Prior Acute Myocardial Infarction Research Articles

Usefulness of QRS duration in the absence of bundle branch block as an early predictor of survival in non-ST elevation acute myocardial infarction

To determine whether an increased QRS duration in the absence of bundle branch block (BBB) on the presenting electrocardiogram of patients with acute myocardial infarction (AMI) is associated with decreased survival, we retrospectively reviewed 781 consecutive patients admitted to the coronary care unit of our institution with AMI without BBB between 1988 and 1998. In patients with ST elevation AMI (n = 412), the groups with QRS duration ≥100 ms and <100 ms had similar survival. Conversely, in patients with non-ST elevation AMI (n = 369), in-hospital, 1-, 3-, and 5-year survival was 84.4%, 75.6%, 66.7%, and 52.2%, respectively, in the group with QRS ≥100 ms compared with 95.4%, 89.2%, 83.8%, and 74.3%, respectively, in the group with QRS <100 ms (p <0.01, log-rank test). In patients with non-ST elevation AMI, those with QRS duration ≥100 ms were more likely to be men, to have had a prior AMI that healed, to be in Killip class II, III, or IV, and to have lower ejection fraction than patients with QRS duration <100 ms. After adjusting for age, sex, prior AMI or stroke, heart rate, and Killip class on admission, QRS duration ≥100 ms was independently associated with in-hospital and overall mortality in patients with non-ST elevation AMI. QRS duration ≥100 ms in the absence of BBB is an independent predictor of increased mortality in patients with non-ST elevation AMI.

Identifying Antistreptokinase Antibodies

An accelerated dose tissue plasminogen activator (tPA) reduces mortality in acute myocardial infarction as compared with streptokinase (SK). Streptokinase is antigenic and will lead to the development of neutralising antibodies that have the potential to limit the effectiveness of repeat SK therapy. Accordingly, tPA is frequently administered to patients with recurrent infarction after SK treatment. Alternatively, one could identify those with high antibody titres and selectively use tPA when resistance was present. To determine the marginal cost-effectiveness of various thrombolytic strategies in patients with prior acute myocardial infarction (AMI), including the identification of patients with resistance to SK, using point-of-care testing. A decision analytical model was used to compare three strategies: repeat SK therapy, tPA to all, or selective tPA use for SK resistance identified using point-of-care testing. The perspective for analysis was that of a Canadian provincial (Ontario) Ministry of Health. Only healthcare costs directly incurred by the insurer were included. Short-term costs were obtained for treatment of AMI and complications. Potential benefits from treatment were estimated only with respect to survival, and are calculated as the additional life-years from the continuing survival of persons who would have died in the first few weeks after AMI but were spared. An incremental cost-effectiveness ratio (CER) was computed as the ratio of these incremental costs and benefits. Therefore, the marginal cost-effectiveness represents dollars (1999 Canadian) per additional short-term (5–6 weeks) survivor. The use of tPA in all patients with prior AMI resulted in the greatest mortality reduction, whereas the selective use of tPA for those with resistance had the most favourable CER. The selective use of tPA is a cost-effective strategy, with CERs varying from $Can85 964 when 5% are resistant to $Can72 100 when 95% are resistant. The CER improves with increasing levels of resistance. Although more expensive, the administration of tPA to all patients with prior AMI remains cost-effective even when levels of resistance are as low as 5%. In patients with a prior MI and possible resistance to SK, the use of tPA, whether selectively based on antistreptokinase antibody status or simply given to all, is cost-effective.

Characteristics and outcomes of young adults who present to the emergency department with chest pain.

