Mortality In post-MI Patients Research Articles

Risk factors for mortality in post-myocardial infarction patients: insights from the improve SCA bridge study

BackgroundUnderutilization of implantable cardioverter defibrillators (ICD) to prevent sudden cardiac death (SCD) in post-myocardial infarction (MI) patients remains an issue across several geographies. A better understanding of risk factors for SCD in post-MI patients from regions with low ICD adoption rates will help identify those who will benefit from an ICD. This analysis assessed risk factors for all-cause and cardiovascular-related mortality in post-MI patients from the Improve Sudden Cardiac Arrest (SCA) Bridge Trial.ResultsFor the entire cohort, the overall 1-year mortality rate was 5.9% (88/1491) and 3.4% (51/1491) for all-cause and cardiovascular mortality, respectively, with 76.5% of all cardiac deaths being from SCD. A multivariate model determined increased age, reduced left ventricular ejection fraction (LVEF), increased time from myocardial infarction to hospital admission, being female, being from Southeast Asia (SEA), and having coronary artery disease to be significant risk factors for all-cause mortality. The risk factors for cardiovascular-related mortality revealed increased age, reduced LVEF, and being from SEA as significant risk factors.ConclusionsWe show several characteristics as being predictors of cardiovascular-related mortality in post-MI patients from the Improve SCA Bridge study. Patients who experience an MI and present with these characteristics would benefit from a referral to an electrophysiologist for further SCD risk stratification and management and possible subsequent ICD implantation to reduce unnecessary death.

Diet quality and long-term cardiovascular mortality after myocardial infarction in the Alpha Omega Cohort

Abstract Introduction A healthy diet is important for the prevention and treatment of cardiovascular disease (CVD). The Dutch Health Council recently defined dietary guidelines for patients with atherosclerotic CVD (ASCVD), which we investigated in relation to long-term mortality after myocardial infarction (MI). Purpose We developed the Dutch Healthy Diet index for CVD patients (DHD-CVD index) and examined its relation with mortality in post-MI patients. Methods We included 4,365 patients of the Dutch Alpha Omega Cohort (60-80 y, 80% male) with a MI <10 y prior to study enrolment. Dietary intake was assessed at baseline (2002-2006), using a validated 203-item food frequency questionnaire. To create the DHD-CVD index, the existing 2015 Dutch Healthy Diet index was adapted using the 2023 Dutch dietary guidelines for ASCVD patients (scale from 0 to maximal adherence [0-150]). Patients were followed for cause-specific mortality through December 2018. Hazard Ratios (HRs) across quartiles of the DHD-CVD-index (ref = Q1, i.e. low overall diet quality) and per 1-SD increment in score were estimated using Cox proportional hazard models. Associations were adjusted for age, sex, total energy intake, smoking, education and physical activity. Results were additionally stratified for sex, obesity and diabetes. Results Of the cohort, 17% smoked, 21% had diabetes and >90% used statins or other CVD drugs. During a follow-up of 48,660 person-years, 2,048 deaths occurred of which 911 were due to CVD. The mean DHD-CVD score was 78.9 (SD 13) points. High diet quality (Q4) was associated with a 29% lower risk of CVD mortality compared to low diet quality (HR: 0.71, 95% CI: 0.56, 0.84), with an HR of 0.88 (95% CI: 0.82, 0.94) per 1-SD. For all-cause mortality, we observed a 14% lower risk for high vs. low diet quality (HR: 0.86, 95% CI: 0.76, 0.98), with an HR of 0.94 (95% CI: 0.90, 0.98) per 1-SD. HRs did not essentially differ between male of female patients, or between obese and non-obese patients. HRs for CVD mortality were stronger in non-diabetic patients (HR: 0.86, 95% CI: 0.79, 0.93; per 1-SD), and no longer statistically significant in patients with diabetes (HR: 0.97, 95% CI: 0.84, 1.11; per 1-SD). Conclusion A high diet quality, measured with the DHD-CVD index, was associated with a lower risk of CVD and all-cause mortality after MI in Dutch patients. Adherence to dietary guidelines for CVD patients should be considered on top of medication use.

