Cardiac In-hospital Mortality Research Articles

Identification of Patients at Risk for Postoperative Respiratory Complications Using a Preoperative Obstructive Sleep Apnea Screening Tool and Postanesthesia Care Assessment

Patients with obstructive sleep apnea are at risk for perioperative morbidity. The authors used a screening prediction model for obstructive sleep apnea to generate a sleep apnea clinical score (SACS) that identified patients at high or low risk for obstructive sleep apnea. This was combined with postanesthesia care unit (PACU) monitoring with the aim of identifying patients at high risk of postoperative oxygen desaturation and respiratory complications. In this prospective cohort study, surgical patients with a hospital stay longer than 48 h who consented were enrolled. The SACS (high or low risk) was calculated; all patients were monitored in the PACU for recurrent episodes of bradypnea, apnea, desaturations, and pain-sedation mismatch. All patients underwent pulse oximetry postoperatively; complications were documented. Chi-square, two-sample t test, and logistic regression were used for analysis. The oxygen desaturation index (number of desaturations per hour) was calculated. Oxygen desaturation index and incidence of postoperative cardiorespiratory complications were primary endpoints. Six hundred ninety-three patients were enrolled. From multivariable logistic regression analysis, the likelihood of a postoperative oxygen desaturation index greater than 10 was increased with a high SACS (odds ratio = 1.9, P < 0.001) and recurrent PACU events (odds ratio = 1.5, P = 0.036). Postoperative respiratory events were also associated with a high SACS (odds ratio = 3.5, P < 0.001) and recurrent PACU events (odds ratio = 21.0, P < 0.001). Combination of an obstructive sleep apnea screening tool preoperatively (SACS) and recurrent PACU respiratory events was associated with a higher oxygen desaturation index and postoperative respiratory complications. A two-phase process to identify patients at higher risk for perioperative respiratory desaturations and complications may be useful to stratify and manage surgical patients postoperatively.

Clinical impact of an inter-hospital transfer strategy in patients with ST-elevation myocardial infarction undergoing primary angioplasty: the Emilia-Romagna ST-segment elevation acute myocardial infarction network

This study sought to evaluate the impact of an inter-hospital transfer strategy on treatment times and in-hospital and 1 year cardiac mortality of patients with ST-segment elevation acute myocardial infarction (STEMI) undergoing primary percutaneous intervention (p-PCI) in the Italian region of Emilia-Romagna, where an efficient region-wide system for reperfusion has been established. 3296 patients with STEMI, undergoing on-site p-PCI (2444 patients) (OS group) or p-PCI after inter-hospital transfer (852 patients) (T group) between 1 January 2004 and 30 June 2006 in the Italian region of Emilia-Romagna, were considered. During the study period, the number of patients undergoing p-PCI increased both for patients admitted to interventional centres and for those admitted to peripheral hospitals. At the same time, the proportion of patients with STEMI initially admitted to peripheral hospitals and not transferred and the door-to-balloon time delays of transfer patients decreased. In spite of longer door-to-balloon delay in the transfer group [112 min (86-147) vs. 71 min (46-104)], in-hospital cardiac mortality (OS 7.0 vs. T 5.4%, P = 0.10) did not significantly differ between the two groups. After multivariable adjustment, the transfer strategy was not associated with increased risk of in-hospital [odds ratio 0.956; 95% confidence interval (CI) 0.633-1.442] and 1 year (hazard ratio 0.817; 95% CI 0.617-1.085) cardiac mortality. This study, concerning an established STEMI regional network, suggests that a strategy of inter-hospital transfer for p-PCI, when supported by an organized system of care, may be applied with rapid reperfusion times and favourable short- and long-term clinical outcomes.

