Poor long-term survival after acute myocardial infarction among patients on long-term dialysis

BACKGROUND: Cardiovascular disease is common in patients on long-term dialysis, and it accounts for 44 percent of overall mortality in this group. We undertook a study to assess long-term survival after acute myocardial infarction among patients in the United States who were receiving long-term dialysis. METHODS: Patients on dialysis who were hospitalized during the period from 1977 to 1995 for a first myocardial infarction after the initiation of renal-replacement therapy were retrospectively identified from the U.S. Renal Data System data base. Overall mortality and mortality from cardiac causes (including all in-hospital deaths) were estimated by the life-table method. The effect of independent predictors on survival was examined in a Cox regression model with adjustment for existing illnesses. RESULTS: The overall mortality (+/-SE) after acute myocardial infarction among 34,189 patients on long-term dialysis was 59.3+/-0.3 percent at one year, 73.0+/-0.3 percent at two years, and 89.9+/-0.2 percent at five years. The mortality from cardiac causes was 40.8+/-0.3 percent at one year, 51.8+/-0.3 percent at two years, and 70.2+/-0.4 percent at five years. Patients who were older or had diabetes had higher mortality than patients without these characteristics. Adverse outcomes occurred even in patients who had acute myocardial infarction in 1990 through 1995. Also, the mortality rate after myocardial infarction was considerably higher for patients on long-term dialysis than for renal-transplant recipients. CONCLUSIONS: Patients on dialysis who have acute myocardial infarction have high mortality from cardiac causes and poor long-term survival.     

Diffuse pulmonary hemorrhage after fibrinolytic therapy for acute myocardial infarction

Occurrence of Non Hodgkin's lymphoma (NHL) in pregnancy is very rare. A 24-year-old woman with NHL stage IVB complicating pregnancy is presented. The diagnosis was made by biopsy at 27 weeks. The patient received combination chemotherapy which led to remission of the disease. The baby was delivered by an emergency caesarean section, due to fetal distress at 31 weeks. Unfortunately after a short period of remission a relapse occurred and magnetic resonance imaging (MRI) showed cerebral involvement, indicating a poor prognosis. She died seven months later from disseminated disease.     

Incidence of hibernating myocardium after acute myocardial infarction treated with thrombolysis

OBJECTIVE: To establish the incidence of hibernating myocardium after myocardial infarction treated with thrombolysis and to observe differences in the clinical outcome between patients with and without hibernating tissue. METHODS: 41 patients underwent gated positron emission tomography with 18-fluorodeoxyglucose and 13N-ammonia at a median of eight days after first myocardial infarction. RESULTS: All 41 subjects had a matched perfusion-metabolism deficit in the region of myocardium indicated as the site of infarction by an electrocardiograph; 32 patients (78%) had scans which also showed at least one area of reduced blood flow and contraction with a concomitant increase in glucose uptake, representing hibernating myocardium. Patients were followed up at a median of six months: all 41 were alive and none had sustained a further infarct or cardiac arrhythmia; 17 subjects with hibernating tissue (53.1%) and two without (25%) reported chest pain after myocardial infarction. CONCLUSIONS: Hibernating myocardium is relatively common shortly after myocardial infarction treated with thrombolysis. It does not influence mortality or the incidence of postinfarction chest pain.     

Overview of randomized trials of intravenous heparin in patients with acute myocardial infarction treated with thrombolytic therapy