Most studies of emergency department (ED) chest pain patients exclude patients <30-40 years old. As a result, the clinical course of these patients is poorly described. To study the clinical characteristics, hospital course, and 30-day outcomes of ED chest pain patients <40 years old. The hypothesis was that patients <40 years old without a cardiac history and with normal electro-cardiograms (ECGs) or no cardiac risk factors would be at a <1% risk for acute coronary syndromes (ACSs) and 30-day adverse cardiovascular (CV) events. This was a prospective cohort study of non-cocaine-using ED patients, 24-39 years old, who received an ECG for chest pain between July 9, 1999, and October 23, 2000. Structured data collection at presentation included demographics, chest pain description, history, laboratory, and ECG data. Hospital course was followed daily. Thirty-day follow-up was performed by telephone. The main outcomes were discharge diagnosis and 30-day adverse CV events [acute myocardial infarction (AMI), death, percutaneous intervention (PCI), or coronary artery bypass grafting (CABG)]. A total of 487 patients presented 527 times and comprised the study group. Patients were most often 30-39 years old (71%), female (60%), and African-American (73%). Thirty-two percent were admitted. Five hundred seven of 527 patient visits (96%) had 30-day follow-up. Patients had the following cardiac risk factors: tobacco, 37%; hypertension, 22%; family history, 19%; diabetes mellitus, 6%; cholesterol, 6%; prior angina, 3%; known coronary artery disease, 3%; and prior AMI, 2%. Patients usually had unremarkable ECGs (61% normal, 98% nonischemic). Overall, 11 of 527 patients had adverse CV events (2.1%; 95% CI = 0.9% to 3.3%): 8 AMIs (1.5%), 4 deaths (0.8%), 5 PCIs (0.9%), and no CABG. Twenty-five patients had a final diagnosis of ACS (4.7%; 95% CI = 2.9% to 6.5%). The incidence of ACS in the 210 patients without a cardiac history and without cardiac risk factors was 0.5% (95% CI = 0% to 1.4%). At 30 days, none of these 210 patients had AMI, PCI, CABG, or death (0%, 95% CI = 0% to 1.4%). The incidence of ACS in the 312 patients with normal ECGs and a negative cardiac history was 0.3% (95% CI = 0% to 0.9%). At 30 days, there was no AMI, PCI, or CABG in these 312 patients, and one patient with metastatic cancer died (adverse CV event 0.3%, 95% CI = 0% to 0.9%). Although young patients, as a whole, have a 4.7% risk of ACSs and a 2.1% risk of adverse CV events at 30 days, those without known cardiac disease or any cardiac risk factors had a <1% risk of ACSs and were free from adverse CV events over 30 days. Likewise, young patients without a cardiac history and with a normal ECG had a <1% risk of ACSs and adverse CV events at 30 days. It may be reasonable to expedite outpatient management and limit unnecessary admissions in these cohorts.

Effect of diabetes mellitus and insulin use on survival after acute myocardial infarction in the elderly (The Cooperative Cardiovascular Project)

Using data from a retrospective cohort study of Medicare beneficiaries hospitalized with an acute myocardial infarction (AMI), we evaluated the role of diabetes mellitus on 30-day and 1-year mortality. We classified subjects as nondiabetics, diabetics controlled with diet alone, diabetics receiving an oral hypoglycemic agent, and diabetics on insulin at time of admission. We compared baseline admission characteristics of subgroups using chi-square and Wilcoxon rank-sum tests and evaluated the effect of each diabetic state using sequential logistic models. We identified 80,832 nondiabetic patients, 9,862 diet-controlled diabetic patients, 14,664 diabetics receiving an oral hypoglycemic agent, and 12,241 diabetic patients on insulin therapy. Although mean age was similar among the groups, prevalence of hypertension, prior AMI, prior congestive heart failure, and prior revascularization were higher among diabetic patients, particularly those taking insulin. Diabetic patients, particularly those taking insulin, were less likely to receive aspirin and β blockers and to undergo coronary revascularization. Diabetic patients had higher 30-day and 1-year mortality than nondiabetic patients. After adjustment for demographics, clinical and hospital characteristics, and treatment strategies, insulin-treated diabetics had the highest risk of mortality, followed by diabetics receiving oral hypoglycemic agents, followed by diet-controlled diabetics. Thus, diabetes is highly prevalent among elderly patients with an AMI. Mortality rates for these patients, particularly insulin-using diabetics, are higher than among their nondiabetic counterparts. Preventive and therapeutic strategies must be developed to ensure improved short- and long-term outcomes for elderly patients with diabetes and AMI.

Common polymorphism in the promoter of the CD14 monocyte receptor gene is associated with acute myocardial infarction in Japanese men

We investigated whether C(-260)-->T polymorphism in the promoter of the CD14 monocyte receptor gene predisposed to coronary atherosclerosis and acute myocardial infarction (AMI) in Japanese men. The frequencies of T allele and T/T homozygotes in patients with AMI were significantly higher than in controls and in patients with angina without prior AMI, suggesting that the CD14 promoter polymorphism is associated with AMI rather than with coronary atherosclerosis, and this polymorphism may be one of the genetic risk factors for AMI in Japanese men.

