articles

Study of inferior myocardial infarction extended to the right ventricle: Series of 100 cases

Ischemic heart disease is a common cause of morbidity and mortality worldwide. Acute inferior wall myocardial infarction accounts for 40% all acute myocardial infarctions. Acute coronary syndromes involving the right side of the heart are associated with increased mortality, a complex clinical course, and lengthy hospitalization, as well as with frequent mechanical and electrical complications. To study the incidence, clinical, therapeutic and angiographic profile of right ventricular (RV) infarction and inferior wall myocardial infarction. One hundred cases of inferior wall infarction were included in the study. Patients with history of previous infarction, bundle branch block, and suspected pulmonary embolism were excluded. Incidence of right ventricular infarction is about 25% in inferior wall myocardial infarction. Most patients presented with retrosternal chest pain associated with sweating. Male constituted 79.62% of the population studied. Smoking is the main cardiovascular risk factor found in 57.28% of cases. Diabetes and hypertension are present in 38% and 25% of cases respectively. Right ventricular failure was present in 23% of patients. The group with RV infarction has more conduction disorders (32% vs 6%). The right coronary artery (RCA) was responsible for the RV infarction in 100%. However, Acute inferior wall myocardial infarction is secondary of RCA in 56% and circumflex in 44%. RV infarction is common in patients with acute inferior wall myocardial infarction. Rapid detection of RV infarction and the early treatment even for patients without hypotension or cardiogenic shock is important to improve the prognosis.

Main Considerations of Cardiogenic Shock and Its Predictors: Systematic Review.

The mortality rate of post-infarction cardiogenic shock (CS) was 80.0-90.0%. Recent studies show a significant reduction of hospital mortality to approximately 50.0%. CS is defined as systemic tissue hypoperfusion resulting from systolic and/or diastolic heart dysfunction, the main cause of which is acute myocardial infarction (AMI). The main predictors are biological markers such as troponin, CKMB and lactate. A systematic literature review and meta-analysis is performed in order to present and correlate the main literary findings on CS and its evolution with possible changes in biomarkers such as troponin, lactate and CKMB. After criteria of literary search with the use of the mesh terms: cardiogenic shock; acute myocardial infarction; biomarkers; troponin; CKMB; lactate; clinical trials and use of the bouleanos “and” between the mesh terms and “or” among the historical findings. In the main databases such as Pubmed, Medline, Bireme, EBSCO, Scielo, etc., a total of 96 papers that were submitted to the eligibility analysis were collated and, after that, 41 studies were selected, following the rules of systematic review - PRISMA (Transparent reporting of systematic reviews and meta-analyzes-http://www.prisma-statement.org/). Some risk factors for its development in AMI are advanced age, female gender, anterior wall infarction, diabetes mellitus, systemic arterial hypertension, previous history of infarction and angina. The CS associated with AMI depends on its extent and its complications, being the main ones: mitral regurgitation, rupture of the interventricular septum and rupture of the free wall of the left ventricule. The diagnosis is based on the clinical manifestations, such as mental confusion, oliguria, hypotension, tachycardia, fine pulse, sweating, and cold extremities; in hemodynamic aspects: systolic blood pressure was < 90.0 mm Hg or 30 mm Hg below baseline, pulmonary capillary pressure was > 18.0 mm Hg and cardiac index was < 2.2 L/min/m2. Laboratory and imaging exams should be requested to evaluate the possible etiology of CS, its systemic repercussions and comorbidities. The treatment aims at the rapid reestablishment of the blood flow in the affected artery, to improve the patient’s prognosis. The biomarkers dosage in the daily clinical practice of the different cardiological centers can facilitate the diagnosis and the conduction of the dubious cases and the best evaluation of the degree of myocardial suffering after CS.

