Nonfatal Reinfarction Rates Research Articles

Long-term outcomes of early-onset myocardial infarction with non-obstructive coronary artery disease (MINOCA)

BackgroundAcute myocardial infarction with non-obstructive coronary artery disease (MINOCA) is frequent in patients experiencing an early-onset MI, but data concerning its long-term prognosis are limited and conflicting. MethodsThe Italian Genetic Study on Early-onset MI enrolled 2000 patients experiencing a first MI before the age of 45 years, and had a median follow-up of 19.9 years. The composite primary endpoint was cardiovascular (CV) death, non-fatal MI, and non-fatal stroke (MACE); the secondary endpoint was rehospitalisation for coronary revascularisation. ResultsMINOCA occurred in 317 patients (15.9%) and, during the follow-up, there was no significant difference in MACE rates between them and the patients with obstructive coronary artery disease (MICAD: 27.8% vs 37.5%; adjusted hazard ratio [HR] 0.79, 95% confidence interval [CI] 0.57–1.09;p = 0.15). The CV death rate was lower in the MINOCA group (4.2% vs 8.4%, HR 0.26, 95%CI 0.08–0.86;p = 0.03), whereas the rates of non-fatal reinfarction (17.3% vs 25.4%; HR 0.76, 95%CI 0.52–1.13;p = 0.18), non-fatal ischemic stroke (9.5% vs 3.7%; HR 1.79, 95%CI 0.87–3.70;p = 0.12), and all-cause mortality (14.1% vs 20.7%, HR 0.73, 95%CI 0.43–1.25;p = 0.26) were not significantly different in the two groups. The rate of rehospitalisation for coronary revascularisation was lower among the MINOCA patients (6.7% vs 27.7%; HR 0.27, 95% CI 0.15–0.47;p < 0.001). ConclusionsMINOCA is frequent and not benign in patients with early-onset MI. Although there is a lower likelihood of CV death,the long-term risk of MACE and overall mortality is not significantly different from that of MICAD patients.

Infarct related artery only versus complete revascularization in ST-segment elevation myocardial infarction and multi vessel disease: a meta-analysis.

The 2015 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) focused update on primary percutaneous coronary intervention (PCI) for patients with ST-segment elevation myocardial infarction (STEMI) only gives a class II b (weak) indication for non-infarct artery intervention at the time of primary PCI. Recent randomized controlled trials, however, suggest strong evidence supporting complete revascularization. A systematic search was conducted in PUBMED, MEDLINE, EMBASE and Cochrane central register for randomized controlled trials comparing complete versus infarct artery (IRA) only revascularization in patients with STEMI. A meta-analysis was performed using the data extracted from each study. Summary risk ratios (RR) and 95% confidence intervals (CI) were calculated for five outcomes. Six trials fulfilled the inclusion criteria yielding 1,792 patients. Follow up ranged from 6 months to 2.5 years. The incidence of major adverse cardiac events (MACE) was significantly lower in the complete revascularization group compared to the IRA only revascularization (13.8% vs. 25.1%, RR =0.51; 95% CI: 0.41-0.64, P<0.00001). It was attributed to significantly lower repeat revascularization rate in the complete revascularization group (8.2% vs. 18.9%, RR =0.41; 95% CI: 0.31-0.54, P<0.00001). This meta-analysis also showed a significant reduction in cardiovascular mortality (2.0% vs. 4.6%, RR =0.42; 95% CI: 0.24-0.74; P=0.003), non-fatal myocardial infarction (4.37% vs. 5.76%, RR =0.64; 95% CI: 0.34-1.20; P=0.16) and all-cause mortality rates [(4.6% vs. 6%), RR =0.75; 95% CI: 0.49-1.14, P=0.17] in the complete revascularization group, compared to the IRA revascularization group. In patients who present with STEMI, complete revascularization is associated with lower rates of MACE and cardiovascular deaths as compared to revascularization of the IRA alone. Even though the outcomes of all-cause mortality and nonfatal re-infarction rates were lower in the complete revascularization group, they were not significant.