The treatment of elderly diabetic patients with acute myocardial infarction: insight from Michigan's Cooperative Cardiovascular Project.

Diabetic patients with acute myocardial infarction (AMI) have higher morbidity and mortality rates than nondiabetic patients with AMI. Thus, reliable adherence to quality care is necessary in these patients to improve outcomes. We analyzed data from the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in Michigan, addressing quality of care in diabetic patients with AMI. All acute-care hospitals in Michigan had 8 consecutive months of baseline CCP data abstracted from medical records of all Medicare patients who were discharged with a principal diagnosis of AMI. Owing to the staggered 8-month periods, abstraction occurred for patients who were discharged between April 1, 1994, and July 31, 1995. Diabetic patients accounted for 33% of 8455 patients with AMI. Diabetic patients were primarily younger, female, and nonwhite. They had a greater frequency of non-Q-wave AMI and presented less often within 6 hours of their infarction. Comorbid conditions, such as hypertension, prior AMI, prior stroke, and/or prior revascularization, were more frequent in diabetic than in nondiabetic patients. Congestive heart failure occurred more frequently in diabetic patients. Length of stay (7.9 vs 7.0 days; P<.001), in-hospital mortality rates (16% vs 13%; P<.001), and rates for mortality within 30 days (21% vs 17%; P<.001) were higher in diabetic patients. Despite greater frequencies of comorbid conditions, poorer outcomes, and greater resource use, there is poor overall adherence to most quality indicators in diabetic patients with AMI. Better methods for systematizing proven prevention and treatment strategies in the care of patients with AMI are needed in this unique high-risk cohort.

Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

A comparison of ionic versus nonionic contrast medium during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction (GUSTO IIb)

The clinical impact of contrast medium selection during primary percutaneous transluminal coronary angioplasty for acute myocardial infarction (AMI) has not been studied. We compared the clinical outcomes of patients who received ionic versus nonionic low osmolar contrast medium in the setting of primary percutaneous transluminal coronary angioplasty for AMI in the second Global Use of Strategies to Open Occluded Coronary Arteries in Acute Coronary Syndromes (GUSTO IIb) trial. Univariable and multivariable analyses were performed to assess the relation between contrast medium selection and clinical outcome (death, reinfarction, or refractory ischemia) at 30 days. Although baseline clinical and angiographic characteristics were generally similar between the 2 groups, patients who received ionic, low osmolar contrast were less likely to have been enrolled at a US site (23% vs 43%, p = 0.001) and less likely to have occlusion of the left anterior descending coronary artery (34% vs 47%, p = 0.03) or a history of prior AMI (8% vs 16%, p = 0.02). The triple composite end point of death, reinfarction, or refractory ischemia occurred less frequently in the ionic group, both in the hospital (4.4% vs 11%, p = 0.018) and at 30 days (5.5% vs 11%, p = 0.044). Although the trend favoring ionic contrast persisted, the differences were no longer statistically significant after adjustment for imbalances in baseline characteristics using a risk model developed from the study sample (n = 454, adjusted odds ratio for ionic contrast 0.48 [0.22 to 1.02], p = 0.055), and using a model developed from the entire GUSTO IIb study cohort (n = 12,142, adjusted odds ratio for ionic contrast 0.50 [0.23 to 1.06], p = 0.072). The results of this observational study warrant further elucidation by a randomized study design in this setting.

QT dispersion may be a useful adjunct for detection of myocardial infarction in the chest pain center