Analysis of risk factors for chronic subdural haematoma recurrence after burr hole surgery: Optimal management of patients on antiplatelet therapy

Objective. Not much is known about surgical management of patients with chronic subdural haematoma (CSDH) treated with antiplatelet or anticoagulant therapy. The aims of this study were to review the surgical outcomes of patients with CSDH and assess the risks of antiplatelet in their surgical management. Methods. We retrospectively analysed 448 consecutive patients with CSDH treated by one burr hole surgery at our institution. Among them, 58 patients had been on antiplatelet therapy. We discontinued the antiplatelet agents before surgery for all 58 patients. For 51 of these 58 patients (87.9%), early surgery was performed within 0–2 days from admission. We analysed the association between recurrence and patient characteristics, including history of antiplatelet or anticoagulant therapy; age (< 70 years or ≥ 70 years); side; history of angiotensin receptor II blocker, angiotensin converting enzyme blocker, or statin therapy; and previous medical history of head trauma, infarction, hypertension, diabetes mellitus, haemodialysis, seizure, cancer, or liver cirrhosis. Results. Recurrence occurred in 40 patients (8.9%), which was one of the lowest rates in the literature. Univariate analysis showed that only the presence of bilateral haematomas was associated with increased recurrence rate while antiplatelet or anticoagulant therapy did not significantly increase recurrence risk. Also, the recurrence rate from early surgery (0–2 days from drug cessation) for patients on antiplatelet therapy was not significantly higher than that from elective surgery (5 days or more after drug cessation). However, multivariate analysis revealed that previous history of cerebral infarction was an independent risk factor for CSDH recurrence. Conclusions. Our overall data support the safety of early surgery for patients on the preoperative antiplatelet therapy without drug cessation or platelet infusion. Patients with a previous history of infarction may need to be closely followed regardless of antiplatelet or anticoagulant therapy.

A influência do plano de saúde na evolução a longo prazo de pacientes com infarto agudo do miocárdio

Little is known, especially in our country, about the influence of health insurance plans on the long term outcome of patients after acute myocardial infarction (AMI). To assess the outcome of patients with AMI who are covered by the National Health System (SUS) or other health insurance plans. We analyzed 1,588 patients with AMI (mean age of 63.3 + 12.9 years, 71.7% male) who were included prospectively into a specific database and followed up for up to 7.55 years. Of this total, 1,003 were placed in the "SUS" group and 585 in the "other insurance plans" group. We applied chi-square, log-rank and Cox (stepwise) to the different statistical analyses. The long term multivariate model with mortality as a dependent variable included 18 independent variables. In-hospital mortality rates in the "other insurance plans" and "SUS" groups were 11.4% and 10.3%, respectively (p = 0.5); in the long term, survival chances in the groups were respectively, 70.4% + 2.9 and 56.4% + 4.0 (p = 0.001, hazard-ratio = 1.43, or a 43% higher chance of death in the "SUS" group). In the adjusted model, the 'SUS' group had a significantly higher chance of death (a 36% higher chance, p = 0.005). Surgical revascularization and angioplasty improved the prognosis of these patients, whereas age and previous history of infarction, diabetes or heart failure worsened the prognosis. Relative to patients with other insurance plans, SUS users present similar mortality rates during hospital stay, but their prognosis is worse in the long term, thus reinforcing the need for additional efforts to improve the care provided to these patients after hospital discharge.

Aortocoronary bypass operation as an emergency intervention after transluminal coronary angioplasty. Which factors prevent the incidence of a major infarct?

Among 830 patients in whom transluminal coronary angioplasty (TCA) was undertaken there were 41 (4.9%) who required an aortocoronary bypass operation for acute complications (vessel dissection with markedly reduced flow; complete occlusion or contrast-medium extravasation). The group of 41 was divided into two, based on angiography (25) or ECG (16) criteria. Group 1 comprised 30 patients, who developed no or only a small infarct peri-operatively; group 2 had eleven patients with large infarcts. The patients of group 1 had a greater exercise tolerance pre-operatively than those of group 2 (118 +/- 28 vs 91 +/- 45 Watt; P less than 0.05) and had a higher revascularization time (interval between end of the cardiac catheterization and onset of reperfusion: 154 +/- 58 vs 264 +/- 173 min; P less than 0.05). Collaterals to the area supplied by the treated vessel were observed only in group 1 patients (10), but not of those in group 2. Age, history of previous infarction, number of diseased coronary arteries, ischaemic reaction during ergometry, initial left-ventricular ejection fraction and symptoms after onset of complications were without significance. It is concluded that an aortocoronary bypass operation should be performed as early as possible after post-TCA vascular complication in order to prevent the development of larger infarcts.

