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.     

Clinical profile of patients admitted to the coronary care unit with possible myocardial infarction without diagnostic ECG and/or enzyme changes

Concern has been expressed about the cost-effectiveness of the Coronary Care Unit (CCU) and solution options offered on account of the large number of patients admitted to the CCU who turn out not to have acute myocardial infarction. In a prospective study over four years, we studied a group of patients admitted to the CCU with suspected myocardial infarction but who did not have diagnostic ECG and/or enzyme changes for the causes of their chest pain. We compared the clinical profile of these patients (Group A) with that of a random sample of patients with confirmed myocardial infarction (Group B). Gastrointestinal disorders, musculoskeletal chest pain, panic and anxiety disorders were the major causes of chest pain in Group A patients. A normal ECG and a normal creatine phosphokinase (CPK) within the first 24 hours, a normal initial random blood sugar, a younger age and absence of coronary risk factors effectively separated Group A patients as low risk from Group B patients as high risk for acute myocardial infarction. These simple parameters will assist physicians providing CCU care in most hospitals in early decision making and in the judicious use of the CCU.     

Variations in the performance of hip fracture procedures

OBJECTIVE: To determine the cause and frequency of unplanned readmissions to a coronary care unit (CCU) after initial transfer to a general cardiac unit, but before hospital discharge. DESIGN: Analysis of 1776 admissions to a CCU during a 16-month period. SETTING: The CCU of a major teaching hospital in South Australia. PARTICIPANTS: All patients admitted to the CCU during the 16-month period. OUTCOME MEASURES: CCU readmissions before hospital discharge were categorized as either "planned" or "unplanned." The latter were investigated for determination of casualty and variations in patient characteristics (including age, sex, initial diagnosis, pharmacotherapy, and duration of stay in the CCU). RESULTS: Of the 1776 CCU admissions examined, 44 (2.5% of total) were unplanned readmissions before hospital discharge. Most of these (39 of 44) were related to "reactivation" of acute myocardial ischemia. Patients whose initial diagnosis was acute myocardial infarction or unstable angina pectoris were more likely to require a further unplanned CCU admission (p < 0.05); those with unstable angina pectoris had a second stay in CCU significantly longer than their first (p < 0.05). Six patients were readmitted within 6 hours of cessation of a heparin infusion (4 of the 6 without aspirin administration), and 11 patients had not received antiplatelet therapy after their initial CCU stay. Overall, a disproportionate number of men were readmitted to CCU (p < 0.05). CONCLUSIONS: In the current study, unplanned readmissions to the CCU: (1) were relatively infrequent, (2) were more protracted than initial stays in CCU, (3) may have been prevented in 15 of the 44 cases with more appropriate pharmacotherapy, and (4) involved a disproportionate number of male patients.     

Anxiety after a heart attack

An objective measurement of anxiety at defined intervals after the onset of acute cardiac symptoms was made in 203 men admitted to the Coronary Care Unit, Royal Infirmary of Edinburgh, and in 83 patients in a Teesside coronary survey. Of the Teesside patients, 50 were treated at home, 22 were admitted initially to a coronary care unit, and 11 were admitted directly to a general medical ward. In the Edinburgh patients the level of anxiety was high early in the illness, fell rapidly, and rose again towards the end of their stay in hospital. At 4 months it was that of a normal population. After transfer from the coronary care unit the group was not more anxious than other patients in the ward. Reaction to the illness was unrelated to its physical severity. Patients who reacted badly at the beginning were less likely to return to work. The pattern of anxiety in the Teesside patients resembled that of the Edinburgh group, and reaction to illness was largely independent of physical aspects. Treatment in hospital, either through a coronary care unit initially or in a medical ward, did not increase emotional distress. At 3 months patients treated initially in a coronary care unit were less anxious than the others. Throughout the period of study the Teesside patients were more anxious than the Edinburgh patients and outcome was not related to anxiety. Social and environmental differences may account for this.     

Understanding of informed consent by elderly patients

Fifty patients, aged 60 years or more, who had been admitted to a hematology ward for more than 1 month, were studied in regard to their understanding of informed consent. The doctors informed 74% of their patients about the disease for which they were being treated. The rate of informing patients remained low in those with advanced age or with malignant tumors. However, only 42% of the patients realized that they had been informed of their diagnosis and clinical condition. The comprehension rate remained low at 43.2% even in patients who were informed by their doctors. While 60% of patients declared that they understood what the doctors described, only 36% could write something about the name or the state of their disease. Even among the patients who could understand the doctor's explanation, the comprehension rate was 43.3%. Sixty-six percent of patients demonstrated their wish to have a correct explanation of their diagnosis, 36% of patients wanted to be treated according to their own wishes, and 48% of patients left the decisions regarding their treatment to the doctors.     