Background QT dispersion has been proposed as a noninvasive measurement of the degree of inhomogeneity in myocardial repolarization. Increased QT dispersion has been reported after myocardial infarction. We hypothesized that increased QT dispersion may be a useful adjunct for risk stratification in patients being evaluated in a chest pain center. Methods and Results Patients were admitted to the chest pain center for evaluation of chest pain. Exclusion criteria included (1) systolic blood pressure <90 mm Hg, (2) ischemia or infarction on the initial electrocardiograph (ECG), (3) elevated creatine kinase or MB fraction, and (4) chest pain associated with cocaine use. Serial creatine kinase and MB levels and ECGs were obtained at 0, 6, and 9 hours. Patients were monitored for (1) creatine kinase and MB rise, (2) ECG changes for infarction, (3) ST-segment changes, and (4) rest angina. A negative evaluation at the chest pain center led to an exercise stress test. Patients with a positive exercise stress test were admitted for further evaluation and patients with a negative exercise stress test result were discharged home. Patients were divided into 3 groups. Group 1 consisted of patients who were found to have an acute myocardial infarction (AMI), group 2 consisted of patients with prior history of coronary artery disease but no evidence of AMI, and group 3 consisted of patients without prior coronary artery disease or AMI. QT dispersion was measured on the initial ECG in all patients. A total of 586 patients were evaluated. Group 1 consisted of 13 patients with mean QT dispersion of 44.6 ± 18.5 ms, group 2 consisted of 267 patients with a mean QT dispersion of 10.0 ± 13.8 ms, and group 3 consisted of 303 patients with a mean QT dispersion of 10.5 ± 10.0 ms. Analysis of variance showed a significantly higher QT dispersion in patients who had AMI compared with other patients with chest pain ( P < .001). Conclusions QT dispersion can be a useful diagnostic adjunct for detection of AMI in patients with chest pain with a normal ECG and normal cardiac enzymes. (Am Heart J 1998;136:496-8)

Resultados de la angioplastia primaria en pacientes con enfermedad multivaso

In patients with acute myocardial infarction treated with primary angioplasty, multivessel disease is associated with a higher mortality. However, if higher mortality is simply due to a higher prevalence of cardiogenic shock or if multivessel disease is an independent risk factor remains unclear. To study if multivessel disease constitute an independent prognostic factor in patients with acute myocardial infarction treated with primary angioplasty, and to ascertain possible mechanisms contributing to the worse prognosis found in these patients. Between august 1991 and october 1996, 312 patients with acute myocardial infarction were treated with primary angioplasty in our center. Characteristics and in-hospital outcome of patients with or without multivessel disease were compared. Patients with multivessel disease (n = 158; 51%) were older (64 +/- 11 vs 61 +/- 13 years; p = 0.017), less often smokers (60% vs. 76%; p = 0.006) and had a higher prevalence of diabetes (35% vs. 20%; p = 0.007), hypertension (54% vs. 39%; p = 0.012), prior acute myocardial infarction (29% vs. 5%; p < 0.001), prior coronary bypass (2% vs. 0%; p = 0.042) and Killip class IV at admission (19% vs. 8%; p < 0.001). Angiographic success rate was not different in patients with or without multivessel disease (89% vs. 92%; NS). Patients with multivessel disease had a higher in-hospital mortality (21% vs. 7%; p < 0.001), need of revascularization (17% vs. 3%; p < 0.001) and incidence of severe mitral regurgitation, (5% vs. 0%; p < 0.001), second or third atrioventricular blockade (10% vs. 1%; p < 0.001) and severe bleeding (4% vs. 1%; p = 0.089). After excluding patients with Killip class III or IV at admission, mortality was also higher in patients with multivessel disease (9% vs. 2%; p = 0.009). Multivariate analysis showed the following independent risk factors for mortality: age > 65 years, Killip class IV and multivessel disease. In patients with acute myocardial infarction treated with primary angioplasty, multivessel disease is associated with higher mortality. This is due not only to a higher prevalence of cardiogenic shock at admission, but also to a worse baseline profile, a higher incidence of complications and a more frequent need of revascularization.

Strategies for the management of acute myocardial infarction: selecting patients for thrombolytic therapy.

Strategies for managing acute myocardial infarction (AMI), with a focus on thrombolytics, are reviewed. Revised guidelines published by the American College of Cardiology and the American Heart Association strongly recommend the use of thrombolytic therapy in carefully selected patients to promote reperfusion of ischemic myocardium. Thrombolytics reduce in-hospital mortality, and the mortality benefit is maintained for at least one year. Which patients are the best candidates for thrombolytics has been debated; variables that have been analyzed include infarct location, time after onset of symptoms, age, sex, blood pressure, and prior AMI. Clinicians should be thoroughly familiar with the absolute and relative contraindications to thrombolytic therapy to minimize potential hemorrhagic complications. The diagnosis of AMI should be clearly established. All patients should receive thrombolytic therapy if they arrive for treatment within 12 hours of the onset of symptoms of AMI and have appropriate ECG changes. Aspirin should be given to all patients, and beta-blockers should also be given if there are no contraindications. Heparin may be given as antithrombotic therapy in patients not receiving thrombolytics or as adjuvant therapy in those receiving thrombolytics. Other adjuvant treatments, notably angiotensin-converting-enzyme inhibitors, are used as indicated. Primary angioplasty may have a role in selected patients. Long-term interventions are intended to prevent recurrence of AMI. Thrombolytic therapy can substantially improve survival and function in patients with AMI, especially when it is given within six hours of the onset of symptoms.