Oxidative injury and antioxidants in coronary artery bypass graft surgery: Off-pump CABG significantly reduces oxidative stress

Background Coronary artery bypass grafting (CABG) can now be performed with or without cardiopulmonary bypass. The former entails global ischemia followed by reperfusion after declamping, whereas the latter does not. In view of growing evidence that reperfusion is associated with oxidative stress, we studied the extent of oxidative stress and antioxidant status in patients undergoing on-pump and off-pump CABG to determine whether the latter significantly reduces oxidative stress. Methods Thirty patients were initially enrolled for the study. The inclusion criteria included patients with atherosclerotic triple vessel disease, undergoing elective CABG, with good LV function, no major risk factors for surgery, with all biochemical investigations within normal limits, having stable angina and no history of previous infarct. Patients with valvular heart disease, ventricular aneurysm, heart failure and poor left ventricular function were excluded. These were alternately posted for on-pump and off-pump CABG. Eight patients were excluded as they developed unforeseen complications during the surgery. Out of the remaining 22 patients, 13 underwent off-pump CABG and 9 underwent on-pump CABG. Five blood samples were collected; baseline, 5, 15, 60 min and 24 h after reperfusion. Samples were analyzed for thiobarbituric acid reactive substances (TBARS), glutathione (G-SH) and catalase (CAT). The results were compared with their preanaesthetic levels in both the groups and also with 20 age- and sex-matched normal healthy individuals. Results Lipid peroxidation was significantly increased after reperfusion in patients undergoing on-pump CABG, maximum increase ( p < 0.0001) was seen 1 h after reperfusion, whereas off-pump CABG reduces oxidative stress. The G-SH levels were significantly decreased after reperfusion in on-pump and off-pump CABG patients, maximum decrease ( p < 0.0001) was seen 5 min after reperfusion in on-pump CABG. The catalase activity was significantly increased after reperfusion in on-pump and off-pump CABG patients, maximum increase ( p < 0.0001) was seen 1 h after reperfusion in on-pump CABG. Conclusion Significant increase in oxidative stress was seen in patients undergoing on-pump CABG, whereas oxidative stress was less in off-pump CABG patients. The G-SH levels were decreased and Catalase activity was increased significantly in both on-pump and off-pump CABG patients.

Postero‐Lateral Scar Tissue Resulting in Non‐Response to Cardiac Resynchronization Therapy

In large cardiac resynchronization therapy (CRT) trials, approximately 20-30% of patients did not respond to CRT. Recent studies indicated that left ventricular (LV) dyssynchrony is needed for response to CRT. However, the presence of LV dyssynchrony may not be the only determinant of response, because some patients with LV dyssynchrony do not benefit from CRT. In the current case report, we present a patient with ischemic cardiomyopathy, NYHA class III heart failure symptoms, and substantial LV dyssynchrony on tissue Doppler imaging who underwent CRT implantation but did not respond. Following CRT, LV dyssynchrony was not reduced and the patient did not improve in clinical symptoms or LV function. The lack of LV resynchronization was explained by the presence of extensive scar tissue in the region of the tip of the LV pacing lead resulting in ineffective LV pacing. In patients with ischemic cardiomyopathy and history of previous infarction, assessment of scar tissue should be considered before CRT implantation.

