Initial Myocardial Infarction Research Articles

Usefulness of silent myocardial ischemia detected by ambulatory electrocardiographic monitoring in predicting new coronary events in elderly patients

Unrecognized myocardial infarction (MI) detected by electrocardiogram (ECG) occurred in 83 of 237 women (35%) and 130 of 469 men (28%) with initial MI in the Framingham study. 1 Unrecognized MI had as serious a prognosis as recognized MI in that study. 1 In our 1985 study, 2 we reported that unrecognized Q-wave MI detected by ECG occurred in 78 of 115 elderly patients (68%) with MI in a long-term health care facility. After instructing staff physicians on the different presenting symptoms of MI in elderly patients, the incidence of unrecognized MI detected by ECG in a prospective study was 23 of 110 MIS (21%). 3 Silent myocardial ischemia detected by ambulatory ECG monitoring is common during daily life in asymptomatic patients with coronary artery disease (CAD) and positive treadmill exercise tests. 4 In unstable angina, 80% of ischemic episodes are silent. 5 Abnormalities in regional and global left ventricular wall motion are similar in patients with CAD, with and without silent ischemia. 6 Rubidium-82 positron-emission tomographic studies have demonstrated reduced myocardial perfusion during episodes of silent myocardial ischemia detected by ambulatory ECG monitoring in patients with CAD. 7 The prognosis of asymptomatic silent ischemia in patients with CAD depends on the extent of CAD and left ventricular dysfunction. 8 The prognostic value of silent ischemia detected by ambulatory ECG monitoring has been reported in patients with unstable angina, 9–11 in high-risk postinfarction patients 12 and in patients with stable CAD. 13,14 We performed a prospective study (1) to determine the prevalence of silent ischemia in elderly patients with CAD, patients with systemic hypertension, valvular heart disease or cardiomyopathy, and in patients with no evidence of heart disease, and (2) to correlate silent ischemia with cardiac events at 26-month follow-up in these groups of patients.

The relationship between perception of supportive behaviors of others and wives' ability to cope with initial myocardial infarctions in their husbands.

Log in or Register Subscribe to journalSubscribe Get new issue alertsGet alerts Enter your Email address: Wolters Kluwer Health may email you for journal alerts and information, but is committed to maintaining your privacy and will not share your personal information without your express consent. For more information, please refer to our Privacy Policy. Subscribe to eTOC Secondary Logo Journal Logo All Articles Images Videos Podcasts Blogs Advanced Search Toggle navigation Subscribe Register Login Articles & Issues Current IssuePrevious IssuesPublished Ahead-of-Print CETop Trending ArticlesVideosFor Authors Submit a ManuscriptInformation for AuthorsLanguage Editing ServicesAuthor Permissions Journal Info About the JournalAbout the AssociationEditorial BoardAdvertisingSubscription ServicesReprintsOpen AccessRights and Permissions All Articles Images Videos Podcasts Blogs Advanced Search

Temporal stability and overlap of behavioral and questionnaire assessments of type A behavior in coronary patients.

To examine the temporal stability of the Type A behavior pattern (TABP) after a cardiac event, both a Videotaped Clinical Interview (VCI) (formerly known as the Videotaped Structured Interview) and the Jenkins Activity Survey (JAS) were administered to 81 male and 19 female patients three times during the first year after hospitalization for an initial myocardial infarction, coronary artery bypass graft, or both. There was no intervention other than the usual treatment provided by the medical care system. The test-retest reliability coefficients were moderately high for all measures of TABP. The JAS provided the most reliable scores in both sexes. The Hard Driving and Competitive component of the JAS decreased significantly throughout the year in both men (p less than 0.001) and women (p less than 0.01), but in men all three overall indices of TABP and their components (other than Hard Driving and Competitive) decreased spontaneously between 1 and 3 months, and then increased again by 1 year to nearly the original levels. In women, there were no consistent changes over time among the indices other than that for the Hard Driving and Competitive component of the JAS. Intercorrelations among the indices demonstrate the failure of the JAS to assess the Hostility component of the TABP and the possibility that the Speed and Impatience subscale of the JAS measures different things in men and women. The newest method of scoring the VCI appeared to provide the best index for measuring TABP in male coronary patients, while the original scoring was more reliable for women.

