History Of Prior Myocardial Infarction Research Articles

Future Strategies for Improving Outcomes in Patients with Diabetes and Acute Coronary Syndromes

Approximately a third of admissions for acute myocardial infarction (MI) occur in individuals with diabetes mellitus (DM). Admission rates for MI are over sevenfold higher among people with DM than in those without DM, and threefold higher after accounting for differences in age and gender. Diabetes shifts the risk of acute coronary syndrome forward by 15–20 years and abolishes female premenopausal protection. Patients with diabetes and acute coronary syndrome have poorer outcomes than comparable nondiabetic individuals. Diabetes is a predictor of prehospital cardiac arrest, shortand long-term mortality, recurrent MI and the development of heart failure and cardiogenic shock in patients with acute coronary syndromes. Despite advances in acute cardiac care, diabetes confers almost a doubling of shortand long-term mortality [1–6]. Predictors of 1-year mortality in a patient with diabetes and MI include age, female gender [7–9], blood pressure, history of prior MI, blood glucose at the time of hospital admission, duration of diabetes, insulin therapy and urine albumin content [10,11]. Diabetes remains a major risk factor for mortality after adjustment for multiple clinical variables, extent of coronary artery disease and therapy [12]. Multiple factors contribute to poorer outcomes in the diabetic patient and are summarized in Box 1. Despite early reperfusion after MI and similar procedural outcomes from percutaneous coronary intervention, patients with diabetes have an increased mortality from heart failure [13–15] and cardiogenic shock [16]. Yet, prior coronary artery bypass surgery appears to have a protective role in patients with diabetes who sustain an acute MI [17].

Family History and the Risk of Sudden Cardiac Death as a Manifestation of an Acute Coronary Event

Observational studies have suggested that a parental history of sudden death increases one's risk of dying suddenly. This study tested the hypothesis that a family history of sudden cardiac death (SCD) is a risk factor for SCD caused by an acute coronary event. A retrospective case-control study included (1) consecutive victims of SCD (n=138) whose deaths were verified to be due to an acute coronary event without a history of prior myocardial infarction at medicolegal autopsy, (2) consecutive patients surviving an acute myocardial infarction (AMI; n=254), and (3) healthy control subjects (n=470). Family history of AMI and SCD among the first-degree relatives was ascertained in each study group. The incidence of SCD in the 1223 first-degree relatives of SCD victims was higher (5.2%) than that in the 2326 relatives of AMI survivors (3.3%; odds ration [OR] 1.6, 95% confidence interval [CI] 1.2 to 2.2, P<0.01) or the 3748 relatives of controls (OR 2.2; 95% CI 1.6 to 3.0, P<0.001). The history of SCD in 2 or more first-degree relatives was also higher (10.9%) among SCD victims than among AMI survivors (3.5%; OR 3.3, 95% CI 1.4 to 7.8, P<0.01) or controls (1.1%; OR 11.3, 95% CI 4.0 to 31.8, P<0.001). The family history of AMI did not differ between the SCD and AMI groups. Male gender and current smoking were the only coronary risk factors that were more prevalent among SCD victims than among AMI survivors (P<0.001 for both). Subjects with a family history of SCD have an increased risk of dying suddenly during an acute coronary event.

Spontaneous Late Thrombolysis of an Occluded Saphenous Vein Graft Subsequent to Acute Myocardial Infarction Treated with Percutaneous Coronary Intervention to the Native Culprit Vessel

A 67-year-old male with prior history of myocardial infarction and coronary artery bypass grafting (individual vein grafts to the left anterior descending artery [LAD] and right coronary artery) presented with an acute anterior ST elevation myocardial infarction and cardiogenic shock. The vein graft to the LAD was occluded with heavy thrombus burden and there was severe native CAD. Given the degree of thrombus burden and other anatomic considerations, percutaneous intervention with stenting was performed to the native proximal LAD. Three months later, after complaining of atypical chest pain, repeat angiogram revealed a spontaneous widely patent vein graft to the LAD and occluded proximal LAD.