Impact of Valvular Regurgitation and Ventricular Dysfunction on Long-Term Survival in Patients With Chest Pain

Doppler echocardiography is often used in evaluating patients with chest pain, but information on prognostic value of this testing and data to help guide selective use are limited. We prospectively studied 448 patients admitted from the emergency department for acute chest pain to assess the utility of qualitative echocardiographic data in predicting long-term survival and the incremental value of this information over routine clinical and electrocardiographic data. Doppler echocardiograms, recorded an average of 21 hours after presentation, were analyzed independently by 2 echocardiographers for global left and right ventricular function and valvular disease. Regional function was assessed by wall motion index. Data on long-term survival were collected with an average follow-up of 35.0 ± 12.1 months. In univariate Cox regression analysis, left ventricular function and size, wall motion index, right ventricular function, and aortic, mitral, and tricuspid insufficiency were significant predictors of total and cardiovascular mortality. In multivariate analysis, moderate or severe left ventricular dysfunction (mortality rate ratio 3.2, 95% confidence intervals 1.8 to 5.8] and more than mild valvular regurgitation (mortality rate ratio 2.0, 95% confidence interval 1.1 to 3.6) were independent predictors of mortality in a model adjusted for clinical and electrocardiographic data. These factors were more common in patients aged >60 years, in those with prior acute myocardial infarction or angina, and in those with rales on physical examination. In the absence of these clinical characteristics, only 8 of 124 patients (7%) had moderate or severe left ventricular dysfunction or valvular regurgitation. In patients with moderate or severe regurgitation, a murmur was noted on the admission physical examination in 41 of 69 cases (59%). We conclude that echocardiographic evidence of moderate or severe left ventricular dysfunction or valvular regurgitation identifies a high-risk group for overall and cardiovascular mortality in patients with chest pain, and this evidence may not be detected clinically.

Thrombolytic therapy for patients with prior percutaneous transluminal coronary angioplasty and subsequent acute myocardial infarction

Our purpose was to evaluate the outcomes of patients with prior coronary angioplasty who underwent thrombolysis for new acute myocardial infarction (AMI) in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries-1 trial. Baseline characteristics and clinical outcomes were compared between patients with (n = 1,647) and without (n = 39,150) previous angioplasty. The relations among prior angioplasty, clinical outcomes, and treatment effects were examined with logistic regression modeling. Patients with previous angioplasty tended to be younger and presented sooner after symptom onset, but had more multivessel disease and lower ejection fractions. Unadjusted mortality was significantly lower in the prior-angioplasty group at 24 hours (1.8% vs 2.7%, p = 0.03) and 30 days (5.6% vs 7.0%, p = 0.036). Although most of the survival advantage was due to low-risk characteristics in this group (lower age and heart rate and fewer anterior wall AMIs), prior angioplasty remained a weak but independent predictor of survival. Recurrent ischemia and reinfarction occurred more often in the prior-angioplasty group, as did bypass surgery (12.2% vs 8.5%) and repeat angioplasty (34.5% vs 21.4%). Patients with prior angioplasty and prior AMI had lower 30-day mortality than those with prior infarction alone (6.3% vs 12.6%, p < 0.01). Treatment effects on 30-day mortality were similar among patients with prior angioplasty (odds ratio 1.2 for accelerated tissue-plasminogen activator v. combined Streptokinase arms, 95% confidence interval 0.73 to 1.9). Patients with prior angioplasty who present with AMI have fewer in-hospital adverse events and lower 30-day mortality than those without such a history.