The prognostic value of admission mean platelet volume to platelet count ratio in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Mean platelet volume to platelet count (MPV/Plt) ratio has been demonstrated to be a good indicator of long-term mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). However, the prognostic value of MPV/Plt in ST-elevation myocardial infarction (STEMI) is not reported. To determine whether the MPV/Plt ratio on admission has any predictive value for major adverse cardiac events including short- and long-term mortality in STEMI. In this prospective study, 470 STEMI patients who underwent primary percutaneous coronary intervention (PCI) were enrolled. The patients were divided into three tertiles based on the MPV/Plt ratio on admission. The first tertile (n = 149) was defined as MPV/Plt ratio ≤ 0.029, second tertile (n = 154) 0.029-0.038, and third tertile (n = 159) ≥ 0.038. Primary clinical outcomes consisted of the sum of cardiovascular (CV) mortality, non-fatal re-infarction, and stroke. Secondary clinical outcomes were CV mortality, non-fatal re-infarction, target-vessel revascularisation, stroke, and advanced heart failure. There was no difference between study groups regarding the primary (p > 0.05) and the secondary outcomes (p > 0.05) except for one-year non-fatal re-infarction rate, which was found to be significantly higher in the highest MPV/Plt ratio group (p = 0.045). Age, Killip class > 1, and left ventricular ejection fraction were found to be independent predictors of long-term CV mortality in multivariate analysis (p = 0.009, p = 0.035, and p < 0.001, respectively). While the MPV/Plt ratio was demonstrated to be associated with one-year non-fatal re-infarction, it was not related to in-hospital, one-month, and one-year CV mortality in patients with STEMI, who underwent primary PCI.

Brief strategic therapy in first myocardial infarction patients with increased levels of stress: a randomized clinical trial

Background: Little is known about the impact of interventions targeting chronic stress levels on clinical outcomes among myocardial infarction (MI) patients with increased levels of stress. Objectives: To examine the impact of the addition of brief strategic therapy (BST) to usual care (UC) on clinical outcomes in first MI patients with increased levels of stress. Design: Eighty-one patients were randomly assigned to BST in conjunction with UC (medical treatment, risk factor information, and guidance on unhealthy behavior change) or to UC. Methods: The outcome measures were scores on the Perceived Stress Scale, reinfarction and cardiac mortality rates, and scores on the Health Survey. Measures were taken before, post-treatment, and at two follow-ups. Results: Patients subjected to BST showed reduced perceived stress at post-treatment and maintained decreased levels at follow-ups. At 1-year follow-up, they had a lower rate of non-fatal reinfarction, and at 2.5-year follow-up, they had a lower rate of fatal reinfarction. Their mental and physical health was improved at post-treatment and this was sustained at follow-ups. Conclusion: The addition of BST to UC favorably influences the disease course after MI in patients with increased levels of stress.

Abstract 232: Comparison of Different Management Strategies for Acute Myocardial Infarction: A Multivariable Network Meta-analysis

Introduction: Many contemporary trials have compared different management strategies, involving combinations of reperfusion therapies and early invasive approaches, for treatment of ST-elevation myocardial infarction (STEMI). We used multivariable network meta - analysis to compare these approaches. Methods: We identified 29 trials in which patients with STEMI were randomized to at least two of the following strategies: thrombolytic therapy (n=4255), primary PCI (n=5850), or routine PCI after administration of thrombolytic therapy (n=4738). We categorized the latter approach as facilitated PCI (FPCI) when the median time interval between thrombolytic therapy and PCI was less than 2 hours and as a pharmacoinvasive approach when this interval was 2 hours or more. We excluded trials that did not routinely use stents during PCI. We identified short-term outcomes (up to 42 days) of death, nonfatal reinfarction, stroke, and major bleeding. We performed multivariable random-effects meta-analysis to compare these strategies. In addition, we estimated the probability that each strategy was associated with maximum risk for each outcome under a Bayesian model with flat priors. Results: Among the strategies evaluated, primary PCI was associated with the lowest mortality and nonfatal reinfarction rates, as well as the lowest risk of stroke ( Table- top panel ). Of the remaining strategies, the pharmacoinvasive approach was associated with the lowest risks of mortality, reinfarction, and stroke. The Bayesian model indicated that the probabilities of death, nonfatal reinfarction, stroke, and major bleeding were lowest for primary PCI and highest for thrombolytic therapy ( Table- bottom panel ). Furthermore, the probability of these outcomes was lower for the pharmacoinvasive approach relative to facilitated PCI. Conclusions: Primary PCI is the preferred approach for treatment of STEMI. Our analysis suggests that a pharmacoinvasive approach may be more effective and safer as compared to facilitated PCI and thrombolytic therapy.