Survival after transcoronary ablation of septal hypertrophy in hypertrophic obstructive cardiomyopathy (TASH): a 10 year experience

Catheter-based treatment of patients with hypertrophic obstructive cardiomyopathy (HOCM) by alcohol ablation (transcoronary ablation of septal hypertrophy, TASH) leads to symptomatic and haemodynamic improvement. However, little is known regarding the survival and its evolution since the introduction of the method in 1995. Theoretically, the method may be harmful, because widening of the obstructed left ventricular outflow tract is achieved by a septal infarction and subsequently by a potentially arrhythmogenic scar. This study sought to determine the impact of TASH on the survival of all patients with HOCM treated in our institution between 1995 and 2005. Survival was assessed from the early beginning in each of 644 consecutive patients to April 2005. Group A comprises a first series of 329 patients who were treated in a dose finding strategy with decreasing amounts of ethanol until December 2001, on average, from 2.9 ml to 0.93 ml/patient. The survival of this group was analysed using Kaplan-Meier estimates, multivariate Cox regression and Log-Rank testing. Group B comprises 315 patients of the following "low alcohol dose era" (mean amount of ethanol 0.8 +/- 0.4 ml, range 0.3-1.5 ml) and their mid-term survival (period to first regular 6-month post-procedural control). All patients (age 58 +/- 15 years, 99.2% follow up, mean 1.4 years): 33 patients died (5.1% all cause mortality), including perioperative deaths. 14/33 (42%) died from cardiac reasons. Annual total (all cause) mortality was 3.2%, total in-hospital mortality 1.2% in all patients (8 of 644 patients, 6 of them with severe comorbidity) and 0.4% in low risk patients. Annual cardiac mortality after hospital discharge was 0.7% (6 patients, all with sudden death). Group A (age 58 +/- 15 years, 98.8% follow up, mean 2.1 years, maximum 6.2 years): 29 patients died (total annual mortality 4.3%), 10 of them from hypertrophic cardiomyopathy related reasons resulting in a total in-hospital mortality of 1.8% (6 deaths), a cardiac annual mortality of 1.5% (including hospital mortality) and 0.6%/year after hospital discharge. Age was identified as an independent predictor of increased overall mortality (P = 0.002) and lower alcohol dosage and the absence of atrial fibrillation as independent predictors of reduced cardiac mortality (P = 0.005 and P = 0.039, respectively). With focus on the median value of the alcohol quantity (2.0 ml), patients treated with high amounts (>2.0 ml) showed a higher total mortality than patients treated with small amounts (< or =2.0 ml) (P = 0.031) and alcohol turned out to be an independent predictor of survival (P = 0.047). The same holds true for a homogenous subset of 262 patients with respect to cardiac mortality (P = 0.018). Group B (age 57 +/- 14 years, 99.7% follow up, mean 7.3 months): Total in-hospital mortality was 0.6% (2 of 315 patients; P = 0.173, group A/B) and cardiac in-hospital mortality 0% (P = 0.016, group A/B). During follow up two patients died, both of them experienced a sudden death reflecting an annual mortality of 1.0%. These data represent the largest available database on survival after alcohol septal ablation of HOCM from a single centre with large experience, and its evolution over 10 years with increasing procedural experience including the pronounced reduction of ethanol quantity in a systematic doses finding strategy. The in-hospital mortality has become very low. Cardiac survival during follow up was excellent, however, the well-known risk of sudden death is not completely eliminated. Longer follow-up time would be desirable for definite evaluation of this relatively new therapeutic option in the management of HOCM.

Impact of Preoperative Anemia on Outcome in Patients Undergoing Coronary Artery Bypass Graft Surgery