Prevalence of presenting symptoms of recognized acute myocardial infarction and of unrecognized healed myocardial infarction in elderly patients

Eighty-three of 239 women (35%) and 130 of 469 men (28%) with initial myocardial infarction (MI) in the Framingham study had unrecognized MI, which was detected by electrocardiogram. 1 We reported that 78 of 115 elderly patients (68%) in a long-term health care facility with either documented clinical history of MI or current electrocardiographic evidence of Q-wave MI had unrecognized MI detected by routine electrocardiogram. 2 Elderly patients may have symptoms other than chest pain associated with MI. 3–6 We performed a prospective study in a long-term health care facility to determine the prevalence of presenting symptoms of recognized acute MI and of unrecognized healed new MI detected by electrocardiogram in elderly patients who developed documented MI.

Myocardial infarct expansion, infarct extension, and reinfarction: Pathophysiologic concepts

Infarct expansion and infarct extension are events early in the course of myocardial infarction with serious short- and long-term consequences. Infarct expansion, disproportionate thinning, and dilatation of the infarct segment probably begin within hours of acute infarction and usually reach peak extent within seven to 14 days. Clinical data suggest that infarct expansion occurs in approximately 35% to 45% of anterior transmural myocardial infarctions and to a lesser extent in infarctions at other sites. Although expansion usually develops in large infarcts, the extent of transmural necrosis rather than absolute infarct size predicts its occurrence. Expansion has an adverse effect on infarct structure and function for several reasons. Functional infarct size is increased because of infarct segment lengthening, and expansion results in overall ventricular dilatation. Thus, patients with expansion of an infarct have poorer exercise tolerance, more congestive heart failure symptoms, and greater early and late mortality than those without expansion. Infarct rupture and late aneurysm formation are two additional stuctural consequences of infarct expansion. Experimental and clinical data suggest that the incidence and severity of expansion can be modified by interventions. Increased ventricular loading conditions and steroidal and nonsteroidal antiinflammatory agents make expansion more severe. Reperfusion of the infarct segment and pharmacologic interventions that decrease ventricular afterload lessen the severity of expansion. Previous myocardial infarction and preexisting ventricular hypertrophy may also limit the development of infarct expansion. Infarct extension is defined clinically as early in-hospital reinfarction after a myocardial infarction. The pathologic finding of infarct extension is necrotic and healing myocardium of several different recent ages within the same vascular territory. Although this pathologic criterion usually cannot be verified, studies employing invasive and noninvasive assessment of patients with early reinfarction provide evidence that the new myocardial injury is usually in the same vascular risk region as the original infarction. A variety of different criteria have been applied in the clinical diagnosis of infarct extension, and this has resulted in a large range of estimated frequencies from under 10% to as high as 86%. High estimates are found in studies using one or two nonspecific criteria such as ST segment shift or reelevation of total CK. The lowest rates have been found when combinations of criteria are used. When new CK-MB isoenzyme elevation is used as the gold standard, an incidence of approximately 20% to 30% is found. Autopsy data from patients who have died after a recent infarction are also consistent with this latter range. The pathophysiologic mechanism of infarct extension has been suggested by angiographic and postmortem studies. Flow to the region supplied by the infarct-related coronary artery is restored to a level sufficient to preserve part of the myocardium within the risk region. This blood supply can be provided by antegrade flow through the infarct-related vessel established by thrombolysis or thrombus retraction, or by flow through collateral channels. Later reduction or cessation of flow caused by rethrombosis or by a change in coronary hemodynamics produces enough ischemia to cause further necrosis. This pattern may repeat several times. Patients with infarct extension have greater incidences of congestive heart failure, arrhythmias, cardiogenic shock, and death. Infarct extension by increasing the amount of transmural necrosis may also lead to infarct expansion and its attendant complications. A number of risk factors for infarct extension have been proposed, but early postinfarction angina is most predictive of high risk. Thus, patients with early postinfarction angina should be considered for early revascularization procedures. More general therapeutic approaches such as treatment with β-blockers, calcium channel blockers, and nitrates have not definitively been shown to be of value in patients of any risk category. Recurrent infarction, or reinfarction, is defined as a new myocardial infarction occurring after the acute hospital phase of an earlier myocardial infarction. The new event may occur in regions either adjacent to or remote from the initial myocardial infarction. As in patients with infarct expansion and infarct extension, patients with reinfarction have increased morbidity and mortality. The incidence of reinfarction found in most studies is between 10% and 20%. Patients with either recurrent angina or a positive exercise stress test are at an increased risk of reinfarction. As with the risk of first myocardial infarction, hypertension, smoking, and elevated serum cholesterol have been identified as risk factors for reinfarction. Patients undergoing noncardiac surgery within 6 months of myocardial infarction also have a higher risk of reinfarction. Prevention of reinfarction should be aimed at reduction of known risk factors. In selected patients, revascularization procedures may be useful in preventing reinfarction. Treatment with daily aspirin and β-blockers has been shown to reduce the incidence of reinfarction and should be considered as routine postinfarction treatment in those patients without contraindication to such therapy.