Usefulness of cardiac calcification on two-dimensional echocardiography for distinguishing ischaemic from nonischaemic dilated cardiomyopathy: a preliminary report

Aortic valve calcification (AVC) and/or mitral annulus calcification (MAC) is considered to be a marker of atherosclerosis and has been demonstrated to predict cardiovascular morbidity and mortality. We hypothesized that the presence of cardiac calcification by echocardiography can be used in the differential diagnosis between ischaemic (DCMI+) and nonischaemic dilated cardiomyopathy (DCMI-). We evaluated 62 patients with DCM (38 males, mean age 66 +/- 10 years, LVEF < 40%), without any prior history of myocardial infarction or coronary intervention, who were undergoing coronary angiography for aetiological diagnosis. DCMI+ was considered present when a > or = 70% stenosis of at least one coronary artery was found. AVC, MAC, aortic wall and papillary muscle calcifications were semiquantitatively assessed by two-dimensional echocardiographic examination with a calcium score ranging from 0 (no calcifications) to 8 (calcium in all four sites). DCMI+ was found in 20 out of 62 patients. As expected, there were no differences in LVEF and LV end-diastolic diameters between DCMI+ and DCMI--patients (29 +/- 8% versus 31 +/- 10% and 66 +/- 6 versus 68 +/- 8 mm, respectively; not significant). Regional wall motion abnormalities and conventional risk factors for atherosclerosis, such as hypertension and hypercholesterolaemia, were significantly more frequent in the DCMI+ compared to the DCMI- group. On the other hand, the calcium echo score was 4.6 +/- 2 (range 1.7-7.3) in DCMI+ patients and 0.8 +/- 0.95 (range 0-4) in DCMI--patients (P < 0.05). A calcium score > or = 3 was observed in 18 out of 20 (90%) DCMI+ patients and only in three of 42 (8%) DCMI--patients. The assessment of cardiac calcification by two-dimensional echocardiography could represent a simple, noninvasive and inexpensive approach to assess the aetiology (ischaemic versus nonischaemic) of dilated cardiomyopathy.

Identifying which patients with diabetes should be tested for the presence of coronary artery disease – The importance of baseline electrocardiogram and exercise testing

Numerous studies have reported that diabetic patients should not always be considered to be coronary artery disease (CAD)-equivalent as was previously suggested. Exercise testing is widely available at a relatively low cost, and even among patients in whom the diagnosis of CAD is highly probable on the basis of age, sex, description of chest pain and history of prior myocardial infarction, exercise testing is often a clinical requirement for risk or prognosis assessment to determine the need for possible coronary angiography or revascularization. Nevertheless, because of either the presence of atypical symptoms or the absence of symptoms often encountered, the screening approach may differ in patients with diabetes mellitus. Because CAD is the major cause of mortality in patients with diabetes, its early detection is important to improve medical interventions and outcomes. This is critical because the available evidence suggests that occult CAD is common among asymptomatic patients with diabetes. Therefore, noninvasive testing for asymptomatic CAD may be helpful for the identification of diabetic patients with severe coronary obstruction in whom revascularization therapy may be considered the first manifestation of silent CAD in patients with diabetes is a fatal cardiac event in approximately one-half of the patients. The present paper reviews some clinical markers that may be helpful to the clinician to increase the yield of finding significant occult CAD while screening patients with diabetes.

Prognostic value of circulating pregnancy-associated plasma protein levels in patients with chronic stable angina

Unstable coronary atherosclerotic plaque can be present in patients with chronic stable coronary artery disease (CAD). Our objective was to assess whether measurement of plasma pregnancy-associated plasma protein (PAPP-A) level, a reflection of plaque instability, in patients with chronic stable CAD had an independent prognostic value on the subsequent incidence of death, acute coronary syndrome (ACS), and revascularization. Patients referred for coronary angiography were recruited. A cohort of 103 patients with stable symptoms for at least 6 weeks and with a coronary angiogram showing at least a 50% luminal diameter narrowing formed our study population. Median follow-up was 4.9 years. Mean age was 65+/-10 years. In a multivariable model that included CAD traditional risk factors, ejection fraction, extent of coronary atherosclerosis, prior history of myocardial infarction, prior revascularization, discharge medications, and C-reactive protein, the plasma PAPP-A was found to be significantly associated with the endpoint of future death [adjusted hazard ratio (HR) 5.29; 95% CI 1.27-22.0; P=0.023] and with the endpoint of future death and ACS (adjusted HR 3.56; 95% CI 1.27-10.0; P=0.015), but not with the endpoint of future death and revascularization. Measurement of plasma PAPP-A level in patients with chronic stable CAD has an independent prognostic value on the occurrence of death and ACS.