The risk of preoperative anemia in patients undergoing heart surgery has not been described precisely. Specifically, the impact of low hemoglobin per se or combined with other risk factors on postoperative outcome is unknown. Thus, we determined the effects of low preoperative hemoglobin and comorbidities on postoperative adverse outcomes in patients with coronary artery bypass graft in a large comprehensive multicenter study. The Multicenter Study of Perioperative Ischemia investigated 5065 patients with coronary artery bypass graft at 70 institutions worldwide, collecting approximately 7500 data points per patient. In 4804 patients who received no preoperative transfusions, we determined the association between lowest preoperative hemoglobin levels and in-hospital cardiac and noncardiac morbidity and mortality and the impact of concomitant risk factors, assessed by EuroSCORE, on this effect. In patients with EuroSCORE < 4 (n=2054), only noncardiac outcomes were increased, whereas patients with EuroSCORE > or = 4 (n=2750) showed an increased incidence of all postoperative events, starting at hemoglobin < 11 g/dL. Low preoperative hemoglobin was an independent predictor for noncardiac (renal > cerebral; P<0.001) outcomes, whereas the increase in cardiac events was due to other factors associated with preoperative anemia. Anemic patients undergoing cardiac surgery have an increased risk of postoperative adverse events. Importantly, the extent of preexisting comorbidities substantially affects perioperative anemia tolerance. Therefore, preoperative risk assessment and subsequent therapeutic strategies, such as blood transfusion, should take into account both the individual level of preoperative hemoglobin and the extent of concomitant risk factors.

Hemoglobin concentration is an independent determinant of heart failure in acute coronary syndromes: cohort analysis of 2310 patients

Anemia is an important determinant of heart failure and death after ST elevation myocardial infarction (STEMI). The frequency of anemia and its impact on these outcomes across the range of acute coronary syndromes (ACS), however, have not been defined. This is a cohort study of 2310 patients with ACS stratified by quartiles of admission hemoglobin concentration [Hb]): Q1, <12.5 g/dL; Q2, 12.5-13.6 g/dL; Q3, 13.7-14.7 g/dL; Q4, >14.7 g/dL. There were 29.7% of women and 23.2% of men who were anemic. Rates of STEMI increased across [Hb] quartile groups from 25.0% (Q1) to 35.5% (Q4) as rates of unstable angina decreased from 52.0% (Q1) to 40.7% (Q4) (P < .0005). Despite this, rates of left ventricular failure (LVF) were inversely related to [Hb] in all diagnostic groups, patients with unstable angina (Q1, 14.2%; Q4, 4.4%; P < .0005) showing a similar trend to patients with non-STEMI (Q1, 26.8%; Q4, 10.4%; P < .0005) and STEMI (Q1, 33.8%; Q4, 20.6%; P < .0005). The age-adjusted odds of LVF in Q4 compared with Q1 were 0.64 (95% confidence interval, 0.45-0.90). Inhospital cardiac mortality was 3.0% and was not influenced by [Hb]. Anemia is a common comorbidity in patients presenting with ACS, and it is a powerful independent determinant of LVF. The association with LVF occurs not only in STEMI but also in less severe diagnostic groups.

Differences in out-of-hospital and in-hospital cardiac arrest mortality outcomes: preliminary results

Differences in out-of-hospital and in-hospital cardiac arrest mortality outcomes: preliminary results

885-3 Correlation between the extent of diseased vessels and the incidence of in-hospital cardiac mortality in acute myocardial infarction

885-3 Correlation between the extent of diseased vessels and the incidence of in-hospital cardiac mortality in acute myocardial infarction

Impact of renal function on morbidity and mortality after percutaneous aortocoronary saphenous vein graft intervention

Background Percutaneous coronary intervention in patients with chronic renal insufficiency (CRI) and native coronary artery disease is often problematic, marred by increased morbidity and mortality rates and a high incidence of restenosis and revascularization. However, little is known about the effect of CRI in patients who have undergone prior coronary artery bypass graft surgery and then undergo saphenous vein graft (SVG) intervention. Methods We analyzed the inhospital and 1-year outcomes of 1265 consecutive patients with normal renal function and varying degrees of renal insufficiency who underwent percutaneous SVG intervention and divided them into 4 groups on the basis of the calculated creatinine clearance (CrCl): group 1, CrCl ≥70 mL per minute (n = 626); group 2, CrCl 50 to 69 mL per minute (n = 357); group 3, CrCl 30 to 49 mL per minute (n = 228); and group 4, CrCl <30 mL per minute (n = 54). Patients undergoing dialysis replacement therapy were excluded from the study. Results Patients with lower CrCl more often were older, female, had diabetes mellitus, and had worse left ventricular function. Angiographic baseline characteristics were comparable among the 4 groups. Overall immediate procedural success was similar for all groups. Patients with a low CrCl had significantly higher inhospital overall and cardiac mortality rates ( P < .001), including a significantly higher incidence of myocardial infarction, vascular complications, pulmonary edema, and renal function deterioration. At 1-year follow-up, the overall mortality rates remained significantly higher in patients with decreased CrCl, with an incremental rise in overall mortality rate associated with lower renal function ( P < .001). Conclusions This study suggests that renal function is a primary determinate of short- and long-term survival in patients undergoing percutaneous SVG intervention and that there is a clear relationship between CrCl and cardiovascular outcome. (Am Heart J 2003;145:529-34.)