Status of Stent for Life Initiative across Europe

Early revascularization with primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) has been shown to reduce mortality, rates of nonfatal reinfarction and stroke, as compared to previous standard of care with thrombolytic therapy. Despite substantial evidence of its effectiveness, the use of PPCI varies considerably across Europe. The Stent for Life Initiative supports implementation of local STEMI treatment guidelines, helps to identify specific barriers to implementation of guidelines and defines actions to make sure that the majority of STEMI patients have access to PPCI. Launching a successful programme for PPCI requires the commitment and collaboration of a broad variety of members of the healthcare system. This narrative review is intended to describe some of the progress already seen in the 10 countries currently included in the Stent for Life Initiative and to report and discuss the engagement of the various stakeholders involved.

Abstract 5488: Comparison of Primary With Fibrinolytic-based Facilitated PCI and Comparison of Fibrinolytic-based PCI With Fibrinolysis Followed by Standard Care for STEMI: Updated Quantitative Review of Randomized Trials

Background: Facilitated PCI for STEMI is defined as the use of pharmacological substances before a planned immediate intervention (&lt; 3h), to improve coronary patency. We undertook an updated meta-analysis of randomized controlled trials to compare fibrinolytic-based facilitated and primary PCI and fibrinolytic-based facilitated PCI and fibrinolysis followed by standard care. Methods: We identified 12 trials of patients with STEMI assigned to facilitated (n=2498) or primary (n=2488) PCI and 8 trials with comparison facilitated PCI (n=969) vs fibrinolysis with standard care (n=955). Outcomes of death, stroke, non-fatal reinfarction, urgent TVR, and major bleeding were assessed. Results: The facilitated approach resulted in a greater than two-fold increase in the number of patients with initial TIMI-3-flow compared with primary PCI approach (p&lt;0.001); however, final rates did not differ (p=n.s.). Significantly more patients assigned to facilitated PCI than those assigned to primary PCI died (5.3% vs 3.9%; RR 1.36; 95% CI 1.04; 1.77; p=0.02), had higher non-fatal reinfarction rates (3.3% vs 1.7%; RR 1.99; 95% CI 1.36; 2.92; p&lt;0.001), higher urgent TVR rates (3.3% vs 1.3%; RR 2.48; 95% CI 1.57; 3.97; p&lt;0.001), and higher stroke rates (1.3% vs 0.5%; RR 2.76; 95% CI 1.38; 5.64; p=0.002). Facilitated PCI was also associated with higher rates of major bleeding (6.4% vs 3.9%; RR 1.62 95% CI 1.26; 2.09; p&lt;0.001). In the 2nd comparison, facilitated PCI did not result in a mortality difference (5.1% vs 5.7%; RR 0.89; 95% CI 0.60; 1.33; p=0.63) and no difference in non-fatal reinfarction (4.2% vs 5.2%; RR 0.81; 95% CI 0.52; 1.25; p=0.37). However, there was a difference in non-fatal reinfarction in the stenting era (4.0% vs 7.0%; RR 0.57; 95% CI 0.34; 0.95; p=0.03). There was no difference in major bleeding and stroke in the comparison of facilitated PCI vs fibrinolysis with standard care. Conclusions: Fibrinolytic-based facilitated PCI has substantial harm in comparison to primary PCI. In comparison to fibrinolysis with standard care facilitated PCI leads to a small reduction in reinfarction but has no beneficial effect on mortality. A strategy of primary PCI should therefore be implemented for all STEMI patients.