Multiple inappropriate defibrillator discharges due to Twiddler's syndrome

A 56-year-old man with a history of prior myocardial infarction, ischemic cardiomyopathy and nonsustained episodes of ventricular tachycardia had received a subpectorally placed implantable cardioverter-defibrillator (ICD) (Medtronic Micro-Jewel II® 7223 Cx with a single-coil electrode Medtronic Sprint® 6932) for primary prevention of sudden cardiac death three years ago. He was referred to our department after having received twenty-five inappropriate shocks. Interrogation and testing of the device revealed exit-block; incorrect sensing could easily be reproduced and visualized in the ICD’s marker channel by shaking the ICD can. The patient denied tampering with the device, had no history of recent weight loss, psychiatric illness or any other obvious condition with which rotation of the device could be associated. Chest x-ray revealed knotting of the lead just distally of the ICD header (Fig. 1) and multiple twisting of the lead on its way through the anonymous vein. Twiddler’s syndrome with multiple kinks could be confirmed intraoperatively (Fig. 2). The lead was extracted and the whole system replaced. Twiddler’s syndrome, originally described in a pacemaker patient by Bayliss in 1968 [1], denotes a complication in pacemaker and defibrillator patients, in which manipulation with the device leads to twisting of can and electrodes with the consequence of lead displacement. While most of the patients persistently deny manipulation with the device, this is the accepted mechanism leading to lead dislodgement. Previously reported factors that may predispose to device rotation include advanced age, female gender, obesity, small size of the device relative to its pocket and psychiatric disease. Fortunately, Twiddler’s syndrome is a rare complication in ICD patients, however, it may lead to severe complications such as inappropriate shock delivery, which itself may cause ventricular fibrillation, or unrescued sudden cardiac death. Despite the fact that only a small number of Twiddler’s syndromes in subpectorally implanted devices have been published so far [e.g. 2, 3], it cannot be reasoned that ICDs in this position are less predisposed to twiddle.

Perioperative internal thoracic artery steal syndrome after coronary bypass surgery

The internal thoracic artery (ITA) flow steal syndrome after coronary bypass operations is rare. In the absence of subclavian artery stenosis, it has mainly been attributed to incomplete harvesting of the conduit along its proximal course. 1 Previous reports describe the recurrence of angina months or years after revascularization. The possibility of an ITA steal phenomenon associated with acute transmural myocardial ischemia occurring perioperatively is presented. Clinical Summary A 73-year-old, hypertensive, non‐insulin-dependent diabetic man with normal left ventricular function and no history of prior myocardial infarction or evidence of pulmonary disease underwent triple bypass grafting for worsening anginal symptoms caused by three-vessel coronary disease. The operation was performed with conventional cardioplegic arrest, and included left ITA grafting to the left anterior descending artery and saphenous vein bypass to the obtuse marginal and right posterior descending branches. The patient was weaned from cardiopulmonary bypass with no inotropic support or sign of myocardial ischemia. Extracorporeal circulation and aortic crossclamp times were 96 and 57 minutes, respectively. Three hours after arrival in the intensive care unit, the patient showed nonsustained ventricular tachycardia, immediately followed by signs of acute transmural anterolateral ischemia. The electrocardiogram gradually normalized with nitroglycerin infusion; intravenous amiodarone was also administered. No further instability occurred, and extubation was accomplished after control coronary angiography, which showed patent bypass grafts and an undivided collateral branch originating from the proximal ITA (Figure 1, A and B). Thereafter, however, blood gas exchanges remained borderline, and despite the application of continuous positive airway pressure, the patient subsequently experienced a low output state (oliguria, serum liver-specific enzyme increase, and paroxysmal supraventricular tachyarrhythmias) and eventually required reintubation for mechanical ventilatory support. The peak serum creatine kinase (myocardial band) level was 1139 (90) U/L. Catheterization was repeated on the basis of the previous angiograms to perform coil embolization of the ITA collateral branch (Figure 1, C). Cardiorespiratory function improved, and the patient was extubated the following day, showing no further complications. Echocardiography documented hypokinesia of the left ventricular apex with normal ejection fraction, and the patient was discharged on postoperative day 12. At 3 months’ follow-up, dobutamine stress echocardiography showed no inducible wall-motion abnormality and increased diastolic ITA flow, indicating a normal-functioning graft. 2