Fatty Liver Index and mortality after myocardial infarction: A prospective analysis in the Alpha Omega Cohort.

Accumulating evidence shows that NAFLD might play a role in the etiology and progression of CVD, but little is known on the association of NAFLD and CVD mortality in patients with a history of a myocardial infarction (MI). Therefore, we studied the relationship of Fatty Liver Index (FLI), as indicator for non-alcoholic fatty liver disease (NAFLD), with 12-year risk of cardiovascular disease (CVD) and all-cause mortality in post-MI patients. We included 4165 Dutch patients from the Alpha Omega Cohort aged 60-80 years who had an MI ≤10 years prior to study enrolment. NAFLD was defined as FLI ≥60. Patients were followed for cause-specific mortality from enrolment (2002-2006) through December 2018. Hazard ratios for CVD and all-cause mortality were obtained by multivariable Cox regression using FLI <30 (indicating absence of NAFLD) as the reference. Baseline FLI as a continuous measure was studied with mortality using restricted cubic splines analyses. The median (IQR) FLI was 68 (48-84). Sixty percent of the patients had FLI ≥60, who were more likely to be male and more often had diabetes, high blood pressure, and high serum cholesterol levels. During 12 years of follow-up, 2042 deaths occurred of which 846 from CVD. Patients with NAFLD were at increased risk of CVD mortality (HR: 1.55 [1.19, 2.03]) and all-cause mortality (HR: 1.21 [1.03; 1.41]) compared to patients without NAFLD. Results remained consistent after excluding patients with obesity and diabetes. To conclude, the adverse association of FLI with CVD mortality was stronger in female than in male patients with conventional cut-off points. FLI ≥60, indicating NAFLD, was a predictor for CVD and all-cause mortality in post-MI patients, independent of other cardiometabolic risk factors. However, cut-off points might differ between male and female patients for predicting CVD mortality.

Abstract 10763: Electrocardiographic Markers of Myocardial Infarction Size

Background: Myocardial infarction (MI) size is an important determinant of mortality in post-MI patients, but the current gold standard test, cardiovascular magnetic resonance imaging (CMR) , is expensive and not widely available. We sought to determine whether information from a readily available standard 12-lead electrocardiogram (ECG) could be utilized to estimate infarct size on CMR. Methods: Patients with a clinical history of MI enrolled in the DETERMINE Trial and Registry who had CMR and ECG performed were included. Patients with left bundle branch block were excluded. Candidate ECGs markers, which may signify the presence of MI [Q waves (Qw), fragmented QRS (fQRS), and T wave inversion (TWI) ] were examined for correlations with MI as a percent of LV (MI%) quantified by late gadolinium enhanced CMR. Contiguous Qw (cQw MI) and TWI (cTWI) in a coronary distribution and Qw and TWI in individual leads were examined separately in linear regression models. Results: Of the 540 patients (mean age 62±11 years, 78% men, and mean LVEF=40±11%) included in the analysis, 334 had cQw MI, 225 had fQRS, 235 had cTWI, and 92 had none of these ECG markers. Patients without any of these ECG markers had an infarct size of 9.2±6.5% as compared to 14.6±7.6%, 18.6±9.1%, and 20.3±9.5% for those with one (n=175), two (n= 200), or all three (n= 73) ECG markers (P&lt;0.001). By multivariate linear regression, the presence of cQwMI, fQRS, and cTWI were independently associated with an increase in MI% by 6.7%, 3.4%, and 4.9%, respectively. On per lead analysis, multivariate linear regression demonstrated a significant continuous relationship between MI% and the number of leads affected by Qw, fQRS, and TWI. MI% was 8.8% when all leads were free of candidate ECG markers and increased by 1.6%, 0.6%, and 0.6% for each lead affected by Qw, fQRS, and TWI, respectively (see table). Conclusion: In patients with prior MI, Qw, fQRS, and TWI on ECG are independently associated with an increase in MI% measured by CMR.