Diagnostic difficulties of myocardial infarct in an admissions and emergency service: influence of age

OBJECTIVE: To analyze the clinical signs and electrocardiographic and enzyme data in patients admitted to an emergency ward for myocardial infarction in order to highlight diagnostic pitfalls. PATIENTS AND METHODS: All patients admitted to our emergency ward between October 1995 and October 1996 with elevated myoglobulin or creatinine phosphokinase (CPK) levels (n = 457 patients) were included in the study series. Patient files were randomly selected (n = 257 files) for review by an emergency ward specialist and a cardiologist to identify cases of myocardial infarction (n = 88 patients, mean age 73.4 +/- 15.2 years). Clinical, electrical and enzyme data (including CPK-MB) were analyzed. RESULTS: The patients had been referred for chest pain (69%), dyspnea (24%) or another disorder (7%). Pain was located in the retrosternal area in 51%, in the lower chest in 19% and elsewhere in 30%. Delay between onset of pain and transfer to the emergency ward was 5 h 20 min +/- 6 h. Signs of left heart failure were observed in 50% of the patients. The admission electrocardiogram showed complete criteria for myocardial infarction in 43% of the cases, incomplete criteria in 21% and was non-contributive in 36%. Enzyme results were elevated in 78% of the cases at the first assay and in 98.2% at the second assay. Both typical chest pain and ECG were observed in only 30% of the cases. Chest pain was present in 55% of the patients over 75 years of age and in 81% of those under 75 years (p = 0.007). CONCLUSION: A typical syndrome is observed in less than one-third of all patients with myocardial infarction admitted to emergency wards. The frequency of atypical presentations increases with age.     

5993 survivors of suspected myocardial infarction. 10 year incidence of later myocardial infarction and subsequent mortality

AIMS: To evaluate the 10-year incidence of later infarction and subsequent mortality, as well as predictors of later infarction, in patients with suspected myocardial infarction and alive on day 15 after admission. METHODS AND RESULTS: 5993 patients admitted with suspected myocardial infarction and alive on day 15 after admission were registered in The First Danish Verapamil Infarction Trial database in 1979-81. 2586 had definite infarction, 402 probable infarction and 3005 no infarction as they fulfilled 3, 2 and 1 criteria for infarction. They were followed for 10 years with respect to later infarction and death, i.e., including death after later infarction. The 10 year infarction rate after index admission was 48.8% in definite, 47.3% in probable and 24.6% in no infarction patients (P < 0.0001). The subsequent 10-year mortality was 82.3% in primary definite, 74.7% in primary probable, and 77.9% in primary no infarction patients (ns), Cox regression analysis with sex, age group, and definite, probable or no infarction as independent variables showed that females aged < 50 years without a primary infarction had the lowest hazard ratio (0.13 relative to males, aged 50-65 years with definite/probable infarction at index admission) for a later infarction, in contrast to the highest hazard ratio (1.17) for males aged > 65 years with definite or probable infarction. CONCLUSION: The 10-year infarction rate in patients with suspected myocardial infarction in whom the diagnosis is ruled out is lower than in those with definite or probable infarction, but the mortality after a later infarction is similar in all three groups.     

A psychophysiological study of the development of delirium in coronary care units

This is a longitudinal investigation of the psychophysiological mechanism for the development of delirium in coronary care units (CCUs). Ten patients satisfying DSM-III-R diagnostic criteria for delirium (group D) and 10 controls (group C) were drawn from patients admitted to CCU. Electroencephalogram (EEG) and eye movement recordings were observed over the days that patients were admitted to CCU and on a control day of admission and compared for each group and between each day. In the D group, slowing of background EEG activity, particularly on day 2, and many R (rapid) group eye movements and RS type (rapid superimposed on slow) eye movements, particularly on day 3, were observed. That is, from days 2 to 3, EEG findings showed an improvement in consciousness, and eye movement recordings manifested signs of anxiety and tension. These psychophysiological findings can be used to explain the transition from prodromal delirium to obvious delirium, and are supported by clinical features.     