Incremental prognostic value of stress echo positivity in the left anterior descending coronary artery territory

Background Dipyridamole stress echo (DSE) positivity is usually titrated according to presence and severity of the induced wall motion abnormalities. The purpose of our study is to assess whether the location of DSE positivity might add to prognostic stratification. Methods The study enrolled 112 patients with known or suspected coronary artery disease (CAD) and without a history of prior myocardial infarction. They were consecutively submitted to DSE (0.84 mg/Kg in 10 min followed by atropine administration, when needed) and coronary angiography (within a 15 ± 7 day period). End points at follow-up were cardiac death and acute coronary syndromes. Results Twenty-seven patients had a negative, and 85 a positive DSE (47 in the LAD territory). Angiographically assessed CAD was present in 82 patients (LAD in 59). At a follow-up of 9 ± 7 months, there were 28 events of cardiac deaths or acute coronary syndromes. Event-free survival was lower in patients with positive DSE (any location) compared to those with negative DSE (47% vs 89%, p = 0.003). In the subset with positive DSE, event-free survival was lower in patients with wall motion abnormalities in the LAD territory compared to those with dysfunction in the left circumflex and right coronary artery territory (31% vs 72%, p = 0.00012 ). At multivariate analysis, stress echo positivity in the LAD territory was independently associated with increased risk (HR: 9.51, CI: 1.61 to 56.11, p < 0.013) and outperformed angiographically assessed LAD stenosis (HR: 0.36, CI: 0.06 to 2.24, p: NS). Conclusions In CAD patients, wall motion abnormalities in the LAD territory during DSE identified a higher risk subgroup. Functional stress echo positivity on the LAD territory overcame the prognostic impact of an anatomic, angiographically assessed LAD disease.

Key factors associated with the under-prescription of statins in elderly coronary heart disease patients: Results from the ELIAGE and ELICOEUR surveys

Introduction The reasons why statins are under-utilized in elderly patients remain poorly understood. The aim of this study was to identify the reasons given by cardiologist for the non-prescription of statins in elderly CHD patients. Methods Two cross-sectional pharmaco-epidemiological surveys were carried out among French cardiologists. The sample consisted of 1148 coronary patients aged 35 to 69 years and 1489 patients aged ≥ 70 years. Patients' risk factors, medical history, treatments, lipid values and the physicians' various motives for the non-prescription of statins were recorded. Results Patients not treated with statins reached 37% in the age-group ≥ 70 years and 14% in the age-group 35–69 years. The main reason given for statin non-prescription was the lack of a medical indication (2.5% of the age-group 35–69 years and 14% of the age-group ≥ 70 years). Among patients ≥ 70 years, the lack of indication was more often cited in the following conditions: 1) in very old patients (36% of lack of indication in the age-group > 85 years vs. 10% in 70–75 years), 2) when lipid values were not available (20% when data were not available vs. 9%) and 3) when the patient had no prior history of myocardial infarction (MI) (20% when no history of MI vs. 7%). These factors were not associated with lack of indication among patients < 70 years. History of intolerance or side effect was given for 1.3% and 14% of patients for each of the groups (35–69 and ≥ 70) and poor overall patient adherence was cited in 1% and 2%, respectively. Conclusion The primary reason for the under-prescription of statins in elderly coronary patients is the perceived lack of indication, which stresses the need of extensive guidelines for prescription in elderly patients. Several factors associated with this perception seem to be specific to the elderly.