Coronary Intervention for Persistent Occlusion after Myocardial Infarction

It is unclear whether stable, high-risk patients with persistent total occlusion of the infarct-related coronary artery identified after the currently accepted period for myocardial salvage has passed should undergo percutaneous coronary intervention (PCI) in addition to receiving optimal medical therapy to reduce the risk of subsequent events. We conducted a randomized study involving 2166 stable patients who had total occlusion of the infarct-related artery 3 to 28 days after myocardial infarction and who met a high-risk criterion (an ejection fraction of <50% or proximal occlusion). Of these patients, 1082 were assigned to routine PCI and stenting with optimal medical therapy, and 1084 were assigned to optimal medical therapy alone. The primary end point was a composite of death, myocardial reinfarction, or New York Heart Association (NYHA) class IV heart failure. The 4-year cumulative primary event rate was 17.2% in the PCI group and 15.6% in the medical therapy group (hazard ratio for death, reinfarction, or heart failure in the PCI group as compared with the medical therapy group, 1.16; 95% confidence interval [CI], 0.92 to 1.45; P=0.20). Rates of myocardial reinfarction (fatal and nonfatal) were 7.0% and 5.3% in the two groups, respectively (hazard ratio, 1.36; 95% CI, 0.92 to 2.00; P=0.13). Rates of nonfatal reinfarction were 6.9% and 5.0%, respectively (hazard ratio, 1.44; 95% CI, 0.96 to 2.16; P=0.08); only six reinfarctions (0.6%) were related to assigned PCI procedures. Rates of NYHA class IV heart failure (4.4% vs. 4.5%) and death (9.1% vs. 9.4%) were similar. There was no interaction between treatment effect and any subgroup variable (age, sex, race or ethnic group, infarct-related artery, ejection fraction, diabetes, Killip class, and the time from myocardial infarction to randomization). PCI did not reduce the occurrence of death, reinfarction, or heart failure, and there was a trend toward excess reinfarction during 4 years of follow-up in stable patients with occlusion of the infarct-related artery 3 to 28 days after myocardial infarction. (ClinicalTrials.gov number, NCT00004562 [ClinicalTrials.gov].).

Long‐term prognostic implications of nonoptimal primary angioplasty for acute myocardial infarction

To evaluate the long-term outcome of a nonoptimal result of a primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). An optimal PCI result was defined as TIMI flow grade 3 and residual stenosis < or = 20%. Long-term clinical follow-up (51 +/-+/- 21 months) data were collected from 1,009 consecutive patients with ST-elevation AMI who underwent primary PCI. Overall, an optimal primary PCI result was achieved in 958 patients (95%). At 5-year follow-up, patients with nonoptimal PCI had a higher rate of all-cause mortality (47% vs 19%; P < 0.00001 by log-rank test) than those with an optimal mechanical reperfusion. Fifty-two percent of the deaths in the nonoptimal PCI group occurred within the first month. Interestingly, after this period, estimated survival of 30-day alive patients was not significantly different to that of patients with an optimal PCI (P = 0.06 by log-rank test). Nonoptimal PCI result emerged as an independent predictor of 1-month mortality (OR = 3.030, 95% CI = 1.265-7.254; P = 0.013), but not of 5-year mortality. At long-term follow-up, cumulative rates of nonfatal reinfarction, hospitalization for heart failure, and additional revascularization procedures were similar between patients with nonoptimal and optimal primary PCI (4% vs 5%, P = 0.695; 4% vs 5%, P = 921; and 22% vs 20%, P = 0.816, respectively). A nonoptimal primary PCI result represents a strong predictor of early mortality. However, in patients surviving the early phase, the incidence of clinical events at long-term follow-up seems to be similar to successfully reperfused AMI patients.