Physical activity at leisure time and long-term survival among heart failure patients with a history of myocardial infarction: a prospective cohort study

Purpose: Few studies have investigated the relationship between leisure time physical activity (LTPA) and outcomes in HF. The contribution of psychosocial factors to this relationship is vital as they can be targeted in preventive interventions. Since depressed, and/or socially unsupported people may have a higher mortality risk, they may gain more from LTPA, but be less active. Aims included studying in patients with a history of myocardial infarction (MI): (1) the relationship between LTPA and mortality, overall and by HF status, and (2) the confounding/moderating effect of depression and social support (SS). Methods: Participants were drawn from the Israel study of First Acute Myocardial Infarction, a multi-center prospective cohort study of patients admitted to hospital with incident MI. Information on LTPA, depression (Mental Health Inventory), SS (Multidimensional Scale of Perceived Social Support) and other prognostic indicators were collected in 2002-2005, 10-13 years after index MI. Follow-up mortality data were obtained through 2011. LTPA (self-reported walking and/or other aerobic activities) was classified as regular (1-150, 150-300, or >300 weekly minutes), irregular, or none. HF was defined according to clinical history and a New York Heart Association classification of III-IV. Cox regressions were performed. Results: The analysis included 1169 patients (mean age 63.9; 82% men); 237 (20%) met HF criteria. During a median of 8.4 years follow-up, 303 deaths occurred (126 (52%) in HF and 181 (19%) in HF-free cases). Regular LTPA was more common in HF-free (47%) vs. HF cases (36%; χ2<0.01). LTPA was positively associated with SS, educational level, participation in cardiac rehabilitation and education on lifestyle factors, and inversely associated with depression and having comorbidity. LTPA showed a strong relationship with mortality after adjusting for demographic, clinical, interventional and psychosocial (including depression and SS) covariates (p for trend<0.01 in all models). The relation did not differ between HF and HF-free cases (p for interaction=0.41); hazard ratios (95% CIs) for death in the most vs. least active categories were 0.43 (0.20-0.90) among HF and 0.47 (0.29-0.76) among HF-free cases. There was no evidence of interaction between depression or SS and LTPA regarding mortality risk. Conclusions: LTPA is a strong predictor of mortality in post-MI patients, regardless of HF status. HF patients, and, among HF patients, those with a high level of depression or a low level of SS are less likely to be active, which defines preventive intervention opportunities.

Simultaneous Assessment of T-Wave Alternans and Heart Rate Turbulence on Holter Electrocardiograms as Predictors for Serious Cardiac Events in Patients After Myocardial Infarction

T-wave alternans based on the modified moving average method (MMA-TWA) and heart rate turbulence (HRT) have been introduced as predictors for cardiac mortality. In this study, we simultaneously recorded MMA-TWA and HRT in patients after myocardial infarction (MI) and designed a prospective observational study. We prospectively enrolled 313 consecutive post-MI patients (age 70 ± 12 years, 232 men). The MMA-TWA and HRT were simultaneously measured using algorithms based on 24-h Holter ECG monitoring during daily activity. MMA-TWA was determined positive when the maximal voltage was >64 µV, and HRT was determined positive when both turbulence onset and turbulence slope were abnormal. The endpoint was defined as overall cardiac mortality and fatal arrhythmic events. MMA-TWA was positive in 14 patients (4.4%) and HRT was positive in 61 patients (19.5%). During follow-up of 1,190 ± 441 days, 28 patients (9%) reached the endpoint, including 12 patients with fatal arrhythmic events. Both MMA-TWA and HRT were significant predictors for the endpoint. On multivariate analysis, HRT had the most significant value, with a hazard ratio (HR) of 5.7 (P=0.0008). When focused on fatal arrhythmic events including sudden cardiac death, MMA-TWA had the most significant value (HR 5.8, P=0.0072). The present study revealed that both MMA-TWA and HRT were significant predictors. MMA-TWA is more associated with arrhythmic events than cardiac mortality in post-MI patients.