Traditional and Nonlinear Heart Rate Variability Are Each Independently Associated with Mortality after Myocardial Infarction

Decreased heart rate variability (HRV) and abnormal nonlinear HRV shortly after myocardial infarction (MI) are risk factors for mortality. Traditional HRV predicts mortality in patients with a range of times post-MI, but the association of nonlinear HRV and outcome in this population is unknown. HRV was determined from 740 tapes recorded before antiarrhythmic therapy in Cardiac Arrhythmia Suppression Trial patients with ventricular premature contractions (VPCs) suppressed on the first randomized treatment. Patients were 70 +/- 121 days post-MI. Follow up was 362 +/- 241 days (70 deaths). The association between traditional time and frequency-domain HRV and mortality and nonlinear HRV and mortality were compared for the entire population (ALL), those without coronary artery bypass graft post-MI (no CABG), and those without CABG or diabetes (no CABG, no DIAB) using univariate and multivariate Cox regression analysis. Strength of association was compared by P values and Wald Chi-square values. Nonlinear HRV included short-term fractal scaling exponent, power law slope, and SD12 (Poincare dimension). For ALL and for no CABG, increased daytime SD12 had the strongest association with mortality (P=0.002 ALL and P <0.001 no CABG). For no CABG, no DIAB increased 24-hour SD12 hours had the strongest association (P <0.001) with mortality. Upon multivariate analysis, increased SD12, decreased ln ULF (ultra low frequency), and history of prior MI and history of congestive heart failure each remained in the model. Nonlinear HRV is associated with mortality post-MI. However, as with traditional HRV, this is diluted by CABG surgery post-MI and by diabetes. Results suggest that decreased long-term HRV and increased randomness of heart rate are each independent risk factors for mortality post-MI.

Surgery for Chronic Total Occlusion of the Left Main Coronary Artery- Myocardial Preservation

We report seven patients with chronic total occlusion of the left main coronary artery that were operated in our institution and discuss the myocardial preservation options in these patients. In addition to total occlusion of the left main coronary artery, three patients also had severe lesions of right coronary artery. Prior myocardial infarction history and significantly depressed left ventricle functions were detected in all three patients with right coronary artery lesions. Five patients were operated on cardiopulmonary bypass while two patients were operated off pump. All patients received alternating antegrade/retrograde cardioplegia for myocardial preservation. In patients with simultaneous right coronary artery disease we first established the origin of the collaterals to the left coronary system. For patients with collaterals arising from the right coronary artery segment distal to the right coronary artery lesion, the antegrade component was administered through the saphenous vein graft bypassed to a distal part of right coronary artery segment. Thus we have achieved a more effective distribution of the antegrade cardioplegia. In off-pump-operated patients the left coronary system was revascularized before the right coronary system. Postoperative low cardiac output syndrome occurred in only one patient who was operated off pump. There was no operative and early mortality. Mean follow-up was 32 +/- 21.42 (range, 4 to 60) months. Alternating antegrade/retrograde cardioplegia was used with acceptable results in patients with total occlusion of the left main coronary artery. In patients with simultaneous RCA lesion we recommend regulation of the antegrade component based on the origin of collaterals that supplies the left coronary system. In off-pump-operated patients we suggest avoiding of clamping of right coronary artery at the beginning of the operation while it still supplies all the coronary circulation.

Impact of Diabetes on Mortality in Patients With Myocardial Infarction and Left Ventricular Dysfunction

