MI Survivors Research Articles

Abstract 6238: Clarifying the Opportunities to Improve Survival After MI in Diabetic Patients

While diabetes is known to be associated with increased mortality after MI, whether these differences in outcome are due to patient characteristics, treatment, or other biological factors is unknown. We analyzed a contemporary cohort of MI survivors to comprehensively adjust for demographics, comorbidities, psychosocial, health status, clinical and treatment factors to determine if residual disparities in outcomes exist. We studied 2481 hospital survivors of MI in the prospective, 19-center PREMIER study (29% with diabetes). Multivariable models with sequential adjustment were employed to identify the extent to which variation in a wide range of patient characteristics (Figure ) accounted for differences in 3-year mortality in patients with and without diabetes. Unadjusted mortality was more than 2.5-fold greater for patients with diabetes (HR 2.55, 95% CI 2.08–3.14). Mortality was most attenuated by diabetes-related comorbidities (Figure ). The fully-adjusted model identified a significant, albeit attenuated, excess 3-year mortality among patients with diabetes (HR 1.57, 95% CI 1.22–1.99). Patients with diabetes experience a substantially increased risk for 3-year mortality after MI, even after accounting for a wide range of patient and treatment characteristics. This suggests that unmeasured, biologic variables associated with diabetes may mediate this difference. Further inquiry into the pathogenesis of diabetic cardiovascular disease is needed to identify new opportunities to improve the prognosis of patients with diabetes.

Latest news and product developments

AbstractSmall AED suicide riskAntiepileptic drugs (AEDs) are associated with a small increase in the risk of suicidal thoughts, the MHRA has warned.In the latest Drug Safety Update (2008;2:Issue 1) the MHRA says that, compared with placebo, AEDs are associated with an additional two cases of suicidal thoughts and behaviour per 1000 patients (0.43 vs 0.22 per cent). This may occur as early as one week after starting treatment. It is unclear whether the risk varies among AEDs.Also in this issue, the MHRA warns of an increased risk of tumour progression and reduced survival in patients with cancer treated with recombinant erythropoietin. Other topics include the use of lenalidomide (Revlimid) and thalidomide for multiple myeloma; new restrictions on the use of moxifloxacin (Avelox) due to adverse effects; and a reminder that metronidazole should be administered orally, not by intravenous injection, for the treatment of C. difficile‐associated diarrhoea.Low‐fat diet least effective option?A low‐fat diet is associated with less weight loss and less favourable metabolic changes over two years than a low‐carbohydrate (Watkins) diet or a Mediterranean diet in 322 moderately obese patients (mean BMI 30kg per m2; N Eng J Med 2008;359:229–41).Estimated energy intake was similar for all diets. Mean weight loss in all randomised patients was 2.9kg for the low fat diet, 4.4kg for the Mediterranean diet and 4.7kg for the low‐carbohydrate diet. The low‐carbohydrate diet was associated with greater increases in HDL‐cholesterol and greater reductions in triglycerides and total cholesterol/HDL‐C ratio compared with the low‐fat diet. Among people with diabetes, fasting plasma glucose and insulin resistance were decreased only in those assigned to the Mediterranean diet, and only the low carbohydrate diet significantly decreased HbA1c.Stopping post‐MI statinsPatients who stop taking a statin first prescribed after an acute MI almost double their risk of death compared with nonusers, a new study shows (Eur Heart J; published online 29 July 2008; doi: 10.1093/eurheartj/ehn346).The analysis of 9939 MI survivors in the General Practice Research Database showed that, compared with patients who had never used a statin, the risk of death was unchanged for those previously taking a statin who continued treatment after MI. The risk was reduced by 28 per cent for those who started a statin post‐MI and continued it but, in those who started a statin but then stopped it, the hazard ratio for death was 1.88 (CI 95% 1.13‐3.07).Stopping control medication (aspirin, beta‐blockers or proton pump inhibitors) did not alter the risk of death.Smoking quit rates with NRT and vareniclineDifferences in quit rates between nicotine replacement therapy (NRT) and varenicline (Champix) are small, according to a multinational study (Thorax 2008;63:717–24). The trial compared transdermal NRT (21mg to 7mg per day over 10 weeks) with varenicline (1mg twice daily for 12 weeks). Over the final four weeks of treatment, the abstinence rate was significantly higher with varenicline (56 vs 43 per cent). After one year, the four‐week abstinence rates were 26 and 20 per cent respectively (p = 0.056) and seven‐day point prevalence abstinence rates at 6 or 12 months were not significantly different. Varenicline reduced craving, withdrawal symptoms and smoking satisfaction compared with NRT but at the cost of a higher incidence of nausea (37 vs 10 per cent).Azithromycin goes OTCThe MHRA has announced that azithromycin will be available without prescription for the treatment of Chlamydia infection.Under the brand Clamelle, azithromycin will be supplied from pharmacies to over‐16s who have tested positive for infection but have no symptoms; their partners may also be treated. A urine testing kit will be marketed to pharmacists.Product newsSodium valproate (Epilim Chronosphere) is now available as modified‐release granules to be taken with food or a drink; 30 sachets, in five strengths from 50750mg, cost £30.Boehringer Ingelheim has introduced a higher strength of its telmisartan/hydrochlorothiazide combination (Micardis Plus) for hypertension; 80mg/25mg costs £14.18 for a month's supply. Copyright © 2008 Wiley Interface Ltd

