Delay and hospitalisation with acute myocardial infarction

We examined patient behaviour and the components of delay to hospitalisation in 149 consecutive cases of proven acute myocardial infarction (AMI) prospectively. The median total delay from onset of chest pain to hospitalisation was 210 mns (range 5 mns to 7 days). The median delay before seeking medical help was 105 mns. Seventy-eight patients (52%) contacted a G.P. Median delay to G.P. contact was 15 mns. The median delay in transportation to hospital was 20 mns. There was no evident diurnal variation in the onset of symptoms. There was no significant differences in help seeking delay between the sexes, between young and old or between those with a previous history of ischaemic heart disease similar to studies in the U.S. and U.K. Patient delay to seeking help remains the major and most crucial component of delay in treating AMI.     

Determinants of decisions to seek medical treatment by patients with acute myocardial infarction symptoms.

Among 43 myocardial infarction patients (mean age 53.4 yrs), Ss who delayed between noting initial symptoms and deciding they were ill were those who reported that they characteristically exhibited some Type A behaviors, experienced little initial pain at a time when work was quite demanding, responded to their symptoms with depression and fatigue, and were currently quite pessimistic about their health. Those who delayed between deciding they were ill and seeking treatment were those who were assessed as Type B on the structured interview and who talked to others to assess the meaning of their symptoms. (38 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A decision tree for the early diagnosis of acute myocardial infarction in nontraumatic chest pain patients at hospital admission

STUDY OBJECTIVE: To find an accurate algorithm for the diagnosis of acute myocardial infarction in nontraumatic chest pain patients on presentation to the emergency department. DESIGN: In a prospective clinical study, we compared the diagnostic performances of clinical symptoms, presenting ECG, creatinine kinase, creatine kinase MB activity and mass concentration, myoglobin, and cardiac troponin T test results of hospital admission blood samples. By classification and regression trees, a decision tree for the diagnosis of acute myocardial infarction was developed. SETTING: Emergency room of a Department of Internal Medicine (University Hospital). PATIENTS: One hundred fourteen nontraumatic chest pain patients (median delay from onset of chest pain to hospital admission, 3 h; range, 0.33 to 22): 26 Q-wave and 19 non-Q-wave myocardial infarctions, 49 patients with unstable angina pectoris, and 20 patients with chest pain caused by other diseases. MEASUREMENTS AND RESULTS: Of each parameter taken by itself, the ECG was tendentiously most informative (areas under receiver operating characteristic plots: 0.87 +/- 0.04 [ECG], 0.80 +/- 0.08 [myoglobin], 0.80 +/- 0.04 [creatine kinase MB mass], 0.77 +/- 0.04 [creatine kinase activity], 0.69 +/- 0.06 [clinical symptoms] 0.67 +/- 0.06 [creatine kinase MB activity], 0.67 +/- 0.05 [troponin T]). In patients presenting 3 h or less after the onset of chest pain, ECG signs of acute transmural myocardial ischemia were the best discriminator between patients with and without myocardial infarction. In patients presenting more than 3 h, however, creatine kinase MB mass concentrations (discriminator value, 6.7 micrograms/L) were superior to the ECG, clinical symptoms, and all other biochemical markers tested. This algorithm for diagnosing acute myocardial infarction was superior to each parameter by itself and was characterized by 0.91 sensitivity, a 0.90 specificity, a 0.90 positive and negative predictive value, and a 0.90 efficiency. CONCLUSIONS: We found an algorithm that could accurately separate the myocardial infarction patients from the others on admission to the emergency department. Therefore, this classifier could be a valuable diagnostic aid for rapid confirmation of a suspected myocardial infarction.     

A two-year retrospective study of patients with acute myocardial infarction in a Norwegian county hospital

The article describes a follow-up study extending over a period of two years (1992-93) of patients admitted with a diagnosis of acute myocardial infarction to a Norwegian district hospital. The mortality was 13.8%. In Norway, treatment of acute myocardial infarction is generally standardized, with only minor variations between hospitals. This follow-up illustrates that patients with uncomplicated acute myocardial infarction who do not require emergency surgical intervention can be safely treated in a district hospital.     