Adverse drug reactions among hospitalized elderly patients. Prospective study

BACKGROUND: It is not clear if old age is a risk factor for adverse drug reactions. AIM: To study the incidence of adverse drug reactions and the effect of age in patients admitted to an Internal Medicine Service in an university hospital. PATIENTS AND METHODS: Two hundred one patients, hospitalized at the Clinical Hospital of the Catholic University, were studied. These patients were followed using a prospective pharmacological surveillance method. For statistical purposes, patients aged 65 years old or older were compared with those younger than 65 years old. RESULTS: Patients over 65 years old had a 33% incidence of adverse drug reactions, mainly involving cardiovascular system and provoking metabolic disturbances. Younger subjects had a 24% incidence of adverse drug reactions, mainly involving the gastrointestinal system and the skin. Sixteen percent of adverse drug reactions were classified as severe and there was a direct relationship between its frequency and the number of drugs prescribed, the hospitalization length and the presence of renal failure. Younger patients with adverse drug reactions had lower serum albumin levels than those without adverse reactions. This relationship was not observed in older patients. CONCLUSIONS: The frequency of adverse drug reactions in hospitalized patients, is related to the number of drugs prescribed and the length of hospitalization.     

Renal transplant in patient older than 65 years of age

OBJECTIVE: To analyze the outcome of renal transplantation in patients more than 65 years old. METHODS: From 1991 to 1997, 83 renal transplants were performed in patients aged over 60 years at our institution; 20 of these patients were more than 65 years old. The control group comprised graft recipients under than age from the 477 cases that had undergone transplantation during the period 1980-1996. Graft donor selection was done according to standard practice. The immunosuppression protocol changed over time; 5 patients received triple therapy and another 15 patients received quadruple sequential immunosuppression therapy. RESULTS: The mean age of the recipients was 66.8 years (range 65-72); 9 patients required dialysis after renal transplantation. Patients aged over 65 years had a 94% survival at 6 months, 88% at 12 months, and 88% at 48 months, whereas the survival rates for the control group were 96%, 95% and 87% for the respective time periods. Graft survival was 95% at one month, 90% at 3 months and 74% at 48 months versus 93%, 87% and 78% for the control group. CONCLUSION: Patients more than 65 years old with chronic renal failure and who are on dialysis can benefit from renal transplantation.     

Women aged 65 or older receiving SSI payments, December 1996

Older women who, even if they do receive Social Security benefits, are still eligible for Supplemental Security Income payments are certainly among the most vulnerable segments of our society. At the end of 1996, there were more than 1.5 million such women aged 65 or older who were receiving SSI payments. It is likely that these women have been poor for much of their lives, as they appear to become eligible for SSI before or close to their 65th birthday. These women represent 23 percent of the SSI caseload, and 8 percent of all women aged 65 or older in the country; almost one-third are aged 80 or older. In addition to the health limitations that accompany increasing age, about a third of these women appear to have been blind or severely disabled for many years, and had been receiving SSI even before they reached age 65. Their SSI payments averaged $237 per month ($137 if they also received Social Security, $394 if they did not). Sixty-three percent of the SSI population who were women aged 65 or older were also getting a Social Security benefit averaging $356 per month, but other than Social Security, they had almost no cash income. A few of these women were institutionalized, and almost 1 out of five reported owning their own home. Approximately half lived alone, and another 20 percent lived with only one other person. Of women aged 65 or older receiving SSI payments, 1 in 5 was not a U.S. citizen, and this group was even less likely to have Social Security benefits, or any other cash income. As a result, their SSI payments were higher. Data are not yet available to judge the impact of the complex series of changes made to SSI eligibility for noncitizens by legislation enacted in 1996 and 1997.     

Class I-restricted cross-presentation of exogenous self-antigens leads to deletion of autoreactive CD8(+) T cells

Intracoronary thrombosis plays a key role in the pathogenesis of acute myocardial infarction (AMI), and the formation of an occlusive thrombus usually precedes the development of myocardial damage. Therefore we evaluated and compared the early sensitivities of thrombin-antithrombin III complex (TAT), D-dimer, myoglobin, creatine kinase (CK) MB mass concentration, and cardiac troponin T (cTnT) on admission to a coronary care unit (CCU) before heparin or thrombolytic therapy was started. We investigated 31 consecutive patients admitted to CCU for evolving AMI within 6 hours from the onset of infarct-related symptoms; the median delay from chest pain onset to CCU admission was 135 minutes. Of all biochemical markers tested TAT had the highest early sensitivity on admission to the CCU, and TAT was significantly more sensitive than cTnT, CKMB mass, myoglobin, and D-dimer. However, TAT increases give no information about the location of clot formation in the body, and the diagnosis of AMI must be subsequently verified by an increase in more cardiac specific proteins, such as troponins or CKMB.     