Hemodialysis Immediately after Acute Myocardial Infarction

Acute myocardial infarction (AMI) is common in patients who have end-stage renal disease. However, the prudent interval after AMI until resuming hemodialysis is unknown. Also incidence and severity of intradialytic morbid events during the initial dialysis treatment after AMI have not been determined. We conducted a retrospective analysis of the course of hemodialyses performed immediately after AMI in 13 maintenance hemodialysis patients (group 1) hospitalized with AMI over the 5-year period 1988-1992. For comparison, the incidence of intradialytic morbid events (hypotension--systolic blood pressure < 90 or diastolic blood pressure < 60 mm Hg or a fall in systolic or diastolic blood pressure of > 30 mm Hg--with and without symptoms, arrhythmias, and unplanned termination of hemodialysis was extracted from the charts of 9 maintenance hemodialysis patients (group 2) admitted during the same period with angina but no AMI, and in 13 stable ambulatory hemodialysis patients (group 3) dialyzed during the same period who had no evidence of heart disease. Patients in groups 1 and 2 were sorted by time interval from onset of chest pain to initiation of hemodialysis (< 12, 12-24, and > 24 h). In group 1, we examined the relationship of anatomic location of AMI, number of antihypertensive medications, predialysis left ventricular systolic ejection fraction, and various other clinical and laboratory parameters to the incidence intradialytic morbid events. The mean (+/- SD) age of the study subjects was 67 +/- 7.5 years in group 1, 57 +/- 3.7 in group 2, and 60 +/- 11 years in group 3 (p = 0.6). Arrhythmias and early termination of dialysis did not occur in any patient. Intradialytic hypotension (IDH) was recorded in 5 (38%) of 13 patients in group 1, in 3 (33%) of 9 in group 2, and in 2 (15%) of 13 patients in group 3 (p = 0.47). 4 (80%) of 5 patients in group 1 had multiple episodes of IDH. There were 0.92 +/- 1.4 episodes of IDH per patient in group 1 as compared with a rate of 0.44 +/- 0.68 per patient in group 2, and of 0.15 +/- 0.36 per patient in group 3 (p = 0.2). IDH responded to 0.9% normal saline replacement in all cases. Group 1 patients who had IDH (n = 5) were older (68 +/- 3 vs. 58 +/- 7 years, p = 0.01), had a lower diastolic blood pressure at the start of hemodialysis (59 +/- 13 vs. 83 +/- 13 mm Hg; p = 0.01), had a lower post-AMI left ventricular systolic ejection fraction (42 +/- 19 vs. 62 +/- 10%; p = 0.04), and also had a lower predialysis serum albumin level (3.6 +/- 0.4 vs. 4.1 +/- 0.4 g/dl; p = 0.09) than those who did not have IDH (n = 8). All 5 group 1 patients who had IDH (100%) had had prior AMI as compared with 2 (25%) of 8 of those who did not have IDH (p = 0.02). AMI involved the inferior myocardial wall in more (4 of 5; 80%) of the group 1 patients who had IDH as compared with those who did not have IDH (2 of 8; 25%; odds ratio = 9.5; p = 0.08; 95% confidence interval = 0.7-341.0). In group 1 patients, the time from onset of chest pain to hemodialysis did not affect the risk of IDH (p = 0.4). We conclude that a low diastolic blood pressure at onset of hemodialysis prior myocardial infarction, inferior myocardial wall involvement, advanced age, and a low predialysis serum albumin level are risk factors for the development of hypotension during the first hemodialysis session after AMI.

Nifedipine and Mortality

When an approved treatment is considered for an unapproved indication, the physician must evaluate the safety of the medication, its value in related conditions, and the individual patient. What is asked is that he make a prudent decision based upon full knowledge of the available evidence.”1 Furberg and his colleagues2 entitle their article “Nifedipine: Dose-Related Increase in Mortality in Patients With Coronary Heart Disease.” They provide a valuable service by making us think more carefully about the benefit/risk ratio of the calcium antagonists as a group. However, by touting calcium antagonists as being unsafe and possibly lethal, they also create a great deal of uncertainty and anxiety among physicians and patients. We feel that they overstate their case. The following is an attempt to show that (1) the allegations focus on short-acting nifedipine, so that even if correct, they cannot be applied to other calcium antagonists; (2) the accusation of a dose-related increase in mortality rests on a biased selection of data chosen for the meta-analysis; and (3) several of the mechanisms suggested for the proposed adverse effects are unlikely. Finally, we shall argue that pharmaceutical companies have been remiss in not obtaining outcome studies for short-acting nifedipine and for other calcium antagonists, especially in the case of ischemic heart disease. Several aspects of the Furberg paper suggest that calcium antagonists in general are accused; for example, the statement that “the literature reviews strongly suggest that the problem may go beyond short-acting nifedipine. Troubling and major adverse cardiovascular events have been linked to other calcium antagonists, primarily dihydropyridines.” It should be clearly and unequivocally stated that Furberg et al2 provide no evidence whatsoever for any adverse effect on mortality or morbidity for any other agent, with one important exception. That exception is nimodipine, approved for use in …