Heart-rate turbulence after ventricular premature beats as a predictor of mortality after acute myocardial infarction

Identification of high-risk patients after acute myocardial infarction is essential for successful prophylactic therapy. The predictive accuracy of currently used risk predictors is modest even when several factors are combined. Thus, establishment of a new powerful method for risk prediction independent of the available stratifiers is of considerable practical value. The study investigated fluctuations of sinus-rhythm cycle length after a single ventricular premature beat recorded in Holter electrocardiograms, and characterised the fluctuations (termed heart-rate turbulence) by two numerical parameters, termed turbulence onset and slope. The method was developed on a population of 100 patients with coronary heart disease and blindly applied to the population of the Multicentre Post-Infarction Program (MPIP; 577 survivors of acute infarction, 75 deaths during a median follow-up of 22 months) and to the placebo population of the European Myocardial Amiodarone Trial (EMIAT; 614 survivors of acute myocardial infarction, 87 deaths during median follow-up of 21 months). Multivariate risk stratification was done with the new parameters and conventional risk factors. One of the new parameters (turbulence slope) was the most powerful stratifier of follow-up mortality in EMIAT and the second most powerful stratifier in MPIP: MPIP risk ratio 3.5 (95% CI 2.2-5.5, p<0.0001), EMIAT risk ratio 2.7 (1.8-4.2, p<0.0001). In the multivariate analysis, low left-ventricular ejection fraction and turbulence slope were the only independent variables for mortality prediction in MPIP (p<0.001), whereas in EMIAT, five variables were independent mortality predictors: abnormal turbulence onset, abnormal turbulence slope, history of previous infarction, low left-ventricular ejection fraction, and high mean heart rate (p<0.001). In both MPIP and EMIAT, the combination of abnormal onset and slope was the most powerful multivariate risk stratifier: MPIP risk ratio 3.2 (1.7-6.0, p<0.0001), EMIAT risk ratio 3.2 (1.8-5.6, p<0.0001). The absence of the heart rate turbulence after ventricular premature beats is a very potent postinfarction risk stratifier that is independent of other known risk factors and which is stronger than other presently available risk predictors.

Mode and risk indicators for death during 5 year follow-up of survivors of acute myocardial infarction. An evaluation with particular emphasis on congestive heart failure and age.

To describe the mortality rate and the place and mode of death during a 5-year follow-up of patients admitted to hospital with congestive heart failure following an acute myocardial infarction (AMI). All the patients admitted to a single hospital following an AMI, regardless of age and whether or not they were admitted to a coronary care unit, were followed up prospectively for 5 years. A total of 882 AMI patients were included. The hospital mortality was 14%. Among patients who were discharged from hospital, the age range was 24-101 (median 70) years, 70% were men, 35% had experienced an anterior AMI and 31% had suffered an inferior AMI. Congestive heart failure was observed in 51% of the patients. Among patients discharged from hospital (n = 740), those with severe congestive heart failure had a mortality of 67% compared with 51% for those with moderate heart failure and 31% for those with no heart failure (P < 0.001). When simultaneously considering age, sex, history of cardiovascular disease, various complications in hospital and medication at discharge, the development of congestive heart failure was found to be an independent predictor of death. The mode and place of death after initial discharge from hospital was similar in patients with and in those without congestive heart failure. Among patients with congestive heart failure who were discharged from hospital, the following factors were associated with an increased risk of death: older age (P < 0.001), no prescription of beta-blockers at discharge (P < 0.01) and a previous history of infarction (P < 0.05). The prognosis during 5 years of follow-up after AMI was directly related to the severity of congestive heart failure based on a clinical assessment. The mode and place of death did not differ between patients with and without heart failure. Treatment with beta-blockers was associated with improved survival. Age had a major impact on the prognosis.

Risk Stratification of Patients After Myocardial Infarction Based on Wavelet Decomposition of the Signal‐Averaged Electrocardiogram