Intravenous heparin is routinely given after thrombolytic therapy for patients with acute myocardial infarction in the United States and in some, but by no means all, other countries. Several trials have documented improved infarct-artery patency in patients treated with heparin; however, none was large enough individually to assess the effect of heparin on clinical outcomes. We performed a systematic overview of the 6 randomized controlled trials (1,735 patients) to summarize the available data concerning the risks and benefits of intravenous heparin versus no heparin after thrombolytic therapy. Mortality before hospital discharge was 5.1% for patients allocated to intravenous heparin compared with 5.6% for controls (relative risk reduction of 9%, odds ratio 0.91, 95% confidence interval 0.59 to 1.39). Similar rates of recurrent ischemia and reinfarction were observed among those allocated to heparin therapy or control. The rates of total stroke, intracranial hemorrhage, and severe bleeding were similar in patients allocated to heparin; however, the risk of any severity of bleeding was significantly higher (22.7% vs 16.2%; odds ratio 1.55, 95% confidence interval 1.21 to 1.98). There was no significant difference in the observed effects of heparin between patients receiving tissue-type plasminogen activator and those receiving streptokinase or anisoylated plasminogen streptokinase activator complex, or between patients who did and did not receive aspirin. The findings of this overview demonstrate that insufficient clinical outcome data are available to support or to refute the routine use of intravenous heparin therapy after thrombolysis. It is not known if these findings are due to lack of statistical power, inappropriate levels of anticoagulation, or lack of benefit of intravenous heparin. Large randomized studies of heparin (and of new antithrombotic regimens) are needed to establish the role of such therapy.     

Relation between ST-segment changes and myocardial perfusion evaluated by myocardial contrast echocardiography in patients with acute myocardial infarction treated with direct angioplasty

The aim of this study was to evaluate the relation between myocardial perfusion and ST-segment changes in patients with acute myocardial infarction treated with successful direct angioplasty. Thirty-seven patients, successfully treated with direct angioplasty, underwent myocardial contrast echocardiography before and after angioplasty. The sum of ST-segment elevation divided by the number of the leads involved (ST-segment elevation index) was calculated at 1, 5, 10, 20, and 30 minutes after restoration of a Thrombolysis In Myocardial Infarction trial grade 3 flow. After recanalization, myocardial reperfusion within the risk area was observed in 26 patients, whereas a no-reflow phenomenon occurred in 11. In patients with myocardial reperfusion, the ST-segment elevation index progressively declined, whereas in patients with no reflow, no significant change was observed. Reduction of > or = 50% in the ST-segment elevation index occurred in 20 of the 26 patients with reflow and in 1 of the 11 with no reflow (p = 0.0002). An additional increase of > or = 30% in the ST-segment elevation index occurred in 3 patients with reflow and in 7 with no reflow (p = 0.003). Sensitivity, specificity, positive and negative predictive values, and accuracy of the reduction in the ST-segment elevation index for predicting microvascular reflow were 77%, 91%, 95%, 62%, and 81%, respectively. The corresponding values of the increase in ST-segment elevation index for predicting no reflow were 64%, 88%, 70%, 85%, and 81%, respectively. In conclusion, after successful angioplasty, different patterns of myocardial perfusion are associated with different ST-segment changes. Analysis of ST-segment changes predicts the degree of myocardial reperfusion.     

Soluble thrombomodulin antigen in plasma is increased in patients with acute myocardial infarction treated with thrombolytic therapy

This study examined school personnel smokers' reports regarding how they would feel if a no-smoking ban was instituted on school premises. Demographics, smoking history, interest in quitting, and perception of school staff as role models for student smoking behaviors were examined as concurrent predictors of personnel attitudes toward a school-wide no-smoking policy. Generally, the fifty-nine respondents, sampled from fourteen schools, were interested in quitting smoking, but they did not favor a policy prohibiting smoking on campus. A staff role model index was a significant predictor of support for a no-smoking policy; the stronger the belief that staff influence their students' smoking, the greater the desire for a smoking ban at school. Compliance by school staff to future regulations that schools become smokefree environments may be improved if staff believe or are taught that they can directly affect students' smoking behaviors.     

Are coronary-care unit changes in therapy associated with improved survival of elderly patients with acute myocardial infarction?