Potential Markers of Arterial and/or Venous Thromboses and their Complications in Primary Antiphospholipid Syndrome

Potential Markers of Arterial and/or Venous Thromboses and their Complications in Primary Antiphospholipid SyndromeAntiphospholipid syndrome is characterized by venous or arterial thromboses and/or recurrent abortions accompanied by antiphospholipid antibodies and it can be primary (PAPS) or secondary (SAPS) to another disease. Arterial thromboses are less common than venous and most frequently they manifest as ischemia or infarction. Venous thromboses are usually multiple and bilateral and the most common complication of venous thromboses are pulmonary emboli. Considering that laboratory diagnosis of PAPS is currently based on persistently positive aCL, aβ2gpl and/or LA tests, and that neither one of those tests can discriminate between PAPS patients with arterial or venous thromboses or their complications, the aim of this study was to investigate the diagnostical significance of the determination of apo(a), oxLDL, anti-oxLDL antibodies, antianxA5 antibodies, hsCRP, C3 and C4 complement components and HPT for discrimination between PAPS patients with diverse clinical manifestations. Considering that elevated oxLDL and anti-oxLDL antibodies concentrations were found in PAPS patients, and also in subgroups of PAPS patients with MI or PE, it can be concluded that those parameters represent additional risk factors which together with other factors may lead to thromboses and their complications in PAPS. Regarding the fact that C3 and C4 concentrations were decreased in PAPS patients and that a positive correlation was found between hsCRP and C3 concentrations, this finding could indicate potential roles of these parameters as markers of atherosclerosis, which represents the leading cause of morbidity and mortality. HPT and apo(a) concentrations are not independent risk factors for MI in PAPS because lower levels were found in those patients in comparison to MI survivors without PAPS. No significant correlation of anti-anxA5 antibodies and the presence of arterial or venous thromboses or their complications was found, but increased concentrations of the IgG isotype of those antibodies could be a marker for recurrent abortions in PAPS, although this finding should be further investigated on a larger number of patients with this clinical finding. Determination of hsCRP in PAPS patients could not be an adequate parameter which would provide discrimination between patients with increased risk for development and/or recurrence of venous and/or arterial thromboses, nor for their complications, because no statistically significant difference in concentrations of this parameter was found among PAPS, IM, PE and SLE patients who were included in this study.