Diabetes is a major risk factor for developing coronary heart disease. In patients with diabetes who survived myocardial infarction (MI), less is known about subsequent morbidity and mortality. We evaluated the effects of diabetes in post-MI patients with left ventricular dysfunction on cardiovascular events and death. The Survival and Ventricular Enlargement, a randomized, double-blind, placebo-controlled multicenter trial, evaluated the efficacy of captopril vs placebo in 2231 patients following acute MI with left ventricular dysfunction defined as an ejection fraction less than or equal to 40%. Patients were randomly assigned to captopril or placebo 3 to 16 days following MI and were followed up for 2 to 5 years (mean, 3.5 years). Among the 2231, 496 (22.2%) were patients with a history of diabetes, of which 168 (33.9%) were treated with insulin. Patients with diabetes were significantly older; more likely to be women; have a history of prior MI or hypertension; be obese or manifest Killip class II or greater; and have higher systolic blood pressure, pulse pressure, and heart rate, as well as lower ejection fraction. During follow-up, 31.3% of patients with diabetes and 20.1% of nondiabetic patients died (P<.001). Furthermore, 50% of the patients with diabetes had at least 1 major cardiovascular event compared with 32.3% among the nondiabetic patients (P<.001). In multivariate analysis that adjusted for all significant differences in baseline characteristics, patients with diabetes had a 39% higher total mortality (P = .001) and 49% more cardiovascular events (P = .001). Among the patients with diabetes, baseline insulin treatment was associated with a greater risk of death (41.1% vs 26.2%; P = .001) and cardiovascular events (58.3% vs 45.7%; P = .008). In patients who survived MI with left ventricular dysfunction, diabetes increased risk of death from all causes even after controlling for differences in other risk factors. Patients with diabetes treated with insulin have a particularly higher mortality risk. Patients with diabetes who survived MI with left ventricular dysfunction, in particular those receiving insulin, are at high risk of subsequent mortality and cardiovascular events and thus require intensive risk factor modification, as well as evaluation for novel therapies.

Gender Dependent Association of Thrombospondin-4 A387P Polymorphism With Myocardial Infarction

To the Editor: A recently identified novel missense variant of TSP-4, A389P (29926 G>C) was correlated with premature myocardial infarction (MI) by an exploratory genetic association study on 184 MI patients from the American population.1 In this study, the TSP-4 387P allele showed the strongest association, with an adjusted odds ratio for MI of 1.89 ( P =0.002 adjusted for covariates) for individuals carrying the 387P allele. This was replicated by the same group using a larger number of patients.2 An in vitro functional study of the TSP-4 A387P substitution provided further evidence in support of a proatherogenic effect. The TSP-4 A387P substitution was shown to have a gain of function effect leading to suppression of endothelial cell adhesion and proliferation.3 The TSP-4 A387P variant also shows ethnic distribution differences. The TSP-4 387P allele showed a dramatically lower prevalence in Asian Chinese populations compared with whites (3.8% versus 19.6 to 23.2%) and failed to associate with coronary artery disease (CAD) or MI in the studied populations.4–5 Interestingly, in a more recent investigation, the TSP-4 variant 387P allele was significantly associated with reduced risk, rather than increased risk, for premature MI (OR=0.43, 0.22 to 0.85) in Netherlands whites.6 Therefore, the true effect of TSP-4 A387P in MI remains unknown. We believe that the contradictory results may be caused by either population genetic mixture or the effects of different modifiers for the TSP-4387P allele among the different ethnic populations. We examined the TSP-4 A387P variant as part of our study to explore potential gene variants as risk factors for MI and the effect of interaction between different variants on MI. …

Geographic variability in patient characteristics, treatment and outcome in an international trial of magnesium in acute myocardial infarction

Background The interpretation of clinical trials and efforts directed at reducing the worldwide burden of coronary disease must take regional differences into account. This study examined the regional differences in baseline characteristics, treatment, and outcome in patients presenting with ST elevation myocardial infarction (STEMI) who were entered into the Magnesium in Coronaries (MAGIC) trial. Methods and results MAGIC randomized 6213 patients to standard care with either placebo infusion or infusion of intravenous magnesium sulphate. There was no difference in mortality between these groups. For this analysis, three geographic regions were identified (Region 1=United States and Canada; Region 2=Bulgaria, Georgia, and Russia; Region 3=Austria, Belgium, Chile, Hungary, Israel, the Netherlands, New Zealand, and Venezuela) and compared with respect to baseline characteristics, treatment, and 30-day mortality. Patients in Region 2 had the highest prevalence of adverse risk factors at entry, including history of prior myocardial infarction, heart failure, stroke, and hypertension; anterior location of index acute myocardial infarction; and presence of pulmonary congestion at presentation. Furthermore, Region 2 patients infrequently received reperfusion therapy compared with those in Region 1. Region 3 was intermediate in this regard. Mortality was highest in Region 2, least in Region 1, and intermediate in Region 3. Conclusion Geographic location, particularly, parts of Eastern Europe, is strongly and independently associated with mortality following STEMI. This geographic variation in mortality confirms prior reports, although adequate explanations continue to be elusive and are beyond the scope of this large simple trial. Future international trials must recognize this variation in design, analysis, and interpretation.