OBJECTIVE: To determine whether changes in coronary-care unit therapy for elderly patients with acute myocardial infarction have been associated with improved survival. MATERIAL AND METHODS: We conducted a retrospective cohort analysis of all patients 70 years of age or older from Olmsted County, Minnesota, who were hospitalized in a coronary-care unit in this county for the treatment of acute myocardial infarction during one of three periods: 1976 through 1978, 1987 through 1989, and 1991. The effect of aspirin, heparin, beta-blockers, thrombolysis, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting on these elderly patients with acute myocardial infarction was assessed. RESULTS: Improvement in 30-day survival was significant for patients 80 years of age or older (45%, 69%, and 78% in 1976 through 1978, 1987 through 1989, and 1991, respectively; P = 0.01 for the trend) but not for patients 70 to 79 years of age (77%, 76%, and 81% for the three time periods, respectively; P = 0.65 for the trend). The opposite pattern was observed for survival in the period more than 30 days after the event. More intensive treatment in the hospital was associated with better 30-day survival (P < 0.0001). CONCLUSION: The improved survival of the elderly patients with acute myocardial infarction in these cohorts can be accounted for by changes in the therapy they received in the coronary-care units.     

One-year outcomes of diabetic versus nondiabetic patients with non-Q-wave acute myocardial infarction treated with percutaneous transluminal coronary angioplasty

Risk factors and outcomes associated with non-Q-wave myocardial infarction (MI) in diabetics and nondiabetics were analyzed for 376 consecutive patients, 77 with diabetes (20%) and 299 nondiabetics (80%), who had non-Q-wave MI and had percutaneous transluminal coronary angioplasty (PTCA) performed before discharge from hospital during the period from January 1992 to February 1996. Diabetics were slightly older (64 +/- 10 years vs 61 +/- 12 years, p <0.053), had more prior coronary artery bypass grafting (CABG) surgery (27% vs 12%, p <0.001), and hypertension (77% vs 49%, p <0.001). There was no significant difference in unstable angina, saphenous vein graft PTCA, single versus multiple vessel disease, or history of MI. PTCA success rates for diabetics versus nondiabetics were similar (96% vs 97%, p = NS). In-hospital complications such CABG, recurrent MI, repeat PTCA, stroke, and death were not statistically significant between the 2 groups. At 1-year follow-up, survival in diabetics (92%) was similar to nondiabetics (94%, p = NS), although event-free survival (PTCA, CABG, MI, death) was worse in diabetics (55% vs 67% for nondiabetics, p <0.05). Although diabetic patients with non-Q-wave MI represent a cohort with more risk factors for poor outcome, aggressive in-hospital revascularization with PTCA results in an excellent short-term outcome as well as 1-year survival similar to the nondiabetic patients. However, total events at 1-year follow-up are more common in the diabetic patients, suggesting that more aggressive screening and therapy in follow-up may be warranted, and that a diabetic with non-Q-wave MI will require increased utilization of cardiovascular resources in the first year after the event.     

In-hospital and follow-up mortality of patients with acute myocardial infarction

Patients with definite acute MI who were admitted to Songkla University Hospital between 1982 and 1990 were studied. The 195 patients and 202 admissions were nearly equally distributed between these 65 and older versus those younger than 65. Three quarters were males. The in-hospital mortality was 19.5 per cent and 76.3 per cent of the deaths were from heart failure. Neither age nor gender determined the mortality once corrected for the Killip's staging. There was no difference in mortality when comparing Q versus non-Q MI, anterior versus inferior wall MI or males versus females. One hundred and thirty-eight patients could be followed for and average of 27.1 months. First year mortality was 11 per cent and the first 2 years was 14 per cent. The in-hospital mortality, representing the prethrombolytic era, appeared to be similar to values reported from the Thai and Western literature. The predominance of death from heart failure rather than from arrhythmia may be a consequence of delayed admission whence arrhythmic death had already occurred or patients will seek hospital advice only if highly symptomatic.     