Comparison of primary and facilitated percutaneous coronary interventions for ST-elevation myocardial infarction: quantitative review of randomised trials

Facilitated percutaneous coronary intervention for ST-segment-elevation myocardial infarction (STEMI) is defined as the use of pharmacological substances before a planned immediate intervention, to improve coronary patency. We undertook a meta-analysis of randomised controlled trials (published and unpublished) to compare facilitated and primary percutaneous coronary intervention. We identified 17 trials of patients with STEMI assigned to facilitated (n=2237) or primary (n=2267) percutaneous coronary intervention. We identified short-term outcomes (up to 42 days) of death, stroke, non-fatal reinfarction, urgent target vessel revascularisation, and major bleeding. Grade 3 flow rates for prethrombolysis and post-thrombolysis in myocardial infarction (TIMI) were also analysed. The facilitated approach resulted in a greater than two-fold increase in the number of patients with initial TIMI grade 3 flow, compared with the primary approach (832 patients [37%] vs 342 [15%], odds ratio 3.18, 95% CI 2.22-4.55); however, final rates did not differ (1706 [89%] vs 1803 [88%]; 1.19, 0.86-1.64). Significantly more patients assigned to the facilitated approach than those assigned to the primary approach died (106 [5%] vs 78 [3%]; 1.38, 1.01-1.87), had higher non-fatal reinfarction rates (74 [3%] vs 41 [2%]; 1.71, 1.16-2.51), and had higher urgent target vessel revascularisation rates (66 [4%] vs 21 [1%]; 2.39, 1.23-4.66); the increased rates of adverse events seen with the facilitated approach were mainly seen in thrombolytic-therapy-based regimens. Facilitated intervention was associated with higher rates of major bleeding than primary intervention (159 [7%] vs 108 [5%]; 1.51, 1.10-2.08). Haemorrhagic stroke and total stroke rates were higher in thrombolytic-therapy-containing facilitated regimens than in primary intervention (haemorrhagic stroke 15 [0.7%] vs two [0.1%], p=0.0014; total stroke 24 [1.1%] vs six [0.3%], p=0.0008). Facilitated percutaneous coronary intervention offers no benefit over primary percutaneous coronary intervention in STEMI treatment and should not be used outside the context of randomised controlled trials. Furthermore, facilitated interventions with thrombolytic-based regimens should be avoided.

Considerations in combination therapy: fibrinolytics plus glycoprotein IIb/IIIa receptor inhibitors in acute myocardial infarction.

The combined use of a fibrinolytic and a platelet glycoprotein (GP) IIb/IIIa receptor inhibitor to target the fibrin and platelet components of occlusive thrombi offers the potential for more rapid and complete reperfusion in patients with acute myocardial infarction (MI), although there have been concerns about the safety of this combination therapy. Data from the recent GUSTO-V and the ASSENT-3 trials support the use of this regimen in that the 30-day death or nonfatal reinfarction rate (7 days) in GUSTO-V and death or in-hospital reinfarction or in-hospital refractory ischemia rate in ASSENT-3 were reduced (p = 0.001 and p = 0.0001, respectively). The need for revascularization in both these trials was also reduced significantly. There was no increased risk of intracranial hemorrhage or stroke with the combination therapy, but an increased rate of nonintracranial severe or major bleeding was observed. At present, patients aged > 75 years should not receive combination therapy. Further studies in subgroup patient populations are warranted.

Abciximab therapy improves 1-month survival rate in unselected patients with acute myocardial infarction undergoing routine infarct artery stent implantation