Differential mortality risk of postprocedural creatine kinase-MB elevation following successful versus unsuccessful stent procedures

This study was designed to evaluate the effect of periprocedural myocardial infarction (MI) on mortality according to success of the stent procedure. The mortality effect of periprocedural MI relative to successful versus unsuccessful procedures has not been examined. All-cause mortality during the first year was evaluated prospectively among 5,850 patients from coronary stent clinical trials. Myocardial infarction was classified according to creatine kinase-MB level as type 1 (>1 but <3 times normal), type 2 (>or=3 but <or=8 times normal), or type 3 (>8 times normal or Q-wave MI). Procedures were classified as successful unless there was a final diameter stenosis >50%; final Thrombolysis In Myocardial Infarction flow grade <3; final National Heart, Lung, and Blood Institute dissection grade >or=D; repeat revascularization within 24 h; or stent thrombosis within 24 h. Myocardial infarction was more frequent after unsuccessful procedures (69.6% vs. 20.4%, p < 0.001). Mortality during the first year was higher in patients with MI (2.8% vs. 1.7%, p = 0.01), but the effect was significant only for type 3 MI (4.7% vs. 1.7%, p = 0.008). Moreover, the mortality difference for any MI was confined to patients with unsuccessful procedures (13.1% vs. 0%, p = 0.03), with no significant effect among patients with otherwise successful procedures (2.1% vs. 1.7%, p > 0.20). The independent predictors of mortality were unsuccessful procedure (p < 0.001), diabetes mellitus (p = 0.001), history of prior MI (p = 0.003), multivessel disease (p = 0.006), and advancing age (p < 0.001), but not periprocedural MI. The association of periprocedural MI with increased mortality during the first year following stent placement was confined to patients with unsuccessful procedures.

Ambulance use in patients with acute myocardial infarction.

To explore the choice of transportation mode to hospital in patients experiencing acute myocardial infarction. A descriptive survey study at the Coronary Care Unit of one Swedish University Hospital. The study was carried out between July 2000 and March 2001. The study population consisted of 114 consecutive patients with acute myocardial infarction. Thirty-two percent stated that they did not know the importance of a short delay when experiencing an acute myocardial infarction. Only 60% called the emergency service number, 112. Patients calling for an ambulance differed from those who did not in several aspects. Medical characteristics associated with ambulance use in a univariate analysis were ST-elevation myocardial infarction and prior history of myocardial infarction. There were no differences regarding gender or age. When looking at the patients' symptom-experience, patients with vertigo or nausea and severe pain chose an ambulance for transport to the hospital. The only significant reasons for not choosing an ambulance were cramping pain and the patient perceiving the symptoms not to be serious. In a multivariate analysis, ST-elevation (OR = 0.30, P = .04), unbearable symptoms (OR = 0.20, P = .03), and nausea (OR = .33, P = .04) appeared as independent predictors of ambulance use and cramping pain (OR = 5.17, P = .01) for not using an ambulance. Patients with acute myocardial infarction view the ambulance as an option for transportation to hospital only if they feel really sick. For that reason, it needs to be made well known to the public that ambulances are not only a mode of transport, but also provide diagnostics and treatment.

Is diabetes mellitus a cardiovascular disease risk equivalent for fatal stroke in women? Data from the Women's Pooling Project.