太极拳锻练对急性心肌梗塞患者的康复作用

目的:探讨长期太极拳锻练对急性心肌梗塞患者的康复作用.方法:将符合入选标准的心肌梗塞患者132例,随机分为对照组(66例)和太极拳锻练康复组(康复组,66例),对照组给予标准心肌梗塞常规药物治疗,康复组在常规药物治疗的基础上进行太极拳康复锻练,为期一年.两组患者于入组时及观察/康复一年期满时分别测试生活质量评分、6min步行距离(6MWT)、左室射血分数(LVEF),并对两组患者在试验期间的心律失常发生率、心绞痛发生率、心肌再梗塞发生率进行了比较.结果:与对照组比较,康复组在生活质量、6min步行距离、左室射血分数方面均有明显提高(P＜0.01),而心律失常发生率、心绞痛发生率、心肌梗塞再发生率明显低于对照组(P＜0.05).结论:太极拳锻练能有效改善心功能,改善心肌代谢,促进心肌梗塞患者的康复.     

Dipyridamole thallium-201 imaging very early after uncomplicated acute myocardial infarction in patients treated with thrombolytic therapy

The aim of this study was to assess the safety and prognostic value of dipyridamole 201T1 imaging very early after acute myocardial infarction in patients treated with thrombolytic therapy. Fifty-two consecutive patients with an uncomplicated clinical course underwent quantitative planar dipyridamole 201T1 imaging 2 5 days after acute myocardial infarction. The patients were followed for 14 +/- 7 months after discharge. No major complications occurred during the test. Of the 30 patients with redistribution, five (16.6%) developed in-hospital unstable angina as against none of the 22 patients without redistribution. During follow-up, a total of live late cardiac events were observed: two deaths and two cases of unstable angina in the group with reversible defects and one reinfarction in the group with fixed defects. The 1-year actuarial probability of being free of cardiac events was, respectively, 66 +/- 10% and 94 +/- 5% in the patients with and without redistribution (P < 0.01). In conclusion, in patients treated with thrombolysis, dipyridamole-201T1 imaging very early after uncomplicated acute myocardial infarction is a feasible and safe test. Patients with fixed defects appear to be at low risk and may be candidates for early discharge; the presence of redistribution identifies a subgroup of patients who may benefit from further careful clinical evaluation.     

Use of thrombolytic agents and other drugs in acute myocardial infarction

Data on all patients with acute myocardial infarction who were treated in the ten hospitals in Health region 1 in Norway were extensively analysed over a two month period. Of all the 487 patients 32% received thrombolytic treatment; i.e 36% of those with definite or suspected myocardial infarction on admission. Thrombolytics were withheld, mainly because only 58% of the patients showed ST elevation or bundle branch block on their ECG, and because of a long delay from onset of symptoms to admission to hospital. With increasing age use of thrombolytics decreased, and high age seemed to some degree to act as a contraindication. Relative contraindications such as history of stroke or peptic ulcer contributed modestly to the limited use of thrombolytics. Aspirin was used by 72% of the patients, and either aspirin or anticoagulants in 87%. At six month follow-up 50% used aspirin and 32% warfarin. Betablockers were given to 57% of the patients in hospital, but were not used to any extent in the acute phase of the disease; at six months the proportion of patients on betablockers was about the same. Oral nitrates were used more extensively than betablockers and there is a clear indication that angiotensin converting enzyme inhibitors are used increasingly for secondary prevention.     

Influence of nighttime blood pressure on left atrial size in uncomplicated arterial systemic hypertension

Little information is available on the relationship between occupational exposure to inorganic arsenic in coal fly ash and urinary excretion of arsenic metabolites. This study ws undertaken in a coal-fired power plant in Slovakia during a routine maintenance outage. Arsenic was measured in the breathing zone of workers during 5 consecutive workdays, and urine samples were obtained for analysis of arsenic metabolites--inorganic arsenic (Asi), monomethylarsonic acid (MMA), and dimethylarsinic acid (DMA)--prior to the start of each shift. Results from a small number of cascade impactor air samples indicated that approximately 90% of total particle mass and arsenic was present in particle size fractions >/= 3.5 micron. The 8-hr time-weighted average (TWA) mean arsenic air concentration was 48.3 microg/m3 (range 0.17-375.2) and the mean sum of urinary arsenic (SigmaAs) metabolites was 16.9 microg As/g creatinine (range 2.6-50.8). For an 8-hr TWA of 10 microg/m3 arsenic from coal fly ash, the predicted mean concentration of the SigmaAs urinary metabolites was 13.2 microg As/G creatinine [95% confidence interval (CI), 10.1-16.3). Comparisons with previously published studies of exposure to arsenic trioxide vapors and dusts in copper smelters suggest that bioavailability of arsenic from airborne coal fly ash (as indicated by urinary excretion) is about one-third that seen in smelters and similar settings. Arsenic compound characteristics, matrix composition, and particle size distribution probably play major roles in determining actual uptake of airborne arsenic.     