Background The impact of abciximab therapy on mortality in unselected patients with acute myocardial infarction (AMI) undergoing routine primary infarct-related artery (IRA) stent implantation is not yet defined, and previous randomized studies have produced conflicting results. Methods A strategy of IRA stenting alone as opposed to IRA stenting plus abciximab was compared in a series of 561 consecutive unselected patients with AMI. Abciximab tretament was strongly encouraged for all patients. The contraindication for abciximab therapy was a high risk of major bleeding as assessed by the operator before mechanical intervention. Results Of 561 patients, 348 patients underwent abciximab therapy and 213 underwent primary IRA stenting alone. The 1-month overall mortality rate was 2.9% in the abciximab group and 10.8% in the stent alone group (P <.001). The relative reduction in mortality rate was 73% for patients overall, 77% in the subset of patients aged ≤70 years (mortality rate, 1.2% vs 5.2%, P =.020), 57% in patients aged >70 years (7.7% vs 18%, P =.043), 63% in patients with cardiogenic shock (17% vs 46%, P =.022), and 77% in patients without cardiogenic shock (1.3% vs 5.6%, P =.002). Multivariate analyses on the basis of all patients, and on the subset of patients aged ≤70 years, showed that abciximab therapy was independently related to the risk of death at 1 month. No differences were seen between groups in the procedural success rate (99.1% vs 98.1%) or in the incidence rates of nonfatal reinfarction (0.3% vs 1.9%) or repeat target vessel revascularization (1.7% vs 1.9%). Conclusion The results of this study strongly support the use of abciximab therapy in nonselected patients with AMI undergoing routine IRA stent implantation. The mechanism of the clinical benefit of abciximab was not related to the patency of the IRA. (Am Heart J 2002;144:315-22.)

Diltiazem in acute myocardial infarction treated with thrombolytic agents: a randomised placebo-controlled trial

Diltiazem reduces non-fatal reinfarction and refractory ischaemia after non-Q-wave myocardial infarction, an acute coronary syndrome similar to the incomplete infarction that occurs after successful reperfusion. We postulated that this agent would reduce cardiac events in patients after acute myocardial infarction treated initially with thrombolytic agents-a clinical application previously unexplored with heart-rate-lowering calcium antagonists. A prospective, randomised, double-blind, sequential trial was done in 874 patients with acute myocardial infarction, but without congestive heart failure, who first received thrombolytic agents. Patients received either 300 mg oral diltiazem once daily, or placebo, initiated within 36-96 h of infarct onset, and given for up to 6 months. The trial primary endpoint was the cumulative first event rate of cardiac death, non-fatal reinfarction, or refractory ischaemia. Additional prespecified endpoints included several composites of non-fatal cardiac events (non-fatal reinfarction combined with refractory ischaemia, all recurrent ischaemia, or the need for myocardial revascularisation). The diagnosis of ischaemia, whether refractory or recurrent, and the need for myocardial revascularisation, was always based on objective electrocardiographical evidence of ischaemia, either at rest or on exertion. For the trial primary endpoint, 131 events occurred in the 444 placebo patients and 97 events in the 430 diltiazem patients (hazard ratio 0.79; 95% CI, 0.61-1.02; p=0.07). For non-fatal cardiac events, diltiazem treatment was associated with a relative decrease (0.76; 0.58-1.00) in the combined event rate of non-fatal reinfarction and refractory ischaemia. There was a similar decrease in the composite non-fatal endpoints of non-fatal reinfarction combined with all recurrent ischaemia (0.80; 0.64-1.00) and non-fatal reinfarction combined with the need for myocardial revascularisation (0.67; 0.46-0.96). The need for myocardial revascularisation alone was significantly reduced by 42% (0.61; 0.39-0.96). No major safety issues were encountered. Diltiazem did not reduce the cumulative occurrence of cardiac death, non-fatal reinfarction, or refractory ischaemia during a 6-month follow-up, but did reduce all composite endpoints of non-fatal cardiac events, especially the need for myocardial revascularisation.

Prognostic significance of nonfatal reinfarction during 3-year follow-up: Results of the thrombolysis in myocardial infarction (TIMI) phase II clinical trial