Early Use of Beta-Blockers Is Associated with Attenuation of Serum C-Reactive Protein Elevation and Favorable Short-Term Prognosis after Acute Myocardial Infarction

Background: We have reported that a marked elevation in serum C-reactive protein (CRP) level is a predictor for infarct expansion and cardiac rupture after AMI. Although β-blockers prevent cardiac rupture after AMI, their effect on serum CRP elevation has not been determined. Methods: We studied a total of 154 patients with first Q-wave AMI. Patients complicated by pump failure were excluded from this study. Eighty-two patients received β-blocker treatment within 24 h of the onset of AMI, while 72 patients received no β-blocker treatment. Peak serum creatine kinase (CK) and CRP levels were determined by serial measurements. Results: There was no difference between the groups according to age, sex, coronary risk factors, pre-infarction angina, infarct site, prior use of cardiovascular drugs, use of revascularization therapy, and prevalence of multivessel disease. β-Blocker treatment was associated with a lower peak CRP level (6.9 ± 6.1 vs.10.8 ± 9.3 mg/dl, p = 0.002), a shorter duration from the onset to the peak CRP level (2 ± 1 vs. 3 ± 2 days, p < 0.0001), a lower incidence of cardiac rupture (p = 0.03) and lower in-hospital cardiac mortality (p = 0.02), despite similar peak CK levels. Conclusion: The early use of β-blockers is associated with decreased serum CRP level and a favorable clinical outcome after first Q-wave AMI, suggesting some beneficial effects of β-blockers on infarct healing after AMI.

New-device angioplasty in women: clinical outcome and predictors in a 7,372-patient registry.

Female gender has been identified as an independent predictor of early complications and mortality after conventional balloon angioplasty. To gain insight into the outcome of women after new-device angioplasty, we reviewed the early and late clinical outcome of 7,372 patients undergoing new-device angioplasty between 1991 and 1996 at the Washington Hospital Center. Patients (2,077 women and 5,295 men) with native coronary artery (82.5%) or saphenous vein graft lesions undergoing new-device angioplasty were included in the study. In-hospital and 1-year major adverse cardiac events (MACE), including death, myocardial infarction, and target lesion revascularization (TLR), were recorded and compared on the basis of gender. Multivariable logistic regression analysis was performed to identify predictors of in-hospital and late mortality, follow-up MACE, and TLR. Women had more baseline comorbid risk factors and smaller reference vessel size compared with men. Women had a higher in-hospital cardiac mortality (1.39% vs 0.66%, P = 0.002), TLR (2.78% vs 1.81%, P = 0.008), and congestive heart failure (4.18% vs 2.29%, P < 0.001) compared with men. Overall in-hospital MACE tended to be higher among women (4.2% vs 3.3%, P = 0.074). Women had a higher 1-year mortality rate (4.39% vs 3.26%, P = 0.018), but a lower follow-up TLR (15.0% vs 18.1%, P = 0.001) and a lower overall MACE rate (29.2% vs 32.7%, P = 0.007) compared with men. Female gender was an independent predictor of in-hospital mortality (odds ratio 2.28, P = 0.02), but not late mortality. Although female gender appears to carry an inherent risk of in-hospital mortality after new-device angioplasty, the procedural success and mortality rates are favorable compared with those associated with balloon angioplasty series. The long-term clinical outcome of women after new-device angioplasty is excellent. The use of new devices is a safe and effective alternative strategy for the treatment of women with ischemic coronary artery disease. Device-specific outcomes, including stents, will require further evaluation.