Quality of life in female myocardial infarction survivors: a comparative study with a randomly selected general female population cohort

BackgroundA substantial burden associated with MI has been reported. Thus, how survivors experience their quality of life (QOL) is now being given increasing attention. However, few studies have involved women and a comparison with the general population. The aims of this study were to determine the QOL of female MI survivors, to investigate whether their QOL differed from that of the general population, and to evaluate the clinical significance of the findings.MethodsTwo cross-sectional surveys were performed; on female MI survivors and the general Norwegian population. The MI survey included women aged 62–80 years, three months to five years after their MI. One hundred and forty-five women responded, yielding a response rate of 60%. A subset of women in the same age range (n = 156) was drawn from a study of 1893 randomly selected Norwegian citizens. QOL was measured in both groups with the World Health Organization Quality of Life Instrument Abbreviated (WHOQOL-BREF).ResultsThe majority (54%) of the female MI survivors presented with ST-elevation in their ECG, 31% received thrombolysis, and 38% had reduced left ventricular ejection fraction. Female MI survivors reported significantly lower satisfaction with general health (p = 0.020) and overall QOL (p = 0.017) than women from the general population. This was also the case for the physical and environmental QOL domains (p < 0.001), but not for the psychological and social relationship domains. Estimated effect sizes between the two groups of participants ranged from 0.1 to -0.6.ConclusionThe burden of MI significantly affects the physical health of elderly women. Still, female MI survivors fare as well as the general female population on psychosocial QOL domains. Action should be taken not only to support women's physical needs but also to reinforce their strengths in order to maintain optimal QOL.

Apparent Temperature and Inflammatory Markers in a European Panel Study

SAA4-PD-06 Introduction: Inflammatory marker levels have been associated with cardiovascular risk, but the effect of climatologic variables in this relationship is not well understood and appreciated. Studies have shown an increase of fibrinogen in winter whereas C-reactive protein (CRP) has not been shown to be seasonally dependent so far. The objective of this study was to analyze the association between apparent temperature, an indicator of perceived temperature based on ambient temperature and dew point temperature, and the inflammatory markers CRP, interleukin-6 (IL-6) and fibrinogen in post-myocardial infarction (MI) patients. Methods: In a multicenter panel study of MI survivors, the 3 inflammatory blood markers were measured repeatedly (up to 8 times) within a period of 13 months. In total, 5835 blood samples in 1006 subjects were collected in 6 European cities. Data on patient characteristics and disease history were gathered at the baseline visit. Meteorologic data were obtained from the country-specific network stations. The association was analyzed using a generalized additive model with random patient effects. The model variables were selected in each city separately based on Akaike's Information Criterion and consisted of time-invariant baseline variables and long-term time trend. Different lag-structures of the apparent temperature effect were tested. For the analysis CRP and IL-6 had to be log-transformed. The effect estimates are presented as percent changes of geometric mean based on a 5°C decrease of apparent temperature. Results: Patient mean levels of CRP ranged between 0.2 and 37.4 mg/L (mean ± standard deviation: 2.6 ± 3.3 mg/L), IL-6 had a range of 0.5 and 61.4 pg/mL (3.0 ± 3.1 pg/L), and levels of fibrinogen were between 1.9 and 6.9 g/L (3.6 ± 0.7 g/L). In the preliminary analysis, the mean of the current and the previous day's apparent temperature was associated with CRP. The city-specific effect estimates were all positive except for one city. Although they ranged between −1.61% and 8.22%; no evidence for heterogeneity was observed. The pooled effect estimate was 1.52% change in CRP (95% CI, −0.03%, 3.10%) in association with a 5°C decrease in apparent temperature. The effects on IL-6 and fibrinogen were heterogeneous between the cities and therefore not pooled. Discussion and Conclusions: The results suggest that a decrease in apparent temperature leads to an increase in CRP level. In susceptible patients, this might lead to an additional risk for cardiovascular events and provides a hint for the observed seasonal variation in death from ischemic heart disease and stroke in the elderly.