Objective: The objective of this study was to investigate the prognostic significance of the wavelet decomposition (WD), when applied to single leads of the signal‐averaged ECG (SAECG) of postinfarction patients, as well as to compare it with conventional time‐domain (TD) analysis in order to optimize the utility of high resolution ECG techniques in risk stratification. Comparisons with clinical variables were also performed.Methods: SAECGs of 769 patients were analyzed (mean age 53 ± 7 years). A total of 42 arrhythmic events occurred within 54 months. For numerical calculations of WD, relative energies of the QRS complex were obtained in seven frequency bands. Conventional parameters of late potential analysis in TD were calculated at 25 and 40 Hz high pass filter.Results: No significant correlation was found between parameters of both methods. Several parameters of the WD of single leads showed slightly higher sensitivity (e.g., 52% vs 36%) and positive predictive values (e.g., 13.3% vs 10.2%) compared with those obtained with the QRS duration of TD analysis. In multivariate analysis, combination of QRS duration with WD parameters (relative risk [rr] =4.55, P &lt; 0.0001), followed by the WD of single leads (rr = 4.19, P &lt; 0.0001), nonsustained ventricular tachycardia in the long‐term ECG (rr = 3.72, P = 0.0005) and the history of previous infarction (rr = 2.72, P = 0.0035) were the most significant predictors in risk stratification.Conclusion: Time domain and wavelet transform of SAECG resulted in an improvement in postinfarction risk stratification compared with the clinical variables included in this study. Wavelet parameters may not be vastly superior to QRS duration, but they are a new index measuring intra‐QRS phenomena.

Measuring outcomes: one month survival after acute myocardial infarction in Scotland.

To examine 30 day survival after acute myocardial infarction as an outcome indicator, and explore the effects of adjusting for available prognostic factors such as age, sex, co-morbidity, deprivation, and deaths outside hospital. Cohort study. The Scottish Record Linkage System was analysed. This national data-base links inpatient data to death certificate information for a population of 5.1 million. All 40,371 admissions to hospital with a principal diagnosis of acute myocardial infarction, plus all 18,452 deaths outside hospital with a principal cause of death registered as acute myocardial infarction (ICD9 code 410) during 1988-1991. The outcome event was death from any cause, within hospital or elsewhere, within 30 days of admission. During 1988-1991, 30 day survival after acute myocardial infarction was 77% in 40,371 hospital admissions, but only 53% when 18,452 acute myocardial infarction deaths in the community were included (a population-based outcome indicator with many advantages). Using logistic regression at an individual patient level, the odds of dying within 30 days effectively doubled for each decade of age (odds ratio compared with patients aged under 55: 2.3 aged 55-64, 4.4 aged 65-74, 8.2 aged 75-84, 12.0 aged 85 plus); were marginally higher in females than in males (odds ratio 1.07); were almost doubled in patients with a history of previous infarction, coronary heart disease, or other heart disease, and were also significantly increased in patients with circulatory disease, respiratory disease, neoplasm, or diabetes. Socioeconomic deprivation had no significant effect. Marked variations in survival between different hospitals and health board areas persisted, even after adjusting for the above prognostic factors. One month survival after acute myocardial infarction could be a useful means of measuring outcome of hospital care. There was important geographical variation in one month survival. These differences could be accounted for by variations in referral, admission, diagnosis, definition, and coding. These variables merit further research and local clinical audit before one month survival after acute myocardial infarction can be reliably used for detecting differences in quality of care. In addition, it would be essential to take account of infarct severity.

Reduced beat-to-beat changes of heart rate: an important risk factor after acute myocardial infarction.

The prognostic significance of heart rate variability derived from 24-hour electrocardiographic recordings was investigated in 250 patients with acute myocardial infarction. During a follow-up of 6 months 15 patients experienced a serious arrhythmic event. These patients showed a significantly reduced beat to beat variability (p = 0.006), a slightly reduced 5-min variability (p = 0.04) and no significant differences in the 24-hour variability compared to the patients free of arrhythmic events. Based on Cox proportional hazard analysis, beat to beat variability remained an independent risk factor (p = 0.0036) in addition to the presence or absence of ventricular late potentials (p = 0.0004) and history of previous infarction (p = 0.04).