Gender-related differences in reperfusion treatment allocation and outcome for acute myocardial infarction

Gender-related differences in outcome after myocardial infarction may relate to biased treatment allocation. To address this concern we analyzed 573 patients presenting with ST-segment elevation acute myocardial infarction (AMI), and treated within 6 hours with reperfusion therapy. Two-hundred eighty patients (49%) received direct coronary angioplasty, whereas 293 (51%) received thrombolytics followed by angioplasty (p = NS). Seventy-four percent were men and 26% were women (p = NS for differences in sex distribution between the 2 treatment groups). Women were older in both groups (p <0.01). Inferior AMI was seen more often in women (64% of direct angioplasty, 71% of lytic first) than in men (51% and 59%, respectively, p <0.03). There was no gender-related difference in presence of multivessel coronary artery disease, prior AMI, prior bypass surgery, baseline ejection fraction, percentage of patients with ejection fraction ≤40%, number of narrowings dilated, or angioplasty success. Patients who underwent direct angioplasty had more multivessel disease (p <0.001) and prior coronary artery bypass surgery (p = 0.002). After a mean follow-up of 129 ± 113 weeks, no gender-related differences were seen in the need for cardiac catheterization, documented restenosis, AMI, coronary artery bypass surgery, clinical ischemia, or death. Patients treated with direct angioplasty were more likely to undergo coronary artery by-pass surgery (p <0.05) or to die (p <0.01). Thus, women undergoing reperfusion therapy for ST-segment elevation were older than men, with a higher frequency of inferior wall AMI. No specific gender-related bias in treatment allocation was evident.

Comparison of coronary lesions obtained by directional coronary atherectomy in unstable angina, stable angina, and restenosis after either atherectomy or angioplasty

The present study investigated the incidence of the histopathologic lesions and of growth factor expression in a consecutive series of directional coronary atherectomy (DCA) samples from 40 unstable angina pectoris patients without prior acute myocardial infarction and compared the findings with those obtained in DCA samples from 18 patients with stable angina without previous infarction and 18 patients with restenosis. We investigated coronary thrombosis, neointimal hyperplasia, and inflammation. For unstable angina, we correlated the angiographic Ambrose plaque subtypes with the histopathologic findings. The immunophenotype of plaque cells and the growth factor expression were assessed with specific antibodies for cell characterization and for the expression of basic fibroblast and platelet-derived AA and AB growth factors and receptors. The incidence of coronary thrombosis was 35% in patients with unstable angina, 17% in those with stable angina, and 11% in patients with restenosis. Neointimal hyperplasia was found in 38% of unstable angina cases, in 17% of stable angina cases, and in 83% of restenosis cases. Inflammation without thrombus or accelerated progression occurred in 20% of unstable angina and 6% of stable angina samples. In 52% of unstable angina cases, inflammation coexisted with thrombosis and/or neointimal hyperplasia. In the unstable angina group, 71% of the plaques with thrombus had a corresponding angiographic pattern of complicated lesions. The growth factor expression, reported as percentage of cells immunostaining with different growth factor antibodies, was highest in restenosis, followed by unstable angina and stable angina lesions.(ABSTRACT TRUNCATED AT 250 WORDS)

709-2 Primary Angioplasty for Acute Myocardial Infarction in Elderly Thrombolytic Candidates: Is It the Best Option?