Heart Rate Turbulence Can Predict Cardiac Mortality Following Myocardial Infarction in Patients With Diabetes Mellitus

Previous studies have described the clinical utility of heart rate turbulence (HRT) as an autonomic predictor in risk-stratifying patients after myocardial infarction (MI). Some reports showed that diabetes mellitus (DM) affects the prognostic value of autonomic markers. We assessed the utility of HRT as a risk marker in post-MI patients with DM and without DM. We prospectively enrolled 231 consecutive DM patients and 300 non-DM patients after acute MI. HRT was measured using an algorithm based on 24-hour Holter electrocardiograms (ECGs), assessing 2 parameters: turbulence onset (TO) and turbulence slope (TS). HRT was considered positive when both TO ≥0% and TS ≤2.5 ms/R-R interval were met. The endpoint was defined as cardiac mortality. Of patients with DM, 9 patients (4%) were not utilized for HRT assessment because of frequent ventricular contractions or presence of atrial fibrillation. Forty-two of 222 patients (19%) were HRT positive. During follow-up of 876 ± 424 days, 26 patients (22%) reached the endpoint. Several factors including left ventricular ejection fraction (LVEF), renal dysfunction, documentation of nonsustained ventricular tachycardia (VT), and a HRT-positive outcome had significant association with the endpoint. Multivariate analysis determined that renal dysfunction and a positive HRT outcome had significant value with a hazard ratio (HR) of 4.7 (95%CI, 1.9-11.5; P = 0.0008) and 3.5 (95%CI, 1.4-8.8; P = 0.007), respectively. In non-DM patients, only a positive HRT outcome had significant value. This study reveals that HRT detected by 24-hour Holter ECG can predict cardiac mortality in post-MI patients whether DM is present or not.

Evaluation of Prognostic Clinical and ECG Parameters in Patients after Myocardial Infarction By Applying Logistic Regression Method

Noninvasive risk stratification of patients who have suffered myocardial infarction (MI) is one of the greatest challenges in today's cardiology. No single test has sufficient predictive ability. Therefore, a combination of the tests must be applied for better post-MI risk stratification. The purpose of this study was to assess noninvasive predictors of 2 years cardiac mortality in post-MI patients and create a stratification model for identification of high-risk patients. Clinical, electrocardiographic, and echocardiographic parameters were evaluated before hospital discharge in 180 survivors of acute MI (mean age 57.0 +/- 9.9, male 82.2%), followed up for 2 years. A multivariate logistic regression analysis was used to determine informative predictors of cardiac mortality. A clinical score was constructed using the regression coefficient from the multivariate model. During follow-up, 16 deaths (8.8%) occurred. Multivariate analysis identified a combination of six variables that showed the strongest association with cardiac mortality. Based on the coefficients of the logistic regression, six variables were used to create a scoring system: filtered QRS duration (QRSd) >114 ms, coefficient of variation (Cv) <or=2.5%, maximal corrected QT interval (QTcmax) >or=445 ms, left ventricular ejection fraction (LVEF) <or=30%, the absence of use of beta-blockers (BB), and absence of treatment by primary percutaneous coronary intervention (PCI). The cutoff value for the score of 10 or higher, defined the "high-risk" patients with a sensitivity of 75% and a specificity of 70%. The mortality rate for the low- and high-risk groups were 12.5% and 87.5%, respectively. The receiver operating characteristic (ROC) analysis yielded area under curve of 0.88. The proposed scoring system could be valuable in predicting 2 years risk of cardiac mortality in post-MI population and allows the stratification of patients into low- and high-risk groups.

Lifestyle, Mediterranean diet and survival in European post-myocardial infarction patients

The extent and benefits of adherence to lifestyle and dietary recommendations in secondary prevention are largely unknown. We examined the frequency of healthy dietary and lifestyle behaviours and their impact on survival in post-myocardial infarction (MI) patients in a prospective cohort study of elderly Europeans. Adherence to a Mediterranean-type diet was measured with a modified Mediterranean Diet Score (MDS) on an eight-point scale. Participants were 426 men and women, aged 70 years or more, from 10 European countries, with a history of MI. During 10 years of follow-up mortality was 53%. Frequency of non-smoking behaviour (85%), moderate to vigorous physical activity (54%), moderate alcohol consumption (45%) and a Mediterranean-type diet (63%) in patients differed only marginally as compared with 'healthy' elderly. The median MDS in patients from northern Europe was two points lower than in southern Europe. Non-smoking [hazards ratio (HR) 0.62; 95% confidence interval (95% CI) 0.44-0.88], physical activity (HR 0.69; 95% CI 0.53-0.90), moderate alcohol consumption (HR 0.77; 95% CI 0.58-1.02) and a Mediterranean-type diet (HR 0.75; 95% CI 0.57-0.97) were associated with lower all-causes mortality. Presence of at least three healthy behaviours was associated with 40% lower mortality. There is a strong relationship between lifestyle and dietary habits and mortality in post-MI patients. The findings implicate that substantial health gain can be obtained by better adherence to dietary and lifestyle recommendations.