Adjunctive coronary endarterectomy: Improved safety in modern cardiac surgery

Advances in cardiac surgery have led to an improved safety record for coronary endarterectomy. We retrospectively reviewed the cases of 64 patients who underwent adjunctive coronary endarterectomy between August 1988 and February 1992. There were 44 men, and the mean age was 65 years. Forty-one patients (64%) had sustained a previous infarction. Overall, endarterectomy was performed on 76 vessels, and the right coronary system was involved in 46 (61%). The postoperative infarction rate was 5%. Incomplete occlusion ( < 90% stenosis) of the endarterectomized vessel significantly increased the risk of infarction (p < 0.05). There were two early deaths (3%). The mean follow-up was 46 months. Clinically, 91% of the survivors were angina free, and 80% had no symptoms of heart failure at the time of follow-up. Left ventricular function had improved in 36% of those restudied (5/14). A total of 17 recatheterizations were done at a mean interval of 19 months after operation. The endarterectomy graft patency rate was 80% (16/20) compared with 78% (28/36) for conventional grafts ( p = not significant). The actuarial survival rates were 89% and 71% at 1 year and 5 years, respectively. A history of previous infarction was significantly associated with higher long-term mortality (p < 0.02). Overall, these results demonstrate that in modern cardiac surgery, coronary endarterectomy is safer than previously thought and can be used effectively to achieve complete revascularization in selected patients.

After correcting for worse baseline characteristics, women treated with thrombolytic therapy for acute myocardial infarction have the same mortality and morbidity as men except for a higher incidence of hemorrhagic stroke. The Investigators of the International Tissue Plasminogen Activator/Streptokinase Mortality Study.

In the prethrombolytic era, women with myocardial infarction were reported to have a worse outcome than men. This analysis evaluates the association of sex with morbidity and mortality after thrombolytic therapy. Data were analyzed from 8261 of the 8387 randomized patients with acute myocardial infarction who received thrombolytic therapy in the International Tissue Plasminogen Activator/Streptokinase Mortality Study (baseline data were missing for 126 patients) and were followed for 6 months. Women made up 23% (n = 1944) of the study population. Baseline characteristics were worse in women: they were 6 years older, were more likely to have a history of previous infarction (P < .01), antecedent angina (P < .01), hypertension (P < .0001), or diabetes (P < .0001); were in a higher Killip class on admission (P < .0002); and received thrombolytic therapy 18 minutes later than men (P < .0001). Fewer women were smokers (P < .0001). Women had a higher hospital (12.1% versus 7.2%, P < .0001) and 6-month mortality (16.6% versus 10.4%, P < .0001) and were more likely to develop cardiogenic shock (9.1% versus 6.3%, P < .0001), bleeding (7.2% versus 5.3%, P < .01), and hemorrhagic (1% versus 0.3%, P < .001) or total stroke (2.2% versus 1.1%, P < .0001) during hospitalization. Reinfarction rates and requirement for angioplasty or surgery did not differ. After correction for worse baseline characteristics, women had similar morbidity and mortality apart from a significantly higher incidence of hemorrhagic stroke, which remained significant even after accounting for weight and treatment allocation (odds ratio, 2.90; P < .01). After thrombolytic therapy for acute myocardial infarction, women have similar morbidity and mortality to men but suffer from a higher incidence of hemorrhagic stroke.

Differential free-radical activity after successful and unsuccessful thrombolytic reperfusion in acute myocardial infarction

Free-radical generation after successful thrombolysis in acute myocardial infarction may jeopardize ischaemic but viable myocardium, thus limiting the optimal benefits of reperfusion. Circulating free-radical activity was assessed in 25 consecutive patients with acute myocardial infarction. Those who successfully reperfused (Group A) were compared with those who did not (Group B). We also compared patients who had or had not developed Q waves and patients with and without previous angina or myocardial infarction. All patients presented within 6 h of the onset of chest pain and received standard intravenous streptokinase therapy. Free-radical activity in serial serum samples collected over 72 h was measured using the percentage molar ratio (PMR) of the concentrations of 9,11-linoleic acid to 9,12-linoleic acid, and malonaldehyde concentration. Throughout the study period Group A (n = 11) showed significantly greater change in serum PMR and malonaldehyde levels compared with Group B (n = 14) (P < 0.01). PMR differences between the two groups were most pronounced at 3 and 12 h (P < 0.001). Patients with non-Q-wave myocardial infarction (n = 5) showed significantly greater changes in serum PMR and malonaldehyde levels (P < 0.01) compared with those with Q-wave infarction (n = 20). A history of previous infarction or angina had no apparent effects on the changes in serum free-radical activity. Successful early reperfusion and non-Q-wave myocardial infarction are both associated with a significantly greater increase in the levels of markers of serum free-radical activity immediately after infarction. The results support present concepts of free-radical-mediated reperfusion injury. Use of these assays may identify those patients who may be at risk from free-radical-mediated reperfusion injury.

