Myocardial infarction in young men. Study of risk factors in nine countries.

In order to determine whether the development of myocardial infarction in different countries is associated with different risk factors, 240 male survivors, aged 40 or less, were studied in nine countries. In the seven centres in developed countries (Auckland, Melbourne, Los Angles/Atlanta, Cape Town, Tel Avic, Heidelberg, and Edinburgh) there was a high procedure of risk factors, particularly of hyperlipidaemia and cigarette smoking. The prevalence of hypertension, obesity, hyperglycaemia, and hyperuricaemia varied from centre to centre. Risk factors were less prevalent in Bombay and Singapore: the most common risks operating in Bombay seemed to be cigarette smoking and hyperglycaemia, while in Singpore cigarette smoking was the commonest. The mean age of the whole group was 35.4 years. Serum cholesterol levels of 7.25 mmol/l (280 mg/dl) or more were present in 25 per cent of all patients, serum triglyceride levels of 2.26 mmol/l )l200 mg/dl) or more in 35 per cent. 80 per cent of the patients were smokers, and 15 per cent were either for hypertension before myocardial infarction or had a raised blood pressure after myocardial infarction. Obesity was found in 19 per cent of all patients and serum uric acid levels over 0.5 mmol/l (8.5 mg/dl) in 17 per cent. 10 per cent of all patients were either treated for diabetes mellitus before myocardial infarction or showed an abnormal glucose tolerance after myocardial infarction. This collaborative study may help, by showing differences in the prevalence of risk factors, to indicate to each centre and to national and to international organizations, the direction for their future studies into the causation and prevention of myocardial infarction in young men.     

HDL, HDL2, and HDL3 subfractions, and the risk of acute myocardial infarction. A prospective population study in eastern Finnish men

BACKGROUND. We investigated the association of cholesterol concentrations in serum high density lipoprotein (HDL) and its subfractions HDL2 and HDL3 with the risk of acute myocardial infarction in 1,799 randomly selected men 42, 48, 54, or 60 years old. METHODS AND RESULTS. Baseline examinations in the Kuopio Ischaemic Heart Disease Risk Factor Study were done during 1984-1987. In Cox multivariate survival models adjusted for age and examination year, serum HDL cholesterol of less than 1.09 mmol/l (42 mg/dl) was associated with a 3.3-fold risk of acute myocardial infarction (95% confidence intervals [CI], 1.7-6.4), serum HDL2, cholesterol of less than 0.65 mmol/l (25 mg/dl) was associated with a 4.0-fold risk of acute myocardial infarction (95% CI, 1.9-8.3), and serum HDL3 cholesterol of less than 0.40 mmol/l (15 mg/dl) was associated with a 2.0-fold (95% CI, 1.1-4.0) risk of acute myocardial infarction. Adjustments for obesity, ischemic heart disease, other cardiovascular disease, maximal oxygen uptake, systolic blood pressure, antihypertensive medication, serum low density lipoprotein cholesterol, and triglyceride concentrations reduced the excess risks associated with serum HDL, HDL2, and HDL3 cholesterol in the lowest quartiles by 52%, 48%, and 41%, respectively. Additional adjustments for alcohol consumption, cigarettes smoked daily, smoking years, and leisure time energy expenditure reduced these excess risks associated with low HDL, HDL2, and HDL3 cholesterol levels by another 26%, 24% and 21%, respectively. CONCLUSIONS. Our data confirm that both total HDL and HDL2 levels have inverse associations with the risk of acute myocardial infarction and may thus be protective factors in ischemic heart disease, whereas the role of HDL3 remains equivocal.     

Incidence of new atherothrombotic brain infarction in older persons with prior myocardial infarction and serum low-density lipoprotein cholesterol >or=125 mg/dl treated with statins versus no lipid-lowering drug