Application of clinical guidelines in the management of pleural effusion

To analyze compliance with recommendations on the diagnosis and treatment of pleural effusion (PE), we conducted a retrospective study of 60 consecutive patients with PE. Thirty had been treated on the internal medicine ward (IM) and 30 had been cared for in the pneumology unit (P). Twelve variables were studied: 3 reflected the efficacy of medical intervention and 9 were related to diagnostic and therapeutic procedures as recommended by the American Thoracic Society and the American College of Physicians. PE was generally managed in accordance with the aforementioned guidelines. However, a number of unnecessary analytical tests were performed on pleural liquid from the first thoracocentesis. Although IM patients were comparable to P ward patients as to age, sex and concurrent chronic disease, the mean hospital stay was shorter for P ward patients (16 days versus 18 days in the IM ward, p < 0.05), and the percentage for whom an etiological diagnosis had been achieved upon discharge was higher in the P group (56% of P patients versus 26% of IM patients, p < 0.002). More P group patients than IM patients were followed up after discharge (83% versus 40%, respectively; p < 0.001). There were no significant differences in the remaining variables. Within the limitations of any retrospective study, these results allow us to conclude that PE is generally managed in accordance with international guidelines at our hospital and that diagnostic efficacy is greater on the pneumology ward, where mean stay is shorter.     

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.     

Depression of young and elderly patients

OBJECTIVE: To compare the presentation and outcome of depression between young and elderly patients. DESIGN: The clinical presentation, treatment and outcome of 47 young patients (21 to 64 years) were compared with 58 elderly (65 years and older) patients admitted to a general hospital psychiatric ward for the treatment of depressive disorders (based on ICD-10). SUBJECTS: There was no significant difference between the sexes in each age group. The majority of the elderly were either widowed (36%) or married (53%) while 45% of the young were single and 51% married. Seventy per cent of the elderly had retired while 64% of the young were in full-time employment. Most patients lived with their families (87% young and 96% elderly). All but one elderly suffered at least one physical disorder with two-thirds having two or more physical disorders; this contrasts greatly to young patients who were physically healthier (p < 0.001). RESULTS: In clinical presentation and symptomatology, the young patients had significantly more suicide ideation (p < 0.003) and psychomotor retardation (p < 0.001) but there was no difference in suicidal attempt, delusion, hallucination or agitation. More young patients (36%) had a past psychiatric illness (often depressive disorders) than elderly patients (8%) (p < 0.001), more elderly patients (88%) were treated with antidepressants than the young patients (62%) (p < 0.002). At one year follow-up, more elderly patients (46%) recovered compared with the young patients (23%) (p < 0.05). CONCLUSION: There were some differences in the symptomatology of depression between young and elderly patients, but the prognosis was better for elderly patients.     

Familial predisposition for degenerative disc disease. A case-control study

STUDY DESIGN: This case-control study was undertaken to determine if relatives of patients who had been admitted for surgery for degenerative disc disease-related problems were at increased risk for lower back pain or sciatica. OBJECTIVES: To determine if familial factors play a role in placing a person at risk for development of degenerative disc disease of the lumbar spine. SUMMARY OF BACKGROUND DATA: It is known that smoking and various occupational factors can place a person at risk for degenerative disc disease problems. It is not known if a familial predisposition may also exist. METHODS: The family members and relatives of 65 patients who had undergone surgery for lumbar degenerative disc disease were interviewed with a standardized questionnaire and compared with a control group of 67 patients who had been admitted to hospital for non-spine-related orthopedic procedures. The same interview and standardized questionnaire was used for both groups by a single observer. RESULTS: In the study group of 65 patients who had undergone surgery for degenerative disc disease, 44.6% were noted to have a positive family history, whereas 25.4% of the patients in the control group had a positive family history. Eighteen and one-half percent of relatives in the study group had a history of having spinal surgery, compared with only 4.5% of the control group. CONCLUSIONS: The results indicate that a familial predisposition to degenerative disc disease can exist along with other risk factors.     