This study sought to assess the independent contribution of nonfatal reinfarction to the risk of subsequent death in patients with acute myocardial infarction undergoing thrombolytic therapy. A composite of "unsatisfactory outcomes" as an end point has increased statistical power and facilitated evaluation of evolving treatment regimens in acute myocardial infarction. The significance of nonfatal reinfarction as a component of a composite end point has not been evaluated in the thrombolytic era. Event rate of nonfatal reinfarction over 3-year follow-up was evaluated in patients with acute myocardial infarction entered into the Thrombolysis in Myocardial Infarction Phase II trial. The independent risk of nonfatal reinfarction for subsequent death within various time intervals of follow-up was determined. The mortality rate after nonfatal reinfarction was compared with that of a matched control group. During 3-year follow-up, 349 of 3,339 patients had a nonfatal reinfarction. Univariate predictors were history (antedating the index event) of angina (p = 0.01), hypertension (p = 0.01), multivessel disease (p = 0.007) and not a current smoker (p = 0.003); the latter was an independent predictor (relative risk [RR] 1.3, 99% confidence interval [CI] 1.0 to 1.8). Forty-three of the 349 patients with a nonfatal reinfarction died: RR for death (vs. patients without a nonfatal reinfarction) was 1.9 (99% CI 1.1 to 3.2) if reinfarction occurred within 42 days of study entry, 6.2 (99% CI 3.0 to 12.9) if reinfarction occurred between 43 and 365 days and 2.9 (99% CI 0.6 to 13.4) if reinfarction occurred between 366 days and 3 years. The cumulative 3-year death rate was 14.1% in patients with a nonfatal reinfarction compared with 7.9% (p < 0.01) in a matched control group. Univariate predictors of death after nonfatal reinfarction were age > or = 65 years (p < 0.001), not low risk category (p = 0.015) and history of heart failure before the index event (p < 0.001). Age > or = 65 years was the only independent predictor (RR 5.4, 99% CI 2.3 to 12.4). Nonfatal reinfarction is a strong and independent predictor for subsequent death. It represents a powerful component for a composite end point in patients who received thrombolytic therapy after acute myocardial infarction.

Community Approach in Rehabilitation and Secondary Prevention After Acute Myocardial Infarction

The effects of a rehabilitation course in a rehabilitation center were compared to those in a community-based rehabilitation program after first acute myocardial infarction. Four hundred fifty-six patients under 65 years of age were randomized at discharge from hospital either to a hospital outpatient clinic group combined with a community-based rehabilitation program (O group, n = 228), or to a residential rehabilitation program (R group, n= 228). The coronary mortality during the 6-year follow-up was 24.1% in the O group, compared to 19.7% in the R group (NS). The nonfatal reinfarction rate was 11.8% in the O group and 13.6 % in the R group (NS). The changes in serum total cholesterol and triglycerides were more favorable only during the first 3 months in R group compared to O group. At follow-up there were no differences between the groups in physical working capacity or return to work. Thus, the community-based rehabilitation program combined with regular outpatient check-ups was comparable with residential rehabilitation with regard to mortality and morbidity, although there was a tendency towards lower lifestyle-related risk factor levels in patients receiving residential rehabilitation.

Reevaluation of the Cottbus Reinfarction Study with 30 mg aspirin per day 4 years after the end of the study

Four to 6 years after the end of the Cottbus Reinfarction Study with 30, 60 and 1000 mg/day aspirin, the survivors (72% of the patients) were reevaluated under standardized conditions at the district hospital. Nearly all patients (82%) of the former 30 mg group took further on 30 mg aspirin daily whereas of the former 1000 mg group only 20% continued to take doses higher than 500 mg aspirin. Forty-five percent changed to very low doses. Whereas the death rate was nearly the same in all three former dosage groups the total reinfarction rate was higher (22.5%) in the previous 1000 mg group in comparison to the 30 mg group (17.4%, p < 0.05). The non-fatal reinfarction rate was by 50% lower in the former 30 mg group compared with the previous 1000 mg group. In the age group 50–59 a 8.6% non-fatal reinfarction rate is contrasted to 1.7% reinfarctions in patients of the former 30 mg group (p < 0.01). The risk factors were not significantly different in the three groups.