Myocardial Infarction Survival: How important Are Patients’ Attitudes and Adherence Behaviors?

Positive attitudes toward and adherence to prescribed medical regimens among patients recovering from initial episodes of myocardial infarction (MI) intuitively have been viewed as beneficial. A cohort of 157 post-MI patients who participated in a cardiac rehabilitation program was tested for compliance with the Health Adherence Scale and Miller Attitude Scale during hospitalization and again six months later. This study reports on follow-up conducted two to five years after initial MI to determine whether patients' attitudes and adherence behaviors had a significant effect on subsequent cardiovascular morbidity and overall mortality after controlling for known risk factors. The data were analyzed using the Cox proportional hazard regression model. Neither positive patient attitudes nor adherence behaviors were associated with a reduced risk of a morbid or fatal event. However, this study found, as have many others, that the known risk factors of alcoholism, widowhood, cigarette smoking, and diabetes were significantly associated with repeat episodes of MI, while the only risk factor associated with mortality was repeat MI. The study suggests that the benefits of positive attitudes and adherence behaviors are outweighed by the influence of existing cardiovascular risk factors. Thus, the prevention of these risk factors remains the primary determinant in the reduction of MI.

Short- and long-term prognostic value of graded exercise testing soon after myocardial infarction.

We attempted to determine whether graded exercise testing (GXT) soon after a myocardial infarction (MI) using an unlimited metabolic equivalent (MET) level and target heart rate (HR) of 90% of the age-predicted maximal HR is a safe procedure and yields prognostic results different from tests that use lower level end points. We administered GXT to a random sample of 85 patients at a mean of 14.8 days post-MI. End points that included ST-segment depression (STD), angina pectoris (AP), ventricular ectopic activity, and achieved MET level during testing were evaluated as predictors of cardiac events that include death, recurrent nonfatal MI, and coronary artery bypass graft surgery. We conducted short-term follow-up monitoring for one year after the initial MI and long-term follow-up monitoring for a mean of 864.7 days. No serious complications occurred during testing. Angina pectoris, STD accompanied by AP, and achieved MET level were predictive (p less than .05) of future fatal and nonfatal cardiac events during the first year of follow-up monitoring. Fifty-nine percent of the patients with AP suffered a subsequent cardiac event within one year, whereas only 17% of those without AP experienced another cardiac event. Sixty-seven percent of the patients with both STD and AP had a subsequent cardiac event within one year, but only 22% of those without AP and STD had a subsequent cardiac event. For the long-term follow-up monitoring, the presence of AP and a low achieved MET level during testing were associated with subsequent cardiac events.(ABSTRACT TRUNCATED AT 250 WORDS)