Effects of Antidepressant Medication on Morbidity and Mortality in Depressed Patients After Myocardial Infarction

Depression after myocardial infarction (MI) is associated with higher morbidity and mortality. Although antidepressants are effective in reducing depression, their use in patients with cardiovascular disease remains controversial. To undertake a secondary analysis to determine the effects of using antidepressants on morbidity and mortality in post-MI patients who participated in the Enhancing Recovery in Coronary Heart Disease study. Observational secondary analysis. Eight academic sites. The Enhancing Recovery in Coronary Heart Disease clinical trial randomized 2481 depressed and/or socially isolated patients from October 1, 1996, to October 31, 1999. Depression was diagnosed using a structured clinical interview. This analysis was conducted on the 1834 patients enrolled with depression (849 women and 985 men). Use of antidepressant medication. Event-free survival was defined as the absence of death or recurrent MI. All-cause mortality was also examined. To relate exposure to antidepressants to subsequent morbidity and mortality, the data were analyzed using a time-dependent covariate model. During a mean follow-up of 29 months, 457 fatal and nonfatal cardiovascular events occurred. The risk of death or recurrent MI was significantly lower in patients taking selective serotonin reuptake inhibitors (adjusted hazard ratio [HR], 0.57; 95% confidence interval [CI], 0.38-0.84), as were the risk of all-cause mortality (adjusted HR, 0.59; 95% CI, 0.37-0.96) and recurrent MI (adjusted HR, 0.53; 95% CI, 0.32-0.90), compared with patients who did not use selective serotonin reuptake inhibitors. For patients taking non-selective serotonin reuptake inhibitor antidepressants, the comparable HRs (95% CIs) were 0.72 (0.44-1.18), 0.64 (0.34-1.22), and 0.73 (0.38-1.38) for risk of death or recurrent MI, all-cause mortality, or recurrent MI, respectively, compared with nonusers. Use of selective serotonin reuptake inhibitors in depressed patients who experience an acute MI might reduce subsequent cardiovascular morbidity and mortality. A controlled trial is needed to examine this important issue.

Timing of arrhythmic death after myocardial infarction: does it affect timing of ICD implantation?The opinions expressed in this article are not necessarily those of the Editors of the European Heart Journal or of the European Society of Cardiology.