Recombinant polyketide synthesis in Streptomyces: engineering of improved host strains

OBJECTIVE: Among the high risk groups for complications from influenza and pneumococcal disease, individuals aged 65 and older hospitalized within the previous year represent the group at highest risk. Studies have demonstrated that targeting hospitalized patients aged 65 and older for immunization before hospital discharge can be successful. This study addressed the efficacy of such a program within a managed care organization to immunize this highest risk group. DESIGN: A cross-sectional study. SETTING: Oxford Health Plans, a major managed care organization in New York serving a large Medicare population. PARTICIPANTS: A total of 106 Primary Care Physicians caring for 153 patients aged 65 and older, who were hospitalized in one of 10 high volume hospitals during October and November of 1996. Nine of these facilities were located in New York and one was in New Jersey. INTERVENTION: Patients aged 65 and older admitted to any of the 10 hospitals were identified daily. A fax was sent to each patient's primary care physician explaining the program and requesting that he/she administer influenza and/or pneumococcal vaccine to his/her patient before hospital discharge. Literature references citing past successful programs were included in the fax. MEASUREMENTS: Measurements included medical record documentation of influenza and pneumococcal immunization, both ordered and given, for the individual member before discharge; patient age; sex; and primary and secondary diagnoses. Physicians were sent follow-up questionnaires to determine reasons for not vaccinating. RESULTS: A total of 206 patients were admitted during the eligible time period. One hundred fifty-three hospitalized patients (average age = 74 years) participated. The median length of stay among this study population was 5 days (range, 1-63 days). The distribution of the median length of stay for the 25th and 75th percentiles was 3 and 9 days. The rate for influenza and pneumococcal immunization, both ordered and given, before hospital discharge was 1.96% for the influenza vaccine (n = 3) and .65% for the pneumococcal vaccine (n = 1), respectively. Results of a follow-up survey mailed to all physicians (n = 106) with eligible members in the study indicated that the most frequent reasons for not vaccinating included: patients were vaccinated before admission, patients were not stable enough to be vaccinated before discharge, and the acute care setting is not appropriate for vaccination. Response rate of 58% (n = 61) was achieved with an initial mailing and one follow-up telephone call to all previous nonresponders. Some physician survey responses do not correlate with data obtained from retrospective patients' claims analysis. CONCLUSION: Well-coordinated and timely attempts to encourage primary care physicians to immunize patients 65 years and older before hospital discharge were unsuccessful in our study. Rather than working with physicians, it may be that managed care organizations should work directly with hospitals to implement influenza and pneumococcal immunization programs.     

Arrhythmias in the post CCU phase of myocardial infarction: their correlation with the acute illness

To estimate the frequency of potentially life-threatening arrhythmias in myocardial infarction following transfer from the coronary care unit (CCU) and to identify features of the acute illness which predict such events, 66 patients were monitored on-line by means of a computer assisted system. Premature ventricular contractions (PVCs) were detected following transfer from the CCU in 64 patients (97%). In 29 (44%) they fell in classes 2 to 4 of Lown. Accelerated ventricular rhythm was detected in five and ventricular tachycardia in three. The presence of these rhythm disturbances did not correlate with age, sex, infarct location, the occurrence of previous infarction, the level of serum cardiac enzymes, the presence of heart failure, atrial arrhythmias, heart block, or serious ventricular arrhythmia in the CCU. Use of procaine amide or quinidine for persistent ventricular arrhythmia in the CCU was correlated with detection of class 2, 3 or 4 PVCs. Thus, PVCs are nearly universal in the late phase of hospitalization for myocardial infarction. Frequent and complicated PVCs are common and occur most frequently in individuals in whom such events have been persistent in the CCU.     

The key informant technique

The clinical outcome of 152 patients aged 65 years or over who were referred to the author's institute between August 1990 and August 1991 with certain specified gastrointestinal malignancies and acute, life-threatening abdominal conditions, were audited concurrently. Two groups were considered: patients aged 65-79 years and those over 80 years. The mortality rate within 30 days of surgery was 14 per cent in both age groups, although significantly fewer patients aged over 80 years (35 of 54) were considered suitable for surgery than in the 65-79 years age group (84 of 98) (0.01 > P > 0.001). Morbidity after operation and cost of treatment were not significantly different between the two groups. Two years after surgery 40 per cent of the patients aged over 80 years and 58 per cent of those aged 65-79 years were alive. Quality of life in these survivors was good with 85 per cent of those aged over 80 years living at home and 72 per cent fit enough to undertake light work.