Diabetes mellitus is an independent risk factor for stroke and is associated with a 1.8- to approximately 6-fold increased risk compared with nondiabetic subjects. Recent guidelines have classified diabetes as a coronary heart disease risk equivalent. Whether diabetes is a cardiovascular disease risk equivalent for stroke is not established. Data were pooled from 9 prospective epidemiological studies in the United States. We followed up 27,269 women (8.5% diabetic, 2.9% with prior myocardial infarction, 2.3% with prior stroke) for an average of 8.3 years, during which 238 stroke deaths were observed. Both diabetic subjects without cardiovascular disease and nondiabetic subjects with history of prior stroke had a significantly increased risk of 10-year stroke mortality compared with nondiabetic subjects without prior cardiovascular disease (hazard ratio [HR], 6.77; 95% confidence interval [CI], 4.56 to 10.05; HR, 3.37; 95% CI, 2.38 to 4.77). History of prior myocardial infarction was not associated with long-term stroke mortality (HR, 0.66; 95% CI, 0.27 to 1.61). After adjustment for risk factors, diabetic subjects had similar risk compared with subjects with a history of prior stroke (HR, 1.29; P=0.43). Diabetic subjects without cardiovascular disease have a fatal stroke risk similar to that of nondiabetic subjects with a history of prior stroke and similar risk factor profile. This suggests that diabetes mellitus may be classified as a stroke risk equivalent and may warrant more aggressive treatment strategies in the future prevention of stroke.

Racial disparity in long-term mortality rate after hospitalization for myocardial infarction: the Atherosclerosis Risk in Communities study

Background The underlying reasons why African American patients have a significantly higher mortality rate than European American patients after a myocardial infarction (MI) remain unclear. This study examined the racial disparity in mortality rates after MI and possible explanatory factors. Methods A prospective analysis was conducted within the Atherosclerosis Risk in Communities (ARIC) study, a community-based study of 15,792 middle-aged adults. From 1987 to 1998, 642 patients (471 European American and 171 African American) hospitalized for MI without prior history of MI were identified. Of these 642 patients, 129 (82 European American and 47 African American) died during follow-up. Results Cox proportional hazard models were used to analyze the racial difference in mortality rate after MI. After adjusting for age and sex, the relative hazard (RH) comparing African American patients to European American patients was 1.80 (95% CI, 1.24-2.61). The RH decreased after adjusting for vascular risk factors (1.29; 95% CI, 0.83-2.00), socioeconomic position (1.31; 95% CI, 0.83-2.09), severity of MI (1.60; 95% CI, 1.05-2.45), and treatment (1.36; 95% CI, 0.92-2.00). In the final model, which included all factors aforementioned, the RH for race was 1.00 (95% CI, 0.56-1.77). Conclusions Our findings suggested that vascular risk factors, socioeconomic position, and treatment play major roles in the racial disparity in mortality rate after MI.

Decline in out-of-hospital coronary heart disease deaths has contributed the main part to the overall decline in coronary heart disease mortality rates among persons 35 to 64 years of age in Finland: the FINAMI study.

Out-of-hospital deaths constitute the majority of all coronary heart disease (CHD) deaths and are therefore of considerable public health significance. We used population-based myocardial infarction register data to examine trends in out-of-hospital CHD deaths in Finland during 1983 to 1997. We included in out-of-hospital deaths also deaths in the emergency room and all deaths within 1 hour after the onset of symptoms. Altogether, 3494 such events were included in the analyses. The proportion of out-of-hospital deaths of all CHD deaths depended on age and gender. In the age group 35 to 64 years, it was 73% among men and 60% among women. These proportions did not change during the study. The annual average decline in the age-standardized out-of-hospital CHD death rate was 6.1% (95% CI, -7.3, -5.0%) among men and 7.0% (-10.0, -4.0%) among women. These declines contributed among men 70% and among women 58% to the overall decline in CHD mortality rate. In all, 58% of the male and 52% of the female victims of out-of-hospital CHD death had a history of symptomatic CHD. Among men with a prior history of myocardial infarction, the annual average decline in out-of-hospital CHD deaths was 5.3% (-7.2, -3.2%), and among men without such history the decline was 2.9% (-4.4, -1.5%). Among women, the corresponding changes were -7.8% (-14.2, -1.5%) and -4.5% (-8.0, -1.0%). The decline in out-of-hospital CHD deaths has contributed the main part to the overall decline in CHD mortality rates among persons 35 to 64 years of age in Finland.