This editorial refers to ‘Temporal trends on the risk of arrhythmic vs. non-arrhythmic deaths in high-risk patients after myocardial infarction: a combined analysis from multicentre trials’ { by Y.G. Yap et al., on page 1385 In spite of significant reduction in total mortality observed in patients discharged after an acute myocardial infarction (MI), ventricular arrhythmias still account for 30–40% of deaths. This figure, which was initially provided by studies carried out in the pre-thrombolytic era, has been subsequently confirmed when most of the patients had been revascularized by thrombolysis or percutaneous coronary intervention (PCI). 1 Early revascularization and a more generalized use of beta blockers, angiotensin-converting enzyme-inhibitors, statins, and antiplatelet agents have largely contributed to the improvement in the prognosis of patients presenting with an ST-elevated acute MI. Nevertheless, identification of patients at risk remains an issue far from being adequately addressed. There is a general consensus that depressed ventricular function, as reflected by a left ventricular ejection fraction (LVEF) ,40%, represents the strongest negative prognostic factor in these patients. 1 Different cut-off values have proved effective in recent clinical trials and an LVEF ,30% has been used as a single inclusion criteria in studies aimed to evaluate, for example, the beneficial effect of implantable cardioverter defibrillator (ICD) after MI. After the publication of MADIT II results 2 that have clearly indicated a significant reduction of total and arrhythmic mortality in post-MI patients with ICD when compared with controls, ICD implantation has been recommended for almost all post-MI patients with an LVEF ,30%. This position has been only partially accepted by the most recent ACC/ AHA/NASPE and ESC guidelines. 3,4 The issue has become even more controversial after the publication of the results of the DINAMIT study. 5 More than 600 patients with a recent acute MI and reduced left ventricular function (LVEF , 35%) were randomized to ICD and control. Revascularization rate (either thrombolysis or PCI) was 62%. The so-called ‘best’ medical treatment was provided to most of the patients. The main result of the study was that prophylactic ICD therapy did not reduce overall mortality in this high-risk population. Moreover, by considering the type of death, it was evident that the reduction in the rate of death due to arrhythmia was offset by an increase in the rate of death from non-arrhythmic causes. A careful comparison of MADIT II with DINAMIT study characteristics provides a partial explanation for such a difference. In addition to the inevitable differences in study population and patient management, it is evident that in MADIT II, the mean time for enrolment was 81 months, whereas in DINAMIT it was 6–40 days. Thus, timing of implantation in relation to the index event was a critical factor not fully considered in the original report and only recently appreciated in the discussion of ICD indication in post-MI patients. Indeed, on reviewing a recent report by MADIT II study group, it is evident that no benefit from ICD could be observed in patients with a less remote MI (,18 months), whereas a tendency for a favourable effect or a significant benefit from ICD was detectable, respectively, at 18–59 months or longer (from 60 to .120 months) after the acute event. One could therefore extrapolate that, according to DINAMIT and MADIT II, ICD benefit cannot be detected in the first 2 years after an acute MI, thus casting additional doubts to the recommendation of an early ICD implantation in all patients with a depressed LVEF. The lack of benefit from ICD implantation in the first 2 years after an acute MI could be interpreted as an indirect evidence in which, in the reperfusion era, the risk of arrhythmic death becomes predominant only several months after the acute event. Is this opinion founded?

Risk stratification and survival in post myocardial infarction patients: a large prospective and multicenter study in Japan

Background: Recent clinical trials suggest that the mortality in high-risk patients with ischemic heart disease can be significantly reduced with the use of implantable cardioverter-defibrillator (ICD). Given the high cost and invasiveness of the procedure, it is important to apply it to the patients after myocardial infarction (MI) highly susceptible to sudden arrhythmic death. Objective: The purpose of this study was to assess clinical predictors of mortality in post-MI patients in Japan. Methods and Results: In 495 consecutive MI survivors, 350 (71%) received acute-reperfusion therapy, whereas 145 (29%) did not. Nonsustained ventricular tachycardia (NSVT) was present in 136 patients (28%) in 24-h ambulatory ECGs at 7±6 in-hospital days. Left ventricular dysfunction (LVEF≤35%) was present in 20/347 patients (5.7%) at 13±8 days. Forty-eight patients (9.7%) died during the follow-up period (48±13 months); 23 from cardiac and 25 from noncardiac causes. Kaplan–Meier survival analyses showed that mortality rates were higher among patients who were ≥70 years old (log-rank test, P<0.0001); had heart failure at admission (Killip scale≥2, P=0.001); did not receive acute-reperfusion (P=0.004); and had left ventricular dysfunction with LVEF≤35% (P=0.02). The presence of NSVT was a significant predictor of death (P=0.036) only in the patients who did not receive acute-reperfusion. Multivariate Cox regression analysis revealed that an independent predictor of total mortality was an age≥70 (odds ratio, 1.06; 95% confidence interval, 1.01–1.11; P<0.00001). Conclusions: High-risk patients after acute MI can be identified on the basis of age, ventricular dysfunction, heart failure and acute-reperfusion therapy. The presence of NSVT before discharge has a prognostic value only in the patients without acute-reperfusion.