Reperfusion therapy has been expanded to include elderly pts (EL), and primary angioplasty (PTCA) has been promoted as a preferable alternative to thrombolytic therapy (TT) for acute myocardial infarction (AMI) in the elderly (EL). The purpose of this study was to compare outcomes of EL and non-EL pts considered eligible to receive TI who received PTCA for AMI. Patients with cardiogenic shock, prior bypass, and reperfusion time &gt; 12 hrs were considered ineligible for TT. Of 781 consecutively treated pts eligible for TT, 75 (9.6%) were ≥ 75 yrs, and 706 (90.4%) were &lt; 75 yrs. EL were more likely to be women (50.7 vs 25.1%, P &lt; 0.0001), have prior AMI (32 vs 18.1%, P &lt; 0.01), and to have anterior infarction (64 vs 40.1%, P &lt; 0.0001). Baseline ejection fraction and reperfusion time were similar in both groups. Outcomes are listed below. &lt;75 years (n = 706) ≥75 years (n = 75) P Value Successful PTCA 664 (94.1%) 74 (98.1%) 0.16 Lab Death 8 (1.1%) 2 (2.7%) 0.24 Hospital Mortality 36 (5.1%) 16 (21.3%) 0.00001 Reinfarction 32 (4.6%) 7 (9.5%) 0.11 Recurrent Ischemia 19 (2.7%) 4 (5.3%) 0.40 Stroke 4 (0.6%) 4 (5.3%) 0.004 For pts &lt;65 yrs (n = 522) compared to ≥ 65 yrs (n = 259), hospital mortality was 3.4% vs 13.1%, P &lt; 0.0001. Despite a high rate of successful reperfusion, PTCA in elderly TT candidates is associated with considerable mortality and morbidity. Further study is needed to establish the best option for the elderly

Late outcome after percutaneous transluminal coronary angioplasty during acute myocardial infarction

Early reperfusion for acute myocardial infarction (AMI) results in improved ventricular function and survival. There is a dearth of data on long-term survival (>5 years) after percutaneous transluminal coronary angioplasty (PTCA) performed either as a primary procedure or in conjunction with thrombolytic therapy. We studied 160 patients who underwent PTCA during AMI between 1981 and 1987 either with (n = 101) or without (n = 59) streptokinase therapy. Mean time to reperfusion was 4.6 hours, and patency was achieved in 134 patients (84%). Mean discharge ejection fraction was 46 ± 14%. Coronary artery bypass grafting was performed before dismissal in 34 patients (21%), including 21 of 130 patients (16%) with 1-or 2-vessel disease and 13 of 30 patients (43%) with 3-vessel disease (p < 0.05). Eleven patients (7%) died in the hospital. The 149 hospital survivors were followed for a mean of 69 ± 21 months (median 72). During follow-up, 22 patients (15%) died, 21 (14%) had reinfarction, 23 (15%) underwent coronary artery bypass grafting, and 21 (14%) underwent repeat PTCA of the infarct-related artery. On univariate analysis, age ≥ 62 years, multivessel disease, ejection fraction ≤40%, previous AMI, and being a nonsmoker at the time of AMI were predictive of late mortality (p < 0.05 each variable). On multivariate analysis, only ejection fraction ≤40% and prior AMI were predictive of late death. In patients treated with PTCA for AMI, late survival is excellent. Early surgical revascularization of high-risk patients may contribute to these encouraging results.

Late outcome after percutaneous transluminal coronary angioplasty during acute myocardial infarction

Early reperfusion for acute myocardial infarction (AMI) results in improved ventricular function and survival. There is a dearth of data on long-term survival (>5 years) after percutaneous transluminal coronary angioplasty (PTCA) performed either as a primary procedure or in conjunction with thrombolytic therapy. We studied 160 patients who underwent PTCA during AMI between 1981 and 1987 either with (n = 101) or without (n = 59) streptokinase therapy. Mean time to reperfusion was 4.6 hours, and patency was achieved in 134 patients (84%). Mean discharge ejection fraction was 46 ± 14%. Coronary artery bypass grafting was performed before dismissal in 34 patients (21%), including 21 of 130 patients (16%) with 1-or 2-vessel disease and 13 of 30 patients (43%) with 3-vessel disease (p < 0.05). Eleven patients (7%) died in the hospital. The 149 hospital survivors were followed for a mean of 69 ± 21 months (median 72). During follow-up, 22 patients (15%) died, 21 (14%) had reinfarction, 23 (15%) underwent coronary artery bypass grafting, and 21 (14%) underwent repeat PTCA of the infarct-related artery. On univariate analysis, age ≥ 62 years, multivessel disease, ejection fraction ≤40%, previous AMI, and being a nonsmoker at the time of AMI were predictive of late mortality (p < 0.05 each variable). On multivariate analysis, only ejection fraction ≤40% and prior AMI were predictive of late death. In patients treated with PTCA for AMI, late survival is excellent. Early surgical revascularization of high-risk patients may contribute to these encouraging results.