Risk stratification using a combination of cardiac troponin T and brain natriuretic peptide in patients hospitalized for worsening chronic heart failure

We prospectively evaluated whether the combination of admission measurements of a marker for myocardial cell injury and a marker for left ventricular overload would effectively risk stratify patients with acutely decompensated heart failure. We measured serum concentrations of cardiac troponin T (cTnT) using a second-generation assay, as well as serum cardiac troponin I (cTnI) and plasma atrial and brain natriuretic peptide (BNP) concentrations on admission in 98 consecutive patients hospitalized for worsening chronic heart failure (mean age 69 years; 5 patients were in New York Heart Association functional class II, 35 were in class III, and 58 patients were in class IV). During a mean follow-up period of 451 days, there were 37 cardiac events, including 21 cardiac deaths (14 in-hospital deaths) and 16 readmissions for worsening heart failure. In a stepwise Cox regression analysis, including these biochemical markers, age, sex, functional class, and left ventricular ejection fraction, cTnT, and BNP were found to be significantly independent predictors of both cardiac death (p <0.05) and cardiac events (p <0.01). A cTnT >0.033 μg/L and/or a BNP >440 pg/ml on admission was correlated with an incremental increase in in-hospital cardiac mortality, overall cardiac mortality, and cardiac event rate. Kaplan-Meier analysis revealed that this combination could reliably stratify the patients into low-, intermediate-, and high-risk groups for cardiac events. Measuring the combination of admission concentrations of cTnT and BNP may be a highly effective means of risk stratification of patients hospitalized for worsening chronic heart failure.

Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery.

Patients undergoing vascular surgical procedures are at high risk for perioperative myocardial infarction (PMI). This study was undertaken to identify predictors of PMI and in-hospital death in major vascular surgical patients. From the Vascular Surgery Registry (6,948 operations from January 1989 through June 1997) the authors identified 107 patients in whom PMI developed during the same hospital stay. Case-control patients (patients without PMI) were matched at a 1x:x1 ratio with index cases according to the type of surgery, gender, patient age, and year of surgery. The authors analyzed data regarding preoperative cardiac disease and surgical and anesthetic factors to study association with PMI and cardiac death. By using univariable analysis the authors identified the following predictors of PMI: valvular disease (P = 0.007), previous congestive heart failure (P = 0.04), emergency surgery (P = 0.02), general anesthesia (P = 0.03), preoperative history of coronary artery disease (P = 0.001), preoperative treatment with beta-blockers (P = 0.003), lower preoperative (P = 0.03) and postoperative (P = 0.002) hemoglobin concentrations, increased bleeding rate (as assessed from increased cell salvage; P = 0.025), and lower ejection fraction (P = 0.02). Of the 107 patients with PMI, 20.6% died of cardiac cause during the same hospital stay. The following factors increased the odds ratios for cardiac death: age (P = 0.001), recent congestive heart failure (P = 0.01), type of surgery (P = 0.04), emergency surgery (P = 0.02), lower intraoperative diastolic blood pressure (P = 0.001), new intraoperative ST-T changes (P = 0.01), and increased intraoperative use of blood (P = 0.005). Patients who underwent coronary artery bypass grafting, even more than 12 months before index surgery, had a 79% reduction in risk of death if they had PMI (P = 0.01). Multivariable analysis revealed preoperative definitive diagnosis of coronary artery disease (P = 0.001) and significant valvular disease (P = 0.03) were associated with increased risk of PMI. Congestive heart failure less than 1 yr before index vascular surgery (P = 0. 0002) and increased intraoperative use of blood (P = 0.007) were associated with cardiac death. The history of coronary artery bypass grafting reduced the risk of cardiac death (P = 0.04) in patients with PMI. The in-hospital cardiac mortality rate is high for patients who undergo vascular surgery and experience clinically significant PMI. Stress of surgery (increased intraoperative bleeding and aortic, peripheral vascular, and emergency surgery), poor preoperative cardiac functional status (congestive heart failure, lower ejection fraction, diagnosis of coronary artery disease), and preoperative history of coronary artery bypass grafting are the factors that determine perioperative cardiac morbidity and mortality rates.