Antithrombotic Agents in Coronary Artery Disease

Each year in the United States alone there are about 1 million “heart attacks”—a term that includes both acute infarction and sudden cardiac death. 1 Braunwald E Friedewald WT Furberg CF Proceedings of the workshop on platelet-active drugs in the secondary prevention of cardiovascular events. Circulation. 1980; 62: 6 Google Scholar , 2 Hurst JW Logue RB Walter PF The clinical recognition and management of coronary atherosclerotic heart disease. in: Hurst JW Logue RB Schlant RC The heart, arteries, and veins. McGraw-Hill Book Co, New York1978: 1216-1219 Google Scholar , 3 Weinblatt E Shapiro S Frank CW et al. Prognosis of men after myocardial infarction: mortality and first recurrence in relation to selected parameters. Am J Public Health. 1968; 58: 1329-1347 Crossref Scopus (148) Google Scholar , 4 Kannel WG Thomas HE Sudden coronary death: the Framingham study. Ann NY Acad Sci. 1982; 382: 3-21 Crossref PubMed Scopus (193) Google Scholar Nearly 300,000 victims die before admission to the hospital, and about another 200,000 die in the first month, most of them in the first 24 hours after the attack. Thus, the cumulative mortality during the first month is about 50%. During the next six months, the cumulative mortality increases another 7-8%, so that by one year, another 10% have died. 1 Braunwald E Friedewald WT Furberg CF Proceedings of the workshop on platelet-active drugs in the secondary prevention of cardiovascular events. Circulation. 1980; 62: 6 Google Scholar , 2 Hurst JW Logue RB Walter PF The clinical recognition and management of coronary atherosclerotic heart disease. in: Hurst JW Logue RB Schlant RC The heart, arteries, and veins. McGraw-Hill Book Co, New York1978: 1216-1219 Google Scholar , 5 Beard OW Hipp HR Robins M et al. Initial myocardial infarction among 503 veterans: five-year survival. Am J Med. 1960; 28: 871-883 Abstract Full Text PDF PubMed Scopus (54) Google Scholar This means that, of the 400,000-500,000 patients who survive the first month, about 10% (40,000-50,000) die during the first year following infarction, generally due to sudden death or recurrent infarction. After patients have survived a year, the reinfarction and death rate stabilizes at 3-5% per year. This rate is similar to that of patients with symptomatic coronary artery disease (ie, angina pectoris) but is significantly greater than that of a randomly selected, age-matched population without overt coronary artery disease that has a 1% yearly incidence of those events. 3 Weinblatt E Shapiro S Frank CW et al. Prognosis of men after myocardial infarction: mortality and first recurrence in relation to selected parameters. Am J Public Health. 1968; 58: 1329-1347 Crossref Scopus (148) Google Scholar , 6 Report from the Committee of Principal Investigators. A cooperative trial in the primary prevention of ischaemic heart disease using clofibrate. Br Heart J. 1978; 40: 1069-1118 Crossref PubMed Scopus (841) Google Scholar

Effects of beta-adrenergic blockade on the natural progression of myocardial infarct size and compensatory hypertrophy

Using contrast-enhanced computed tomography, the effects of beta-adrenergic blockade were assessed on experimentally produced myocardial infarcts in dogs evaluated serially over the course of approximately 1 month. Infarct size, initial perfusion defect (jeopardized segment) and noninfarcted muscle mass were studied in two groups of conditioned mongrel dogs. Group 1 (n = 11) served as the control group and Group 2 (n = 10) was pretreated with propranolol (2 mg/kg). Each animal in the propranolol-treated group was given identical amounts of the agent twice daily for 7 days after coronary occlusion. Both groups developed increases in the noninfarcted muscle mass of the left ventricle (compensatory hypertrophy). The mean increase averaged 19.8% over 30 days when the two groups were included together. Infarct size was smaller in the propranolol-treated group, and averaged 28% less (p less than 0.05) than that of the control group 30 days after initial myocardial infarction. Thus, pharmacologic interventions were shown by computed tomography to alter the size of an acute experimental myocardial infarct, particularly when examined over the time course of infarct healing. Moreover, compensatory hypertrophy occurred in both the control and propranolol-treated groups.

Smoking and myocardial infarction: secondary prevention.

This prospective study examines the question 'Is it too late to stop smoking cigarettes once you have had a myocardial infarction?' One hundred and nineteen cigarette smokers (90 men, 29 women) who survived their first myocardial infarction for one month were followed for five years or until their death if earlier. The age corrected mortality rate of men who continued to smoke cigarettes was 2.2 times the age corrected mortality rate of those who stopped smoking after their infarct. The women who continued to smoke had 2.4 times the age corrected mortality of those who stopped smoking. The age and sex corrected mortality rates for the combined group of men and women show that those who stopped smoking after their infarction have 55% of the mortality of those who continued to smoke (P less than 0.05). These results suggest that smoking is not merely a 'risk factor' for myocardial infarction but is also a causal factor whose effects can be avoided by both men and women after an initial myocardial infarction.