All NSAIDs Increase Mortality in MI Survivors

All NSAIDs Increase Mortality in MI Survivors

Pravastatin cost effective in elderly MI survivors

Pravastatin cost effective in elderly MI survivors

EPIDEMIOLOGIC DATA IN CLINICAL PRACTICE

Epidemiologic studies illustrate that PAD is a very common finding when screening is performed in older adults. The outcomes in those with PAD in population studies reflect and extend the findings from clinical studies of PAD, confirming that older adults with PAD are disabled and have a high risk for CVD and total mortality. With the aging of the population, the prevalence of PAD is increasing. It is common in both men and women and increases in prevalence with age, such that at least 12% of community-dwelling adults aged 65 and older will have significant disease on noninvasive testing, most without classic intermittent claudication. Furthermore, PAD is strongly related to other manifestations of CVD and its risk factors. Those with PAD identified in epidemiologic studies have a two- to three-fold risk in CVD morbidity and mortality. Current treatment goals for PAD patients include improving function, primarily using exercise and medical therapy, and reduction of systemic risk and can be extended to those identified by screening. In addition, PAD must be thought of as a marker of advanced systemic atherosclerosis. Inasmuch as the risk of CVD and mortality in those with PAD is similar to those with a history of MI or stroke, those with PAD can be approached with the same measures for secondary CVD prevention as recommended for MI and stroke survivors. A simple bedside measure of the AAI can be used to improve the detection of PAD in clinical practice. Although there is no study that shows directly that screening and preventive treatment will reduce complications of PAD, a preventive approach in PAD patients is likely to improve overall survival, reduce MI, and will, perhaps, also reduce the risk of disabling leg pain and amputation. Future descriptions of the natural history of PAD in ongoing cohort studies may indicate that this is already beginning to occur.

Myocardial infarction: survivors' and spouses' stress, coping, and support.

Despite evidence that spouses play an important role in the recovery of MI survivors, there have been few studies of pertinent psychosocial factors from the perspectives of both survivors and spouses. Accordingly, the aim of this study was to describe stress, coping strategies and social support experienced by survivors and spouses. This study was limited to first-time MI to focus on a time of uncertainty and transition. Twenty-eight persons (14 couples) participated. Both survivors and their spouses reported similar post-MI stresses: emotional impact, lifestyle changes, encounters with health professionals, and their partners' reactions. Spouses and survivors used diverse strategies to cope with the stresses of MI. Seeking informational support was prevalent. Both spouses and survivors engaged in 'protective buffering' of their partners. Couples described deficient support, conflict and miscarried helping efforts within their relationships. Spouses and survivors referred to inadequate informational support from health professionals.

Reproducibility of time-domain and three different frequency-domain techniques for the analysis of the signal-averaged electrocardiogram

Because time-domain (TD) analysis of the signal-averaged ECG (SAECG) has some limitations that limit its use, several frequency-domain analysis techniques were developed in an attempt to improve the dignostic ability of the SAECG. However, it is not known how reliable these techniques are at detecting late potentials. This prospective study compares the short-term reproducibility of 4 analysis techniques: TD analysis, spectral temporal mapping (STM), spectral turbulence analysis (STA), and acceleration spectrum analysis (ASA), in a large series of normal patients and post-myocardial infarction (MI) patients. Two consecutive SAECGs were recorded in 634 patients that were divided into 3 groups: 117 remote MI patients undergoing programmed electrical stimulation for the inducibility of ventricular tachycardia (Group 1), 407 consecutive acute MI survivors (Group 2), and in 110 healthy volunteers (Group 3). The diagnostic reproducibility of the 4 techniques was evaluated by comparing rates of inconsistent results (1 normal and the other abnormal). The numeric reproducibility for each technique was assessed by comparing the normalized differences of each single SAEGG parameter between the 2 recordings. inconsistent results of diagnostic reproducibility were observed in 4.1%, 6.9%, 9.8%, and 18.0%, with TD, STA, ASA, and STM, respectively. Comparisons of these rates were significantly different (P<.05) except between STA and ASA (P=.07). The numeric reproducibility was highes for TD parameters, lowest for STM factors of normality, and intermediate for STA and ASA indices. TD analysis remains the most reproducible SAECG analysis technique, whereas STM showed the worst reproducibility, which limits its clinical applicability. STA and ASA provide an acceptable intermediate reproducibility, the former being slightly, although not significantly, more reproducible than the latter.