Ratio of left ventricular peak E-wave velocity to flow propagation velocity assessed by color M-mode Doppler echocardiography in first myocardial infarction: Prognostic and clinical implications

OBJECTIVESTo determine the ability of the ratio of peak E-wave velocity to flow propagation velocity (E/Vp) measured with color M-mode Doppler echocardiography to predict in-hospital heart failure and cardiac mortality in an unselected consecutive population with first myocardial infarction (MI).BACKGROUNDSeveral experimental studies indicate color M-mode echocardiography to be a valuable tool in the evaluation of diastolic function, but data regarding the clinical value are lacking.METHODSEchocardiography was performed within 24 h of arrival at the coronary care unit in 110 consecutive patients with first MI. Highest Killip class was determined during hospitalization. Patients were divided into groups according to E/Vp <1.5 and ≥1.5.RESULTSDuring hospitalization 53 patients were in Killip class ≥II. In patients with E/Vp ≥1.5, Killip class was significantly higher compared with patients with E/Vp <1.5 (p < 0.0001). Multivariate logistic regression analysis identified E/Vp ≥1.5 to be the single best predictor of in-hospital clinical heart failure when compared with age, heart rate, E-wave deceleration time (Dt), left ventricular (LV) ejection fraction, wall motion index, enzymatic infarct size and Q-wave MI. At day 35 survival in patients with E/Vp <1.5 was 98%, while for patients with E/Vp ≥1.5, it was 58% (p < 0.0001). Cox proportional hazards model identified Dt <140 ms, E/Vp ≥1.5 and age to be independent predictors of cardiac death, with Dt < 140 ms being superior to age and E/Vp.CONCLUSIONSIn the acute phase of MI, E/Vp ≥1.5 measured with color M-mode echocardiography is a strong predictor of in-hospital heart failure. Furthermore, E/Vp is superior to systolic measurements in predicting 35 day survival although Dt <140 ms is the most powerful predictor of cardiac death.

Reply

General Internal Medicine Section, Veterans Administration Medical Center, 111A1, 4150 Clement Street, San Francisco, California 94121.In Reply:-Dr. Rigg et al. suggest that the relatively low cardiac morbidity and mortality observed in the study by Bode et al. [1] reflects the case mix of patients in that study. They hypothesize that studying only high-risk patients would generate a more accurate estimate of the effect of anesthesia choice on cardiac outcome.To the extent that randomized controlled trials enroll less ill patients than are typically seen among the total surgical population, the low event rates seen in such studies may be partially an artifact. However, patients undergoing lower extremity vascular surgery, including those enrolled in trials, are already high-risk. [2] It is not at all clear how Rigg et al. would subclassify such patients into “high” high-risk and “low” high-risk, nor do they provide a source for these estimated event rates. And would patients at high high-risk, even if they could be identified, undergo elective vascular surgery? Most physicians would consider an expected perioperative mortality of 20% to be prohibitively great. A study enrolling such patients may take forever. Finally, there is little, if any, reason to believe that intraoperative anesthesia choice would reduce perioperative mortality rate, which has variety of causes, [3] by 25%.Our review and informal meta-analysis were performed on published trials, weighted appropriately for sample size. [4] Because publication bias generally favors the publication of trials with positive results, inclusion of unpublished trials generally leads to a reduction in the summary effect size, not the converse. Similarly, although most of the trials had relatively few patients, small published trials generally overestimate the effect of a treatment. Although these potential biases would favor detecting a beneficial effect of regional anesthesia compared with general anesthesia, no significant benefit was found: 0%(95% CI, -3% to +3%) difference for in-hospital or short-term cardiac mortality and 1.5%(95%CI, -4% to +7%) difference for any cardiac event or death favoring general anesthesia. [5]Despite the potential physiologic advantages from regional anesthesia compared with general anesthesia in patients undergoing vascular surgery, there has been no demonstrated statistical, and more importantly, clinical benefit on cardiac outcomes. There may, however, be other reasons to prefer one of the techniques. Nor does the lack of benefit mean that additional research in reducing perioperative car-diac morbidity and mortality is futile. Other strategies, such as those addressing the management of postoperative pain or perioperative myocardial ischemia, are promising. [6] As to further trials comparing the effects of currently available techniques of regional and general anesthesia on cardiac outcome, our conclusion still stands: none are needed.Alan S. Go, M.D.Warren S. Browner, M.D., M.P.H.General Internal Medicine Section; Veterans Administration Medical Center, 111A14150 Clement Street; San Francisco, California 94121(Accepted for publication February 3, 1997.)