Ischaemic heart disease, stroke and total mortality in women--results from a prospective population study in Gothenburg, Sweden.

The aims of this study were to determine the prognosis for women with different symptoms and signs indicating ischaemic heart disease and to relate entry characteristics to events of ischaemic heart disease and stroke, and to overall mortality during a 12-year follow-up period. A prospective cohort study was started as a cross-sectional investigation in 1968-69 (1462 participants aged 38-60, participation rate 90.1%). The same sample was re-studied in 1980-81 (1154 participants, participation rate 78.9% of those studied in 1968-69). In addition, a clinical series comprising all women of similar age in Gothenburg with myocardial infarction during the years 1968-70 (47 women) was followed up for 12 years. The 12-year overall mortality rate for women with initial myocardial infarction in the clinical series was 45%. The 12-year overall mortality rates for women who at the time of the initial study either were considered to have angina pectoris or showed electrocardiographic changes indicating ischaemic heart disease at rest or at work were 10%, 17% and 10% respectively (expected figures 7%, 12% and 10%). Twenty-three women (1.6%) developed myocardial infarction during the follow-up period (8 fatal, 15 non-fatal). New symptoms of angina pectoris were recorded in 56 women (4.0%), new electrocardiographic changes indicating ischaemic heart disease in 73 women (6.0%), and new signs of stroke in 13 women (0.9%). Altogether 75 women (5.1%) died during the follow-up period. These five end-points were taken into consideration. Women with previously untreated arterial hypertension were offered control visits during the follow-up period and were prescribed antihypertensive drugs when clinically indicated. In this group of women, hypertension was not a predictor for any of the end-points. No other systematic intervention was carried out. Increased abdominal adiposity, increased serum triglycerides and low peak expiratory flow were independent predictors of at least three of the end-points studied: myocardial infarction, stroke and death. Increased abdominal adiposity was also an independent predictor of angina pectoris. Initial diabetes was an independent predictor of both myocardial infarction and of death. Low energy intake predicted myocardial infarction and electrocardiographic changes indicating ischaemic heart disease. High serum gastrin levels predicted myocardial infarction. Low education and high degree of mental disorder were independent predictors of angina pectoris. Physical inactivity at leisure and physical inactivity at work were independent predictors of stroke and of death, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Infarct Size as a Determinant of Acute and Long-Term Prognosis

Enzymatic estimates of infarct size based on the analysis of either plasma total or CK-MB activity are substantially larger in patients who succumb to myocardial infarction compared with survivors. Similarly, if patients are stratified according to infarct size calculations, mortality increases as infarct size increases. Enzymatic markers of infarction are closely related to other indicators of prognosis, including infarct type (transmural versus nontransmural), infarct location (anterior versus inferior), the degree of left and right ventricular dysfunction, and the frequency of ventricular dysrhythmia. Hence, at least some of the prognostic impact of these variables may be due to the initial extent of infarction sustained. Multivariate analysis has been employed by several groups to analyze the independent contribution of these clinical descriptors to prognosis after infarction. These analyses have consistently indicated a substantial independent impact of enzymatic estimates of infarct size on prognosis. In studies of patients with initial myocardial infarction, infarct size index calculated from total plasma CK time activity curves had the greatest independent influence on survival. Unfortunately, the utility of enzymatic estimates of infarction as prognostic indicators in individual patients is attenuated by alterations in the strength of the apparent association between CK infarct size and prognosis in specific clinical situations. Thrombolytic therapy is now employed with increasing frequency during acute myocardial infarction. It has become abundantly clear that plasma CK release kinetics are profoundly modified by this procedure. Peak plasma total and CK-MB activity is markedly increased compared with that of patients undergoing routine therapy for infarction, with a profoundly altered CK time activity curve.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of serial QRS changes during acute inferior myocardial infarction using a QRS scoring system