Depression, Heart Rate Variability, and Acute Myocardial Infarction

Clinical depression is associated with an increased risk for mortality in patients with a recent myocardial infarction (MI). Reduced heart rate variability (HRV) has been suggested as a possible explanation for this association. The purpose of this study was to determine if depression is associated with reduced HRV in patients with a recent MI. Three hundred eighty acute MI patients with depression and 424 acute MI patients without depression were recruited. All underwent 24-hour ambulatory electrocardiographic monitoring after hospital discharge. In univariate analyses, 4 indices of HRV were significantly lower in patients with depression than in patients without depression. Variables associated with HRV were then compared between patients with and without depression, and potential confounds were identified. These variables (age, sex, diabetes, and present cigarette smoking) were entered into an analysis of covariance model, followed by depression status. In the final model, all but one HRV index (high-frequency power) remained significantly lower in patients with depression than in patients without depression. We conclude that greater autonomic dysfunction, as reflected by decreased HRV, is a plausible mechanism linking depression to increased cardiac mortality in post-MI patients.

Prognosis in myocardial infarction survivors with left ventricular dysfunction is predicted by electrocardiographic RR interval but not QT dispersion

Objectives. The aim of the study was to assess if QT dispersion and RR interval on the standard 12-lead electrocardiogram (ECG) predict cardiac death and late arrhythmic events in postinfarction patients with low left ventricular ejection fraction (LVEF). QT dispersion on a standard electrocardiogram (ECG) is a measure of repolarization inhomogeneity, but its prognostic meaning in myocardial infarction (MI) survivors is unclear, especially in patients with left ventricular dysfunction. RR interval has been shown to predict mortality in post-MI patients, but its prognostic power has not been compared with other noninvasive risk factors. Methods. Retrospective cohort study. Ninety patients were identified, from a series of 547 consecutive postinfarction patients admitted to our institution for phase II cardiac rehabilitation, as having a LVEF of <0.40 at two-dimensional echocardiography (mean LVEF 0.35±0.04; range 0.20–0.39). QT dispersion and RR interval were analyzed on the admission 12-lead electrocardiogram, 20±10 (range 8–45) days after MI, using specially designed software. Additional risk markers were collected from clinical variables, signal-averaged ECG and Holter recording. Results. During 24±18 (range 1–63) months of follow-up, 10 of 90 patients (11%) died, all from cardiac causes, and there were 18 late arrhythmic events, defined as sudden death or the occurrence of a sustained ventricular arrhythmia ≥5 days after the index MI. QT interval and dispersion were not significantly prolonged in patients who died compared to survivors and not significantly different between patients with and without arrhythmic events. Mean RR interval from standard ECG was significantly shorter in patients with both cardiac death (682±99 vs. 811±134 ms; P=0.004) and arrhythmic events (720±100 vs. 818±139 ms; P=0.006). A Cox proportional hazards model identified RR interval from standard ECG ( P<0.001) and a history of more than one MI ( P=0.002) as significant predictors of cardiac death independent of thrombolytic therapy, LVEF, filtered QRS complex duration at signal-averaged ECG, mean RR and its standard deviation at 24-h Holter monitoring. Conclusions. Measurement of QT interval and dispersion 3 weeks after MI has no prognostic power in patients with LV dysfunction after a recent MI. RR interval on standard 12-lead ECG is as good a prognostic indicator as other, more expensive, noninvasive markers. These findings may be relevant in this era of limited health care resources.

Cardiovascular effects of antidepressant drugs

This article reviews data on the cardiovascular effects of tricyclic antidepressants. While cardiotoxic in overdose, at therapeutic doses tricyclics exhibit relatively benign cardiovascular effects in depressed patients without preexisting cardiac disease, with the exception of orthostatic hypotension. They have been shown to delay conduction, manifested by prolonged PR, QRS and QT intervals on the standard ECG. Depressed patients with conduction disease, particularly bundle branch block, when treated with TCAs at therapeutic plasma levels, are at a higher risk of developing symptomatic A-V block than patients free of conduction disorders. Tricyclic antidepressants have been found to reduce ventricular arrhythmias, a property shared with type 1A antiarrhythmic compounds. Recently, a variety of type 1 antiarrhythmics has been shown to increase mortality in post-MI patients. The implications this may have for the TCA treatment of post-myocardial infarction depressed patients needs further study. The newer n...