Primary ventricular tachycardia in acute myocardial infarction: clinical characteristics and mortality. The SPRINT Study Group.

To examine the immediate and long-term clinical and prognostic significance of primary ventricular tachycardia, defined as tachycardia of ventricular origin occurring within 48 hours of acute myocardial infarction in patients without hemodynamic compromise (Killip class I). Prospective cohort study. Intensive coronary care units in eight regional, referral, and university hospitals. A total of 162 patients with primary ventricular tachycardia, both sustained and nonsustained (study group), and 2578 counterparts without ventricular tachycardia (reference group). In-hospital rates of atrial fibrillation, atrioventricular block, congestive heart failure, cardiogenic shock, and cardiac arrest. In-hospital and 1-year follow-up rates of sudden death, nonsudden cardiac death, and noncardiac death. The study and reference groups had similar mortality (in-hospital, 6.8% and 9.6%, P greater than 0.2 and at 1 year after discharge, 3.7% and 5.4%, P greater than 0.2, respectively) and in-hospital complication rates (atrioventricular block, 13.0% and 9.7%, P greater than 0.2; cardiogenic shock, 3.7% and 3.0%, P greater than 0.2; cardiac arrest, 1.8% and 4.4%, P greater than 0.2, respectively). Patients with sustained ventricular tachycardia (28 patients) compared with those with nonsustained ventricular tachycardia (134 patients) had higher rates of polymorphic tachycardia (50% compared with 6%, P = 0.001), in-hospital total cardiac mortality (21% compared with 4%, P = 0.003) and sudden-death mortality (14% compared with 2%, P = 0.001); they also showed a trend toward a higher in-hospital mortality than the reference group (21.4% compared with 9.6%, P = 0.15) but had no increased mortality 1 year after discharge (4.6% compared with 5.4%, P greater than 0.2). As a group, patients with primary ventricular tachycardia do not differ from counterparts without primary ventricular tachycardia in their in-hospital clinical course and 1-year prognosis. Primary sustained ventricular tachycardia is often polymorphic and carries worse in-hospital prognosis than nonsustained tachycardia. However, it does not predict recurrent ventricular tachycardia or increased sudden-death rates during the next year.

Relation between acute ventricular arrhythmias, ventricular late potentials and mortality in acute myocardial infarction

The relation between ventricular late potentials and the occurrence of acute (in-hospital) and hyperacute (before hospital admission) ventricular tachycardia or fibrillation was studied in 281 consecutive patients with uninterrupted acute myocardial infarction. The prevalence of late potentials was significantly higher in patients with than without ventricular tachycardia/fibrillation (65 vs 22%; p < 0.01). These relations persisted among patients with left bundle branch block, although a different definition was used for identifying late potentials in these patients. Multivariate analysis showed that presence of late potentials and peak creatine kinase enzyme level were the only 2 independent variables associated with early ventricular tachycardia/fibrillation. Total in-hospital mortality, as well as in-hospital cardiac mortality, was significantly higher among patients with than without acute ventricular tachycardia/fibrillation. However, at 1 year, mortality rates did not differ between the 2 groups. The following conclusions were drawn from this study: (1) Late potentials are closely related to ventricular tachycardia/fibrillation in hyperacute and acute phases of infarction. (2) Presence of left bundle branch block does not mitigate against the finding of late potentials in these patients. (3) Early ventricular tachycardia/fibrillation in acute infarction is related to large infarctions and to a high in-hospital mortality rate.