The evolution of changes in the QRS complex during the initial 3 days after the onset of an initial inferior myocardial infarction (MI) was studied in 82 consecutive patients. Each patient's standard 12-lead electrocardiogram was assigned points (a QRS score) according to the absolute duration of the Q and R waves and the amplitude ratios of R-to-Q and R-to-S waves. This QRS score has been demonstrated to correlate (r = 0.74) with the anatomic extent of single inferior MI. By this sytem, 43 patients (53% of the study group) had an initial electrocardiogram that registered a score of 0 and developed QRS points only after admission. The QRS scores of 18 additional patients (22% of the study group) changed after admission. Forty-nine score changes were noted on Day 2 and 18 on Day 3. All of these changes resulted in an increased QRS score. Alteration of the QRS complex during initial inferior MI evolves over 2 to 3 days in many patients. There is a distinct pattern to this evolution, which results in sequential increases in a QRS score based upon electrocardiographic indicators of the extent of myocardial necrosis. This QRS scoring system might be applied to evaluate clinically interventions aimed at limiting the extent of necrosis in patients with initial acute inferior MI.

Myocardial infarction in young adults: Risk factors and natural history

The risk factors and clinical course of 165 patients under 40 years of age (mean age 35) having an initial myocardial infarction (MI) (Group I) were compared to 100 patients over 40 (mean age 50) (Group II). Six risk factors were analyzed: smoking 20 pack-years, hyperlipidemia, hypertension, family history of ischemic disease, diabetes mellitus, and obesity. Only two patients in Group I and six patients in Group II had no risk factors, but the mean number of risk factors in Group I (3) differed from Group II (2) ( p< 0.05). Group I had only 18% of patients without either obesity, hyperlipidemia, hypertension, or diabetes mellitus as risk factors while Group II had 41 patients with similar findings ( p< 0.001). Group I had hyperlipidemia, obesity, and family history more commonly than did Group II while hypertension was more frequent in the older patients. A prior history of angina was present in nearly half of Group I and II but physical exertion just prior to MI was more common in Group I (32%) than in Group II (20%) ( p < 0.05). Death at the time of MI was more frequent in Group II ( p < 0.001) but congestive failure occurred in 17% of both groups. On follow-up, 45% of both groups had no complications, and the rates of subsequent MI and angina pectoris were similar in both groups. However, late death was less frequent in Group I than in Group II. Patients under 40 with myocardial infarction have more risk factors than those over 40 which may play some role in pathophysiology of young myocardial infarction. Physical exertion at the time of myocardial infarction is more common in younger patients. The complication rate is similar in both young and older myocardial infarction patients but the mortality rate, both early and late, is lower in young myocardial infarction patients.

Characteristics of males with myocardial infarction below age 40

All cases of initial myocardial infarctions (MI) diagnosed among men below age 40 in Göteborg during 1970–1977 have been studied. The cases have been compared with a random sample from the general population in Göteborg with respect to socio-economic factors and conventional risk factors. The MI-cases showed a special socio-economic pattern prior to the infarction and were more often single and of foreign origin, had more previous sickness benefit days and were more often registered for alcohol abuse than contemporaries in the general population. Moreover, the surviving MI-cases were found to be heavily burdened with the conventional risk factors smoking, cholesterolemia and high blood pressure.

Absence of secular changes in the prognosis of patients with an initial myocardial infarction.

A community-based study was conducted in metropolitan Baltimore in which secular trends in the in-hospital and long-term prognosis of 935 male and female patients hospitalized with an initial myocardial infarction were examined for the two periods of 1966-1967 and 1971. The in-hospital case fatality rate among males in both periods remained unchanged (19.0% vs 19.0%), whereas there was a decrease over time among women hospitalized in 1966-1967 as compared to those in 1971 (37.2% vs 26.6%) (p less than 0.10). For patients discharged alive from the hospital and followed up for as long as 10 years, no significant differences in overall survival were observed between male patients discharged in 1966-1967 and 1971 or between female patients discharged in these two periods. These findings may reflect the lack of major therapeutic advances in the care of the acute coronary patient between the two study periods and, therefore, support continuing efforts directed at the primary and secondary prevention of the atherosclerotic process.