Use of alteplase for myocardial infarction in two community hospitals

A drug-use evaluation (DUE) of i.v. alteplase for the treatment of acute myocardial infarction (AMI) in two community hospitals is described. From November 1987 to June 1989, all 118 patients who were treated with i.v. alteplase for suspected AMI at two large community hospitals were monitored daily to determine patterns of use of alteplase, clinical outcomes, the hospital time needed to diagnose AMI and begin therapy, and the pharmacy time needed to prepare and deliver alteplase. Patient inclusion criteria were (1) chest discomfort of less than six hours' duration and unrelieved by nitroglycerin or nifedepine, (2) age less than 75 years, and (3) electrocardiographic evidence of transmural AMI. Each patient received alteplase 100 mg i.v. and i.v. heparin therapy; 58% of the patients were also given aspirin 81-325 mg/day. The data for the two institutions were combined; there was no control group. The mean +/- S.D. age of patients was 58 +/- 10 years; 75% were men. Treatment began at a mean of 181 +/- 111 min after symptom onset, including the time it took for the 96 patients whose symptoms began outside the hospital to reach the hospital. The mean hospital time required to initiate treatment was 89 +/- 65 min. The mean pharmacy time required to prepare and deliver alteplase was 12 +/- 6 min. The in-hospital mortality rate was 6.4%, the rate of patency of the infarct-related artery was 85% at a mean of seven days in the 95 patients who underwent coronary angiography, and the nonfatal reinfarction rate was 1.8%. Severe bleeding complications occurred in only two patients, and no patient suffered a stroke.(ABSTRACT TRUNCATED AT 250 WORDS)

Identification of patients at low risk of dying after acute myocardial infarction, by simple clinical and submaximal exercise test criteria

A consecutive series of 559 hospital survivors of acute myocardial infarction aged less than 66 years were studied; 93 were designated prospectively as low-risk because they were suitable for early submaximal exercise testing and had none of the following clinical or exercise test 'risk factors': (1) angina for at least one month prior to infarction; (2) symptomatic ventricular arrhythmias, or (3) recurrent ischaemic pain, both after the first 24 h of infarction; (4) cardiac failure; (5) cardiomegaly; and (6) an abnormal exercise test (angina, ST-depression or poor blood pressure response). Altogether 301 patients were exercised; their mortality over a median follow-up of 2.4 years was 10.2%, versus 24.6% in the 258 patients not exercised (P = 0.0005). Absence of clinical 'risk factors' alone, in the exercised patients, identified 156 with a mortality of 5.4% versus 15.6% in the 145 with at least one clinical 'risk factor' (P = 0.004). The fully defined low-risk group comprised 93 of the former patients who had neither clinical nor exercise test 'risk factors'. None of these patients died compared with 19 of those with at least one 'risk factor' (mortality = 14.7%; P = 0.002). Their respective rates of non-fatal reinfarction were similar and never exceeded 5% per annum. Therefore, simple clinical and exercise test criteria can positively identify low-risk patients after infarction in whom secondary prevention may be inappropriate.

Propranolol After Myocardial Infarction

To Editor.— Since November 1981,The Journalhas published two articles that gave partial results of BHAT. The second article (1982;247:1707) made following definite recommendation on duration of treatment after MI: the investigators recommend use of propronolol for at least three years in patients with no contraindications to β-blockade who have had a recent MI. This conclusion came without any formal argument or presentation of supporting data. The implications of this recommendation are important and, therefore, further discussion of basis for this recommendation seems in order. Presumably, a recommendation to use propranolol for three or more years after MI should be based on demonstration that propranolol will reduce mortality or nonfatal reinfarction rates during this entire time interval. Only data for mortality have been published in some detail. Therefore, we examined mortality data in reference to three-year treatment

Hypertension and myocardial infarction

In a representative series of male patients ( n = 504) surviving the hospital stay of a first myocardial infarction the prevalence of hypertension and the influence of hypertension on the prognosis during 2 yr follow-up were studied. According to the definitions used hypertension had been detected before or was detected after myocardial infarction in 36% of the patients. Two thirds had a history of hypertension known before infarction. The systolic and diastolic blood pressures measured at 3 months and 1 yr after infarction increased with age. There was no difference between patients with and without hypertension with respect to a number of different variables recorded during the hospital period, nor in multiple risk according to a logistic function. There was no difference in death rate between the two groups. However, the rate of non-fatal reinfarction was significantly higher among the hypertensive patients. Hypertension remained as a risk factor for after myocardial infarction when the possible confounding influences of serum lipid levels and tobacco smoking were analysed.