Exercise-induced changes in the QT interval duration and dispersion in patients with sudden cardiac death after myocardial infarction

Background: Prolongation of the QT interval and increased QT dispersion have been proposed to be associated with arrhythmic risk after myocardial infarction. However, controversy remains regarding the prognostic value of ventricular repolarization abnormalities in the risk stratification of patients surviving acute myocardial infarction. Hypothesis and objective: The QT interval is sensitive to myocardial ischaemia, and exercise-induced ischaemia may change the QT interval regionally, resulting in increased QT dispersion. This study examined whether there are abnormalities of ventricular repolarization during exercise and whether assessment of the exercise-induced changes in QT interval duration and dispersion would be able to differentiate patients at high risk from those at low risk of sudden cardiac death after myocardial infarction. Methods: Twenty-six post-myocardial infarction patients (mean age 54.5±8.9 years, 22 men) were retrospectively studied. Thirteen patients who died suddenly (SCD patients) during a follow-up of 39±6 months were compared to 13 patients who remained event-free, i.e. no ventricular tachyarrhythmias, no reinfarction, no by-pass (MI survivors). The two groups were pair-matched for age, gender, site of infarction, left ventricular ejection fraction and use of beta blocker. A further 13 patients with chest pain, normal coronary arteriograms and negative exercise test results were studied as controls. They were age and gender matched with the post-infarction patients. A 12-lead exercise ECG was recorded from each patient before, during and after exercise. QT and RR interval were measured on the exercise ECGs at each stage and QT dispersion was defined as the difference between the maximum and minimum QT intervals across the 12-lead ECG. Results: There were no significant differences in RR, QT and QTc (Bazett's and Fridericia's correction) intervals, or QT dispersion between any groups before exercise. A significant difference in QT and QT dispersion was found at peak exercise between post-infarction patients and controls ( P=0.03 and P=0.0001, respectively), but no difference was observed between SCD patients and MI survivors. The maximum QTc at peak exercise was longer in SCD patients compared with MI survivors ( P=0.02) and a maximum QTc>440 ms (Bazett's correction) was common in SCD patients but not in MI survivors or controls (62%, 15%, 15%, P=0.01). The differences in QT, QTc or QT dispersion observed at peak exercise were no longer significant after exercise. Conclusions: Exercise-induced prolongation of the QTc interval differentiates patients at high risk of sudden cardiac death from those at low risk, whereas exercise-induced changes in QT dispersion failed to identify patients at high risk of sudden cardiac death after myocardial infarction.

Amiodarone reduced arrhythmic but not all-cause mortality among MI survivors with depressed LV function

Amiodarone reduced arrhythmic but not all-cause mortality among MI survivors with depressed LV function

Hiding worries from One's spouse: associations between coping via protective buffering and distress in male post-myocardial infarction patients and their wives.

The relationship between protective buffering, a style of coping in which the individual hides his/her concerns from spouse, and level of distress was studied among post-myocardial infarction (MI) patients and their spouses. Forty-three male married MI survivors and their wives completed measures of psychological distress and protective buffering at 4 weeks and 6 months post-hospital discharge. At both time periods, a greater propensity for protective buffering by the patient was related to higher levels of patient distress. Protective buffering by wife was also associated with higher levels of wife distress. In addition, patient buffering at 4 weeks predicted increased patient distress at 6 months. The results suggest that male MI patients who conceal their worries from their spouses adjust more poorly over time.

‘Typical’ MI survivors may benefit from cholesterol-lowering therapy, say researchers

‘Typical’ MI survivors may benefit from cholesterol-lowering therapy, say researchers

991-70 Decreasing Risk of Symptomatic Sustained Ventricular Tachycardia in Myocardial Infarction Patients

Our knowledge of natural history in survivors following myocardial infarction (Ml) is mainly based on data collected before the fibrinolytic era. In a prospective risk stratification study, 823 MI survivors underwent 24-h Holter monitoring (HM) 12–16 days after the acute event. Ventricular extrasystoles (VES) were present in 77% of the pts, ≥ 20 VES/h in 10%. ventricular pairs (VP) in 27%, ventricular salvoes (VS) in 12% and nonsustained ventricular tachycardias (&gt;5 consecutive VES)(nsVT) in 9%. During the 12-months follow-up (only one patient was lost) there were 66 (8%) deaths, 26 sudden or instantaneous (SD)(39%), 23 non-sudden, 6 non-cardiac and 11 of unknown causes. SD-rates were 3% in those with monomorphic VES, 9% with ≥ 20 VES/h or VP, 10% with VS and 13% with nsVT (p = 0.01). Only one pt developed a symptomatic sustained ventricular tachycardia 2 months after discharge and only 5 pts had syncopes of unknown origin. In the fibrinolytic era, arrhythmias are still as prevalent as at the time before thrombolysis. The sudden death rate is also similar. However, symptomatic sustained ventricular tachycardia has become an extremely rare event.