Illness behaviour and outcome following survived myocardial infarction: A prospective study

Patterns of illness behaviour were examined in 120 survivors of acute myocardial infarction (MI) between 10 and 14 days after their admission to a coronary care unit. Factor analysis of these data revealed 8 orthogonal dimensions which have been reported previously [1]. Factor score profiles were constructed for each patient to represent the degree to which specified dimensions of illness behaviour were characteristic of individual patient responses. All patients were followed up 8 months after discharge from hospital, either by personal interview and examination for those surviving this period, or by consulting death certificates and medical records for those who had died in the intervening period. Information on cardiological outcome and occupational rehabilitation were sought for survivors, while cause of death was ascertained for non-survivors. Rates of recurrent MI (survived or otherwise) and return to work were consistent with expectations arising from previous studies. Several aspects of illness behaviour evident soon after MI were also found to be predictive of outcome. Those with poor cardiological outcomes at 8 months were more likely than others to have expressed concern about somatic functioning and recognition of contributory life stress soon after the initial MI. Those failing to return to work at 8 months were more likely than others to have accepted the sick role and expressed subjective feelings of tension following the initial MI.

Prognosis after initial myocardial infarction: The Framingham study

During 20 years of follow-up of 5,127 men and women initially free of coronary heart disease in the Framingham cohort, 193 men and 53 women had one or more recognized, symptomatic myocardial infarctions. An additional 45 men and 28 women had unrecognized myocardial infarctions. Subsequent mortality and morbidity including angina, reinfarction, congestive failure and sudden death were ascertained. One in five men who had a first myocardial infarction died within 1 year, a mortality rate 14 times that of those free of coronary heart disease. In men who survived the 1st year, a recognized myocardial infarction increased risk of death over the next 5 years to 23 percent, four times that of the general population. The next 5 years carried a 25 percent mortality (three times that of the general population). The prognosis was distinctly worse in women than in men chiefly because of a higher (45 percent) early mortality rate in women. Patients with recognized and unrecognized myocardial infarctions had similar survival rates after 3 years. A second myocardial infarction occurred in 13 percent of the men and in 40 percent of the women within 5 years of the first infarction. Thus, women were more prone to death and reinfarction than men. Congestive heart failure occurred as commonly as reinfarction, affliction 14 percent of the men within 5 years of the initial infarction. Once congestive failure ensued, half of the affected patients were dead within 5 years. Angina developed in one third of the patients within 5 years of their first infarction.

Doughnut pattern of technetium-99m pyrophosphate myocardial uptake in patients with acute myocardial infarction: A sign of poor long-term prognosis

Thirty survivors of acute myocardial infarction with 3+ or 4+ positive technetium-99m pyrophosphate myocardial scintigrams were followed up for 28 ± 3.1 months (mean ± standard deviation). Three patient groups were identified from the pattern of radioactive uptake in the scintigram: Group I, 16 patients with focal uptake (anterior in 7, lateral in 2, posterior in 3 and inferior in 4); Group II, 6 patients with anterior myocardial infarction and a doughnut pattern of uptake; Group III, 8 patients with nontransmural myocardial infarction and a diffuse pattern of uptake. Late complications developed in all patients with the doughnut pattern of uptake compared with 43 percent of patients with the focal pattern and 12 percent of patients with the diffuse pattern. After discharge from the hospital, five of six patients with a doughnut pattern of uptake died (mean survival time 9.8 months after the initial myocardial infarction). This mortality rate (83 percent) was significantly greater than that of patients with a focal (mortality rate 6 percent) or diffuse (no mortality) pattern of uptake. The doughnut pattern of technetium-99m pyrophosphate myocardial uptake in patients with acute myocardial infarction appears to identify a subgroup of patients with a very poor long-term prognosis.

Occlusive Coronary Thrombosis and Oral Anticoagulants

The results of post-mortem examination in 173 patients followed over an average period of five and a half years after their initial myocardial infarction are described. These 173 patients were divided into four groups according to whether or not they had received an oral anticoagulant and if so how adequately. An index of coronary and myocardial lesions was established for each heart. Recent occlusive coronary and myocardial lesions was established for each heart. Recent occlusive coronary thromboses were four times less frequent in the group of patients who had received adequate anticoagulant therapy than in the other three groups of patients (p less than 0,001). There was no significant difference between the inadequately treated groups and the untreated group. The recurrences of myocardial infarction were associated in 90 per cent of the cases with a recent occlusive thrombosis in the corresponding coronary artery and were found four times less frequently in the group subjected to effective long-term anticoagulant therapy (p less than 0,001).