BACKGROUND: We report the incidence of new atherothrombotic brain infarction (ABI) in older men and women with prior myocardial infarction and a serum low-density lipoprotein (LDL) cholesterol of >or=125 mg/dl treated with statins and with no lipid-lowering drug. METHODS: The incidence of new ABI was investigated in an observational prospective study of 1410 men and women, mean age 81 +/- 9 years, with prior myocardial infarction and a serum LDL cholesterol of >or=125 mg/dl treated with statins (679 persons or 48%) and with no lipid-lowering drug (731 persons or 52%). Follow-up was 36 +/- 21 months. RESULTS: At follow-up, the stepwise Cox regression model showed that significant independent predictors of new ABI were age (risk ratio = 1.04 for a 1-year increase in age), cigarette smoking (risk ratio = 3.5), hypertension (risk ratio = 3.1), diabetes mellitus (risk ratio = 2.3), initial serum LDL cholesterol (risk ratio = 1.01 for each 1 mg/dl increase), initial serum high-density lipoprotein cholesterol (risk ratio = 0.97 for each 1 mg/dl increase), prior stroke (risk ratio = 2.5), and use of statins (risk ratio = 0.40). The Cochran-Armitage test showed a trend in the reduction of new ABI in persons treated with statins as the level of serum LDL cholesterol decreased ( p <.0001). CONCLUSIONS: Use of statins caused a 60%, significant, independent reduction in new ABI in older men and women with prior myocardial infarction and a serum LDL cholesterol of >or=125 mg/dl.     

Decrease in triglyceride level by bezafibrate is related to reduction of recurrent coronary events: a Bezafibrate Infarction Prevention substudy

BACKGROUND: Fibrates were reported to be effective in reducing recurrent coronary events in coronary heart disease patients with elevated triglycerides. It is not known whether this effect is related to the extent of triglyceride reduction. METHODS: Participants comprised 3090 coronary heart disease patients enrolled in the Bezafibrate Infarction Prevention study, which showed a nonsignificant reduction (9.4%; P=0.26) in fatal or nonfatal myocardial infarction and sudden death during a mean follow-up time of 6.2 years. RESULTS: Significant reduction in triglyceride serum level was evident only among patients allocated to bezafibrate, ranging between 0.06 mmol/l (5 mg/dl) in the lowest decile of baseline triglycerides level and 0.68 mmol/l (60 mg/dl) in the highest baseline decile. The extent of triglyceride reduction with bezafibrate was significantly associated with the reduction of risk; relative risk reduction of 55% (hazards ratio: 0.45; 95% confidence interval: 0.24-0.84) was observed among patients with baseline triglycerides>or=2.26 mmol/l who reduced triglyceride level to >0.50 mmol/l (>44.3 mg/dl). In contrast, the risk of recurrent events among patients treated with bezafibrate and achieving less triglyceride reduction or failing to reduce triglyceride level was not significantly different from that of patients treated with placebo. CONCLUSION: Bezafibrate treatment was associated with significant risk reduction among coronary heart disease patients with elevated triglyceride levels that substantially reduced their triglyceride level with treatment.     

Metformin-glibenclamide versus metformin plus rosiglitazone in patients with type 2 diabetes inadequately controlled on metformin monotherapy

AIM: This double-blind study evaluated the efficacy and safety of metformin-glibenclamide tablets vs. metformin plus rosiglitazone therapy in patients with type 2 diabetes inadequately controlled on metformin monotherapy. SUBJECTS AND METHODS: After an open-label, metformin lead-in phase, 318 patients were randomly assigned to treatment based on metformin-glibenclamide 500/2.5 mg tablets (initial daily dose 1000/5 mg) or metformin 500 mg plus rosiglitazone 4 mg (initial daily dose 1000-2000 mg + 4 mg, depending on previous treatment) for 24 weeks. Doses were titrated to achieve the therapeutic glycaemic target. The primary efficacy variable was the change in HbA1C. RESULTS: At week 24, metformin-glibenclamide tablets resulted in significantly greater reductions in HbA1C (-1.5%) and fasting plasma glucose [-2.6 mmol/l (-46 mg/dl)] than metformin plus rosiglitazone [-1.1%, p < 0.001; -2 mmol/l (-36 mg/dl), p = 0.03]. More patients receiving metformin-glibenclamide attained HbA1C <7.0% than did those in the metformin plus rosiglitazone group (60 vs. 47%) and had fasting plasma glucose levels <7 mmol/l (<126 mg/dl) by week 24 (34 vs. 25%). Both treatments were well tolerated. Frequency of adverse gastrointestinal events was comparable between groups. Four per cent of patients receiving metformin-glibenclamide withdrew because of symptomatic hypoglycaemia contrasted with 3% of patients receiving metformin plus rosiglitazone who withdrew because of persistent hyperglycaemia. Hypoglycaemic events were mild or moderate in intensity and were easily self-managed. CONCLUSIONS: Metformin-glibenclamide tablets resulted in significantly greater reductions in HbA1C and fasting plasma glucose compared with metformin plus rosiglitazone in patients with type 2 diabetes inadequately controlled on metformin monotherapy.     