Tailored thrombolytic therapy. A perspective.

In contrast with current standard regimens, it seems more appropriate to tailor thrombolytic therapy to individual patient characteristics. A proposed model for such tailored therapy is based on individual assessment of benefits and risks of thrombolytic therapy, taking into account the response of individual patients to the therapy given. Potential benefits of thrombolysis in individual patients can be predicted by use of demographic patient characteristics (age, sex, history of previous infarction) together with indicators of the ischemic area at risk (total ST segment deviation) and treatment delay. Using these parameters, the number of "lives saved" by thrombolytic therapy for specific patient characteristics can be estimated. Similarly, the risk of intracranial hemorrhage during thrombolytic therapy can be estimated from the patient's age, blood pressure at admission, and body weight. Depending on benefit/risk estimates, a choice can be made between regimens with high, medium, or modest thrombolytic efficacy. Continuous multilead ECG ischemia monitoring and rapid assays of myocardial proteins in serum can be used to assess the occurrence or absence of reperfusion and to detect signs of reocclusion. Such data help to decide whether thrombolytic therapy should be continued or intensified or might be discontinued in individual patients before the total standard dose has been administered. Such tailored reduction of the total thrombolytic dose will reduce the risk for bleeding complications in some of the patients. The concept of tailoring thrombolytic therapy and the models presented for benefit/risk assessment should be tested in clinical studies and may subsequently help the physician to select the optimal approach in individual patients.

Relationships of site of infarction and history of previous infarction with short- and long-term prognosis after acute myocardial infarction in Japan

We studied the outcome in 308 patients with acute myocardial infarction (MI) admitted to the coronary care unit of Kobe General Hospital. Short-term outcome (within 28 days after MI) and long-term outcome (more than 28 days) were examined with survival curves to find any relationship with a history of previous MI and with the site of the MI. In the short term, 38 of the 308 patients died of cardiac causes. The group with anterior MI tended to have higher mortality than the group of patients with inferior MI, and among patients without a previous MI, patients with anterior MI had significantly higher mortality ( p = 0.01). In multivariate analysis by the logistic regression model, the site of the MI was found to be independently associated with the short-term outcome. In the long term, with a mean follow-up of 3.4 years, 23 of the 308 patients died of cardiac causes. Different sites of the MI did not result in different outcomes in patients with or without a previous MI. Of patients with anterior or inferior MI, those with a previous MI tended to have higher mortality, and of patients with an inferior MI, the difference was significant ( p =0.001). In multivatiate analysis by the proportional hazards model, a history of MI was more predictive than the site of the MI. In conclusion, the site of the MI was associated more with the short-term outcome than with the long-term outcome, and a history of MI was associated more closely with the long-term outcome.

Cerebrovascular events after myocardial infarction: analysis of the GISSI trial. Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico (GISSI).