Influence of a history of arterial hypertension and pretreatment blood pressure on the effect of angiotensin converting enzyme inhibition after acute myocardial infarction. Trandolapril Cardiac Evaluation Study

OBJECTIVE: To evaluate the influence of a history of arterial hypertension and the level of pretreatment blood pressure on the efficacy of the angiotensin converting enzyme (ACE) inhibitor trandolapril on mortality and morbidity in patients with acute myocardial infarction (AMI) and left ventricular dysfunction. METHODS: Data from the Trandolapril Cardiac Event study, in which 1749 patients with an enzyme verified AMI and echocardiographic evidence of left ventricular dysfunction were randomized in a double-blind manner to treatment with trandolapril or placebo, were retrospectively analysed. Follow up time was 24-50 months (mean 26 months). RESULTS: Four hundred patients (23%) had a history of arterial hypertension. A total of 173 (43%) patients with a history of hypertension died during follow up versus 500 (37%) patients in the normotensive group. Treatment with trandolapril in the hypertensive individuals was associated with a reduction in the relative risk of death to 0.59 (95% confidence interval 0.44-0.80), versus 0.85 (0.72-1.02) in the normotensive individuals. The significant reduction in mortality in hypertensive individuals persisted after multivariate analysis controlling for a broad spectrum of potential confounders. Also, benefit from ACE inhibition increased with increasing blood pressure at the time of randomization. Significant interactions between benefit from ACE inhibition and hypertension history, and systolic and diastolic blood pressure were found. CONCLUSION: ACE inhibition after AMI complicated by left ventricular dysfunction may be of particular importance in patients with a history of arterial hypertension or a relatively high pretreatment blood pressure. However, further investigations are necessary to establish the clinical impact of these results.     

Withholding thrombolysis in patients with diabetes mellitus and acute myocardial infarction

The benefits of thrombolytic therapy in a patient with diabetes having a myocardial infarction are now well accepted but this treatment may be withheld inappropriately because of concerns about retinal haemorrhage. We therefore examined whether junior doctors alter their use of thrombolysis for the treatment of acute myocardial infarctions according to the type of diabetic retinopathy present. A questionnaire asking whether thrombolysis would be given to a 50-year-old male smoker with insulin-treated diabetes and an acute anterior MI was shown, with four unlabelled retinal photographs, to all doctors prescribing thrombolytic therapy in a south London teaching hospital and an affiliated district general hospital. In all, 24 medical SHOs, 16 medical registrars/specialist registrars, 3 medical senior registrars, and 23 casualty SHOs were interviewed. Of these 89% would thrombolyse such a patient with normal fundi, 55% with background diabetic retinopathy, 54 % if this also involved the macula, and 26% if they saw proliferative retinopathy. The more senior grades were more aggressive in their approach. As we believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis irrespective of their retinal appearance these results suggest thrombolytic therapy is being withheld inappropriately.     

Influence of residual antegrade coronary blood flow on the long-term prognosis of medically treated patients with myocardial infarction and single-vessel disease

This is a review article concerning an influence of trematodes infections on a defence system of snails. Changes in: snails' plasma composition, a number of hemocytes, size of a hemopoietic organ, molecules secreted by hemocytes and defence cells activities caused by the infections are discussed in detail. The differences in humoral and cellular response between susceptible and resistant strains of snails as well as between young and old snails are also presented in the article. Finally, the problem of an existence of the specific immunological memory in snails is analyzed.