Relationship between blood glucose on admission and prognosis in patients with acute myocardial infarction treated with percutaneous coronary intervention

BACKGROUND: Diabetes mellitus in patients with myocardial infarction affects in-hospital and late mortality. It has been shown that the glucose level on admission can also affect prognosis. This conclusion was based on an analysis performed on a heterogeneous group of patients, treated not only with percutaneous coronary intervention (PCI) but also with fibrinolysis. Moreover, the threshold values hyperglycaemia for the diagnosis of were also variable. AIM: To assess whether glucose level on admission affects in-hospital and one-year prognosis in patients with ST-segment elevation myocardial infarction (STEMI) treated with PCI. METHODS: Consecutive patients with STEMI treated with PCI were included in the analysis. Patients with STEMI complicated by cardiogenic shock were also included. Three groups according to the glucose level on admission were analysed: group I - <7.8 mmol/l (140 mg/dl), group II - 7.8-11.1 mmol/l (140-200 mg/dl), and group III - > or = 11.1 mmol/l (200 mg/dl). RESULTS: The incidence of diabetes mellitus in the total group (1027 patients) was 26.1%, and of cardiogenic shock - 9.2%. Group I consisted of 472 patients, group II - 307 patients, and group III - 248 patients. Compared with normoglycaemic patients, those with elevated glucose level were older, more often female, had more often hypertension, diabetes mellitus, cardiogenic shock, were more often treated with fibrinolysis before PCI but were less often smokers. Multivessel disease and initial patency of the infarct-related artery (TIMI 0-1) were more often observed in patients with higher glucose level. A trend towards a higher incidence of reocclusion was also more often present in patients with increased glucose level. Moreover, mean creatine kinase concentration was the highest and the left ventricular ejection fraction was the lowest in group III. During the in-hospital stay, the complication rate was as follows: stroke (1.1% vs. 1.3% vs. 4.4%), and mortality (2.8 vs. 4.9 vs. 13.3%) in groups I, II, and III, respectively. The same tendency was observed during the one-year follow-up period: stroke (1.3 vs. 2.9 vs. 6.9%), mortality (6.4 vs. 9.1 vs. 22.6%). The 1 mmol/l (18 mg/dl) increase of the baseline glucose level among various risk factors was an independent prognostic factor of higher -year mortality (HR=1.06; 95% CI 1.02-1.09). Diabetes mellitus did not affect prognosis among patients included in the analysis. CONCLUSION: Elevated glucose level on admission is associated with adverse prognosis in patients with STEMI treated with PCI.     

High stored iron levels are associated with excess risk of myocardial infarction in eastern Finnish men.

BACKGROUND. Iron can induce lipid peroxidation in vitro and in vivo in humans and has promoted ischemic myocardial injury in experimental animals. We tested the hypothesis that high serum ferritin concentration and high dietary iron intake are associated with an excess risk of acute myocardial infarction. METHODS AND RESULTS. Randomly selected men (n = 1,931), aged 42, 48, 54, or 60 years, who had no symptomatic coronary heart disease at entry, were examined in the Kuopio Ischaemic Heart Disease Risk Factor Study (KIHD) in Eastern Finland between 1984 and 1989. Fifty-one of these men experienced an acute myocardial infarction during an average follow-up of 3 years. On the basis of a Cox proportional hazards model adjusting for age, examination year, cigarette pack-years, ischemic ECG in exercise test, maximal oxygen uptake, systolic blood pressure, blood glucose, serum copper, blood leukocyte count, and serum high density lipoprotein cholesterol, apolipoprotein B, and triglyceride concentrations, men with serum ferritin greater than or equal to 200 micrograms/l had a 2.2-fold (95% CI, 1.2-4.0; p less than 0.01) risk factor-adjusted risk of acute myocardial infarction compared with men with a lower serum ferritin. An elevated serum ferritin was a strong risk factor for acute myocardial infarction in all multivariate models. This association was stronger in men with serum low density lipoprotein cholesterol concentration of 5.0 mmol/l (193 mg/dl) or more than in others. Also, dietary iron intake had a significant association with the disease risk in a Cox model with the same covariates. CONCLUSIONS. Our data suggest that a high stored iron level, as assessed by elevated serum ferritin concentration, is a risk factor for coronary heart disease.     