Prognosis with PTCA for Early Ischemia in Acute MI Survivors

Acute MI survivors with spontaneous or stress-induced ischemia shortly after admission are increasingly treated with PTCA, but prognosis has not been well described. In this observational study, Harvard investigators considered 505 consecutive acute MI survivors who underwent PTCA, following them for a mean of 34 months. Short-term, both patients …

ACE Inhibitors in MI survivors - results from the SAVE trial

ACE Inhibitors in MI survivors - results from the SAVE trial

Spontaneous Platelet Aggregation, Tourniquet Ischaemia, and Aspirin in Survivors of Myocardial Infarction

Platelet number, plasma beta-thromboglobulin (beta-TG), spontaneous platelet aggregation (SPA), serum thromboxane B(2) (TXB(2)), and 6-keto-PGF(101) were assessed in 9 males with proven atherosclerosis (survivors of myocardial infarction, (MI) in a stable condition) and compared with values for 9 young, healthy controls. Results were obtained before and after 3-day treatment with aspirin. In addition, SPA was assessed before and after a tourniquet test. MI survivors had higher beta-TG (p < 0.01) and SPA values (p < 0.05), and a lower platelet count (p < 0.05) than controls. Aspirin significantly attentuated all these changes. These data suggest that platelet function is increased in survivors of MI. Tourniquet-induced ischaemia significantly (p < 0.05) enhanced SPA in MI survivors but not in controls. Aspirin did not inhibit SPA following ischaemia in contrast to its effect under pre-ischaemic conditions or in controls. It seems that the proaggregatory threshold is decreased in MI survivors. The results challenge the assumption that an acute coronary event with underlying atherosclerosis is due to an interaction between atherosclerosis plaque and normal platelets.

Aprindine Reduces Mortality After 1 Month in High Risk MI Survivors

Aprindine Reduces Mortality After 1 Month in High Risk MI Survivors

Exercise testing early after myocardial infarction: Historic perspective and current uses

Exercise testing performed earlier than six weeks post-MI is accepted as “standard” medical practice. Although both heart rate-limited and symptom-limited exercise protocols are used with nearly equal frequency, the latter appears more valuable because the prognostic yield is greater without sacrificing patient safety. Treadmill or cycle ergometers are the preferred modes of testing because of higher exercise work loads imposed and increased sensitivity and specificity or results. The physiologic exercise responses to graded work loads among these acute MI survivors include a mean maximal heart rate range of 118 to 136 beats/min, a peak systolic blood pressure between 137 and 170 mmHg, a mean peak double product from 16,000 to 22,400, and a mean maximal work load between 4.8 and 7.0 METS. Exercise findings which are most clinically useful are (1) greater than 1 mm ST segment depression from rest level, (2) presence of angina pectoris during exercise, (3) decrease in systolic blood pressure with increasing work, (4) presence of complex or frequent VEBs, and (5) exercise tolerance less than 4 METS. These exercise findings identify, in recent post-MI survivors, groups of patients that have significantly different estimated future cardiac morbidity and mortality rates. The most consistent indices of multi-vessel coronary heart disease are ST segment depression, angina pectoris, and poor exercise tolerance. The most important role of stress testing in this period post-MI is identification of individuals who urgently need evaluation for coronary bypass surgery. In addition to risk stratification, exercise testing provides valuable information regarding exercise prescription for cardiac rehabilitation, direct psychologic benefit for resuming an active lifestyle, and motivation for exercise participation. Although safety of the early post-MI stress test has not been systematically studies, reports from individual studies indicated low morbidity and mortality. Attesting to this is the frequency with which it is performed as a routine office procedure. Finally, there has been a growing use of this procedure not only among cardiologists but also among internists and family practice physicians.