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.     

Hospital mortality in acute myocardial infarction: is it possible to predict using admission data?

We described the development and psychometric properties of the Community Living Attitudes Scale, Mental Retardation Form (CLAS-MR), a 40-item measure based on the input of self-advocates and focused on contemporary community living philosophies. The CLAS-MR, which consists of four subscales that tap attitudes about people with mental retardation, demonstrated acceptable internal consistency, retest reliability, and construct validity with samples of 104 college students and 283 community members. Using data from a sample of 355 staff members from community agencies, we confirmed the factor structure of the measure. Given the importance of attitudes toward persons with mental retardation in policy making and community inclusion, the CLAS-MR can help chronicle the diffusion of the new paradigm of empowered community living for persons with mental retardation.     

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.     

Direct admission to the coronary care unit by the ambulance service for patients with suspected myocardial infarction

BACKGROUND: Direct access to the coronary care unit (CCU) for general practitioner (GP) referred cases of suspected acute myocardial infarction (AMI) (fast track admission) substantially reduces the time to thrombolysis. Until now, this policy has been confined to GP referrals. OBJECTIVES: To determine the time taken to admission to CCU under the fast track policy (ambulance referrals and GP referrals) and the time taken to start administration of thrombolytics (ambulance referrals, GP referrals, and accident and emergency referrals). METHODS: Fast track admission policy was extended to include referrals from ambulance personnel who respond to emergency service calls. Ambulance personnel referred cases were also examined to see if they were referred appropriately to the CCU. RESULTS: 100 ambulance personnel referrals and 260 GP referrals to CCU with chest pain were studied. Forty accident and emergency referrals who had AMI requiring thrombolysis were also studied. In the ambulance referred group the time to admission from phone call was a median of 10 minutes (range 2 to 45), a saving of 30 minutes compared with GP referrals (median 40 minutes, range 2 to 217). The median diagnostic electrocardiogram (ECG) to thrombolysis time was longer in the accident and emergency referrals with AMI than either ambulance referrals or GP referrals admitted under the fast track policy. Diagnostic ECG to thrombolysis time: accident and emergency 50 minutes (range 15 to 385); ambulance referrals median 33 minutes (range 6 to 69); GP referrals median 29.5 minutes (range 5 to 110 minutes); (p = 0.056 accident and emergency compared with ambulance referrals, p < 0.002 accident and emergency compared with GP referrals). Of 100 ambulance referrals 52 patients exhibited symptoms suggestive of ischaemic heart disease (confirmed AMI, unstable angina, and angina) and a further 18 patients were required to stay in CCU for other cardiac problems. Thus a total of 70 (70%) were considered appropriate compared with 155 of 260 (55.8%) GP referred cases. CONCLUSIONS: Extending the fast track admission policy to ambulance personnel reduces delay to admission for patients with suspected MI without adversely affecting the appropriateness of admissions.     

Falling hospital mortality for acute myocardial infarction in Quebec hospitals

OBJECTIVE: To present in-hospital mortality trends for acute myocardial infarction (AMI). DESIGN: Observational study using the Quebec administrative hospital database, which records all hospitalizations for AMI, for the period 1986 to 1996. RESULTS: From 1986 to 1996, the case fatality rate for AMI decreased from 18.4% to 12.7% despite an increase in the total number of admissions, due to an ageing population. Men and women have had similar yearly mortality reductions--7.6% versus 7.4%, respectively--although the absolute case fatality rate remains significantly higher for women. The mortality reduction for men was constant over the decade, while the decline for women was more pronounced over the last five years. Improving case fatality rates were also observed in the elderly and again were most evident from 1991 to 1996. CONCLUSIONS: These data show a sharp decline in case fatality rates for AMI patients treated in Quebec hospitals from 1986 to 1996, suggesting that treatment advances observed in clinical trials are being applied at a population level. While improved survival has been observed in all patient groups, the data suggest that the part of the decline in mortality may be due to increased penetration of proven treatment strategies in women and the elderly.     

Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians

BACKGROUND: Both cardiologists and generalist physicians care for patients with acute myocardial infarction, but little is known about their patients' characteristics, treatments, and outcomes. METHODS: We identified attending and consulting physicians, patient characteristics, drugs, procedures, and mortality from clinical and administrative records of 1620 Medicare beneficiaries aged 65 to 79 years who were treated for acute myocardial infarction at 285 hospitals in Texas during 1990. RESULTS: Patients treated by attending cardiologists were younger, had prior congestive heart failure less frequently, and were initially treated in hospitals offering coronary angioplasty or bypass surgery more often than patients treated by attending generalist physicians (for each, P<.004). Adjusting for patient and hospital characteristics, cardiologists were more likely than generalist physicians to prescribe thrombolytic therapy and aspirin (P<.05) but not beta-adrenergic blocking agents (beta-blockers). Cardiologists used coronary angiography and angioplasty more often (P<.003), but not echocardiography or exercise testing. Adjusted 1-year mortality did not differ significantly between patients of attending cardiologists and generalist physicians (odds ratio, 1.01; 95% confidence interval, 0.76-1.35) or between patients of generalist physicians with and without a consulting cardiologist (odds ratio, 0.83; 95% confidence interval, 0.60-1.16). However, patients initially admitted to hospitals offering coronary angioplasty and bypass surgery had lower adjusted 1-year mortality than patients admitted to other hospitals (odds ratio, 0.68; 95% confidence interval, 0.47-0.98). CONCLUSIONS: Compared with generalist physicians, cardiologists used some, but not all, effective drugs more frequently, as well as coronary angiography and angioplasty. Although these differences were not associated with lower adjusted mortality among cardiologists' patients, cardiologists were more likely to treat patients in hospitals with better outcomes. Future studies should identify organizational factors that improve outcomes of myocardial infarction.     

Can ECG changes predict the long-term outcome in patients admitted to hospital for suspected acute myocardial infarction?

SETTING: The activity of KRM 1648 (KRM), a new benzoxazinorifamycin, and rifabutin (RBT), alone or in combination with clarithromycin (CLA), was evaluated against Mycobacterium avium complex (MAC) that multiplied in human alveolar macrophages (AM). DESIGN: AM were recovered by bronchoalveolar lavage, incubated in RPMI 1640 medium with 10% human AB serum, infected with four strains of MAC (of non-acquired immune deficiency syndrome [AIDS] origin), and then treated with each drug alone or in combination. After incubation for 7 days, colony forming units in each well were counted on 7H10 agar. RESULTS: Although concentrations between 0.2 microgram/ml and 20 micrograms/ml of both rifamycins showed clear dose-dependent activities against all MAC strains tested, only 20 micrograms/ml of each drug had modest bactericidal effect. In combination with 2.0 micrograms/ml of CLA, however, 0.2 microgram/ml of both drugs caused a bactericidal response against two of the four MAC strains examined. CONCLUSION: According to this human alveolar macrophage model of MAC infection, KRM and RBT in combination with CLA was found to be a promising candidate against human pulmonary MAC infection, and deserves clinical evaluation.     

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.     

Varying thrombolytic administration rates in elderly patients with acute myocardial infarction

Receipt of thrombolytic therapy in patients aged 75 or over with proven acute myocardial infarction admitted initially to either the coronary care unit (CCU) or a geriatric medical ward (GMW) was studied retrospectively in a hospital administering thrombolysis only in the CCU. Mean age and age distribution of patients admitted to each unit initially showed no significant difference. Of 50 patients admitted directly to the CCU, 28 (56%) received thrombolysis, compared with 13 of 50 (26%) GMW admissions (P < 0.02). Of 37 GMW admissions, 14 (38%) failed to receive thrombolysis without documented contraindication compared with 2 of 22 (9%) CCU admissions (P < 0.05). Aspirin was administered in 39 (78%) CCU and 31 (62%) GMW admissions (P < 0.05). Non-administration of aspirin without apparent contraindication occurred in 3 of 11 (27%) compared with 8 of 19 (42%) GMW admissions (NS). Elderly patients thus failed to receive thrombolytic therapy as a result of initial admission to a unit unable to administer this treatment.     