To describe the epidemiology of cerebrovascular events in patients given or not given fibrinolytic treatment and to assess the prognostic implications and risk factors. Case series derived from the GISSI randomised trial. 176 coronary care units in Italy giving various levels of care. 5860 patients with acute myocardial infarction treated with 1.5 million units of intravenous streptokinase and 5852 patients not given fibrinolytic treatment. Cerebrovascular event, sex, age, blood pressure, history of previous infarct, site of infarction, and Killip class. 99 of 11,712 patients (0.84%) had a cerebrovascular event. Older age, worse Killip class, and anterior location of infarction seemed to be risk factors for cerebrovascular events (40/3201 aged 65-75 v 42/7295 aged less than 65, odds ratio 2.18; 9/437 class 3 v 55/8277 class 1, 1.81; and 57/4878 anterior v 24/4013 posterior, 1.96). No significant difference was found in the rate of cerebrovascular events between patients treated with streptokinase and controls (45/5852 (0.92%) streptokinase v 54/5860 (0.77) control). More patients in the streptokinase group than in the control group had cerebrovascular events (especially haemorrhagic strokes) on day 0-1 after randomisation (27 streptokinase v 7, control), although this was balanced by late events in control patients (54 streptokinase v 45 control at one year). The mortality of patients who had a cerebrovascular event was higher than that of those who did not (47% (47/99) v 11.6% (1350/11,613]. Although the incidence of cerebrovascular events complicating myocardial infarction was low, they increased morbidity and mortality. Treatment with streptokinase did not significantly alter the incidence, but age and poor haemodynamic state were associated with an increased risk.

Late streptokinase infusion and antithrombotic treatment in myocardial infarction reduce subsequent myocardial ischemia

Of 255 consecutive patients with acute myocardial infarction, 111 were eligible for attempted late thrombolysis. They were randomly assigned to either thrombolytic and antithrombotic treatment (treatment group) or routine treatment (control group). Patients in the treatment group received streptokinase initiated late (mean 32 hours; range 12 to 49) after the onset of symptoms, followed by heparin infusion for at least 5 days and warfarin and dipyridamole for at least 3 months. Patients were examined clinically and by bicycle ergometry on discharge from the hospital and after 3 and 12 months. The two groups did not differ with respect to deaths or reinfarctions. There was a trend toward a lower incidence of angina pectoris in the treatment group. Exercise tolerance in this group was significantly higher than in the control group (at 3 months 124 ± 39 W vs 107 ± 41 W; p < 0.05). The difference was entirely accounted for by patients with no previous history of infarction or angina pectoris (at 3 months 142 ± 37 W vs 112 ± 45 W; p = 0.01). ECG signs of myocardial ischemia, silent or symptomatic, occurred at significantly lower levels of exercise among patients in the control group compared with patients in the treatment group. The results support the notion that thrombolytic therapy given as late as 12 to 49 hours after the onset of symptoms may reduce the incidence of residual ischemia during the postinfarction period.

Role of resting thallium 201 perfusion in predicting coronary anatomy, left ventricular wall motion, and hospital outcome in unstable angina pectoris

We performed quantitative thallium scintigraphy in 66 unstable angina patients, 5.6 ± 5.1 hours after rest pain, to predict coronary anatomy, left ventricular wall motion, and hospital outcome. Thallium defects and/or washout abnormallties were present in 5 of 10 (50%) patients with coronary stenoses < 50%, 27 of 33 (82%) patients with coronary stenosis ≥ 50% and no history of previous myocardial infarction, and in 23 of 23 patients (100%) with histories of previous infarction. Defects were uncommon in the territory of vessels with < 50% (13 of 61, 21%), but significantly more common in the territory of vessels with ≥ 50% stenosis (57 of 137, 42%), p < 0.005. With the addition of washout abnormalities to defect analysis, sensitivity for detection of coronary stenoses improved to 67% (92 of 137), p ≤ 0.005, but specificity fell to 59% (36 of 61), p < 0.01. Segmental wall motion abnormalities were less common in segments with normal perfusion (21%) or in those with washout abnormalities alone (19%), than in segments with thallium defects (45%, p < 0.005). Defects in patients with previous infarction were common in both segments, with normal (26 of 66, 40%) or abnormal (24 of 45, 53%) wall motion. Eleven of 18 patients with in-hospital cardiac events, but no history of myocardial infarction, had resting thallium defects, whereas only 8 of 25 patients without cardiac event had thallium defect ( p = 0.056). We conclude that quantitative analysis of thallium scintigrams early in unstable angina allows prediction of angiographically significant coronary artery disease, does not accurately “predict” segmental wall motion abnormalities, but identifies patients with in-hospital cardiac events.