Relative prognostic value of clinical, biochemical, echocardiographic and haemodynamic variables in predicting in-hospital and one-year cardiac mortality after acute myocardial infarction.

This study examined the relative value of clinical, biochemical, echocardiographic and haemodynamic variables, obtained early after acute myocardial infarction in predicting in-hospital and one-year cardiac mortality in 66 consecutive patients. Clinical examination and cross-section echocardiography were obtained in all 66 patients. An echocardiographic score index was calculated by grading wall motion from 0 to 5 in each of 16 left ventricular segments. Right-sided cardiac catheterization was performed soon after admission in 51 patients. Cardiac enzymes were measured every fourth hour in all patients and peak levels were identified in 55. During the follow-up of one year, 14 patients died of cardiac causes, seven of them during hospital stay; three patients died of a non-cardiac cause and were excluded from analysis. The echocardiographic score index was the best predictor of cardiac death and survival (chi 2 = 35), followed by Killip class on admission (chi 2 = 22), stroke volume index (chi 2 = 17) and a biochemical risk index (chi 2 = 11). Stepwise logistic discriminant analysis performed in the patients in whom all variables were obtained resulted in three independent prognostic variables: the echocardiographic score index, systemic vascular resistance at the time of catheterization and the development of infarct expansion. High- and low-risk patients are well identified by echocardiography in the acute phase of myocardial infarction.

In-hospital cardiac mortality after acute closure after coronary angioplasty: Analysis of risk factors from 8,207 procedures

Cardiac death consequent to acute vessel closure after coronary angioplasty occurred in 13 of 294 closures from 8,207 consecutive procedures performed at two centers since 1981 (0.16% cardiac mortality rate). To determine the predictors of cardiac death after acute coronary closure, 50 clinical, angiographic and procedural variables were analyzed by an observer unaware of the clinical outcome for each of the 13 patients who died and also 190 patients randomly chosen, in whom vessel closure after angioplasty did not result in death during hospitalization. Univariate analysis found female gender (p < 0.0001), collateral channels from the vessel dilated (p < 0.0001), use of balloon counterpulsation (p < 0.0002), pre- and postprocedural hypotension (p = 0.0003 and p = 0.003, respectively), jeopardy score ≥2.5 (p = 0.003), left ventricular hypertrophy (p = 0.013), hypertension (p = 0.02), diabetes (p = 0.02) and multivessel disease (p = 0.03) to be predictive of death. Multivariate analysis found collateral vessels, female gender and multivessel disease to be independent predictors of death.Thus, cardiac death after elective coronary angioplasty is very rare in experienced centers and occurs most often in women with a large amount of potentially ischemic myocardium. Hypotension often precedes the fatal closure event. Close attention to the amount of potentially ischemic myocardium and to the fluid volume status of these patients would seem to be especially warranted.

Treatment of myocardial infarction with intracoronary streptokinase: Efficacy and safety data from 209 United States cases in the Hoechst-Roussel registry

Efficacy and safety data from 209 U.S. cases in the Hoechst-Roussel intracoronary streptokinase (STK) registry were analyzed. Successful recanalization was achieved in 76% of infarct-related occluded coronary arteries. Postinfarction complications (i.e., malignant arrhythmia, heart block, and pump failure) were substantially less frequent after successful recanalization compared to the recanalization failures. Cardiac in-hospital mortality was 2.5% in the recanalized group and 18% in the group in which recanalization failed. Several severe hemorrhagic complications occurred in patients who were heparinized. The data suggest that myocardial reperfusion following STK coronary recanalization during evolving myocardial infarction may salvage myocardium. Except for excessive bleeding associated generally with heparinization, side effects and adverse reactions were readily controlled.