Treatment with ramipril improves systolic function even in patients with mild systolic dysfunction and symptoms of heart failure after acute myocardial infarction

BACKGROUND: Clinical signs of heart failure such as pulmonary rales and dyspnea, ventricular dysfunction, and ventricular arrhythmia are independent predictors of a poor prognosis after acute myocardial infarction (AMI). HYPOTHESIS: The study aimed to assess the effect of ramipril treatment on mildly depressed left ventricular (LV) systolic function, assessed by atrioventricular (AV) plane displacement in patients with congestive heart failure after AMI. METHODS: The study was a substudy in the Acute Infarction Ramipril Efficacy Study, a double-blind, randomized, place-bo-controlled trial of ramipril versus placebo in patients with symptoms of heart failure after AMI. In all, 56 patients were included in the main study, 4 refused to participate in the substudy, and 4 were excluded for logistical reasons. Echocardiography was performed at entry and after 6 months. Patients who underwent coronary artery bypass grafting during the follow-up period were excluded. RESULTS: At baseline, the patients had modest LV dysfunction, and mean AV plane displacement of 9.7 mm. During follow-up, AV plane displacement increased in ramipril-treated patients from 9.5 to 10.9 mm (p < 0.01). No statistically significant changes were seen in the placebo group. CONCLUSIONS: Ramipril improves LV systolic function in patients with clinical signs of heart failure and only modest systolic dysfunction after AMI. Measurement of AV plane displacement is a simple and reproducible method for detection of small changes in systolic function and may be used instead of ejection fraction in patients with poor image quality.     

A paradigm shift for acute myocardial infarction: from coronary patency to myocardial reperfusion

OBJECTIVE: To evaluate the safety and efficacy of amitriptyline hydrochloride in the treatment of severe recurrent idiopathic cystitis (IC) in cats. DESIGN: Prospective study. ANIMALS: 15 cats with IC that failed to respond to other treatments. PROCEDURE: Each cat received 10 mg of amitriptyline, PO, every 24 hours in the evening for 12 months or until signs recurred. Urinalysis, CBC, serum biochemical analysis, urine bacteriologic culture, and cystoscopy were performed initially, and after 6 and 12 months in responders. Severity scores of owner-observed signs of lower urinary tract (bladder and urethra) disease were recorded. RESULTS: During the first 6 months of treatment, 11 of the 15 cats had no owner-observed signs of lower urinary tract disease. During the next 6 months, 9 of 15 cats remained free of signs of cystitis. Despite clinical improvement, cystoscopic abnormalities persisted in all cats at the 6- and 12-month evaluations. Hematuria and proteinuria were decreased at the 12-month evaluation compared with the initial evaluation. Two of 15 cats initially appeared somnolent after amitriptyline treatment. Of 9 cats completing the study, 7 had increased body weight and 8 had decreased coat quality compared with the initial evaluations. Four cats developed small cystic calculi during the first 6 months of the study. Serum biochemical or hematologic abnormalities were not detected during the study. CLINICAL IMPLICATIONS: Amitriptyline treatment successfully decreased clinical signs of severe recurrent IC in 9 of 15 cats treated. Somnolence, weight gain, decreased grooming, and transient cystic calculi were observed during treatment in some cats.     

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.     

Clinical implications of left ventricular function in patients with acute myocardial infarction

Correlation of left ventricular filling pressure (55 patients) with the left ventricular stroke work index (61 patients) provided a rapid means of objectively determining ventricular performance after myocardial infarction. Pressure was monitored by means of the Swan-Ganz balloon-tipped catheter and thermal indicators were used for measuring cardiac output. A hemodynamic grouping of these myocardial infarction patients on the basis of the stroke work index showed close correlation with morbidity and mortality and provided a more accurate prognostic indicator than did the commonly used clinical predictors. Serial assessment of ventricular function further aided in defining the prognosis when it was not clear on admission. Thus, the levels of normal or abnormal ventricular function and the effect of therapeutic measures can be rapidly evaluated by determining the pressures and flows in patients with acute myocardial infarction.