Myocardial infarction and anti-ethinylestradiol antibody. Apropos of a case in an 18-year-old woman

An 18-year-old woman presented with a large anterior myocardial infarction. Her cardiovascular risk factors were cigarette smoking in moderation and oral contraception with a synthetic oestroprogestative pill prescribed a few months previously. Coronary angiography showed occlusion of the left anterior descending artery but no other lesions. Biological investigations excluded an abnormality of coagulation. Antibodies to synthetic steroids (ethinylestradiol and progesterone) and circulating immune complexes were found in the serum. The role of antiethinylestradiol antibodies in the mechanism of myocardial infarction is discussed. These antibodies are present in 30 per cent of women taking oral contraceptives and their titres are significantly higher in 90 per cent of women who develop vascular thrombosis unrelated to atherosclerosis. The mechanism of the thrombogenic action of the antibodies and circulating immune complexes is also considered.     

Combined intense lifestyle and pharmacologic lipid treatment further reduce coronary events and myocardial perfusion abnormalities compared with usual-care cholesterol-lowering drugs in coronary artery disease

OBJECTIVES: The purpose of this study was to determine if combined intense lifestyle and pharmacologic lipid treatment reduce myocardial perfusion abnormalities and coronary events in comparison to usual-care cholesterol-lowering drugs and whether perfusion changes predict outcomes. BACKGROUND: Lifestyle and lipid drugs separately benefit patients with coronary artery disease (CAD). METHODS: A total of 409 patients with CAD, who underwent myocardial perfusion imaging by dipyridamole positron emission tomography at baseline and after 2.6 years, had quantitative size/severity of perfusion defects measured objectively by automated software with follow-up for five additional years for coronary artery bypass graft, percutaneous coronary intervention, myocardial infarction, or cardiac death. Patients were categorized blindly according to prospective, predefined criteria as "poor" treatment without diet or lipid drugs, or smoking; "moderate" treatment on American Heart Association diet and lipid-lowering drugs or on strict low-fat diet (<10% of calories) without lipid drugs; and "maximal" treatment with diet <10% of calories as fat, regular exercise, and lipid active drugs dosed to target goals of low-density lipoproteins <2.3 mmol/l (90 mg/dl), high-density lipoproteins >1.2 mmol/l (45 mg/dl), and triglycerides <1.1 mmol/l (100 mg/dl). RESULTS: Over five years, coronary events occurred in 6.6%, 20.3%, and 30.6% of patients on maximal, moderate, and poor treatment, respectively (p = 0.001). Size/severity of perfusion abnormalities significantly decreased for patients receiving maximal treatment and increased for patients undergoing moderate and poor treatment (p = 0.003 and 0.0001, respectively). Combined intense lifestyle change plus lipid active drugs and severity/change of perfusion abnormalities independently predicted cardiac events. CONCLUSIONS: Intense lifestyle and pharmacologic lipid treatment reduce size/severity of myocardial perfusion abnormalities and cardiac events compared with usual-care cholesterol-lowering drugs. Perfusion changes parallel treatment intensity and predict outcomes.     

The Prospective Cardiovascular Münster Study: prevalence and prognostic significance of hyperlipidemia in men with systemic hypertension

The ongoing Prospective Cardiovascular Münster (PROCAM) trial was initiated to identify risk factors for coronary artery disease (CAD). By comparing patients' long-term cardiac status (clinical signs of atherosclerosis, myocardial infarction, stroke or death due to atherosclerotic disease) with results from entrance questionnaires, physical examinations, blood pressure measurements, electrocardiograms at rest and blood analyses, the characteristics and strategies for identifying people in the general population who are at risk for developing CAD were to be determined. From PROCAM trial data, 3 predictive criteria for identifying such people have been determined: They are a total cholesterol/high density lipoprotein (HDL) cholesterol ratio of 6.5 was determined to be the threshold for CAD risk. Combined analysis of lipid parameters identified high-risk patients as those with cholesterol values of greater than or equal to 300 mg/dl, and low-risk patients as those with cholesterol and triglyceride values less than 200 mg/dl. The remaining subjects are classified according to their HDL cholesterol values. If the HDL cholesterol value is less than 35 mg/dl, the subject is considered to be at high risk, if HDL cholesterol is greater than or equal to 35 mg/dl the patient is considered to be at average risk. The upper 20% of risk was computed by means of a multiple logistic function based on statistics for age, total cholesterol and HDL cholesterol levels, systolic blood pressure, angina pectoris, diabetes mellitus, cigarette smoking and family history of myocardial infarction. A further analysis was the risk incurred by hypertension. Hypertension was observed in 16.5% of men and 13.9% of women.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiovascular trials in diabetes: past and present. Invited lecture of the XXXVth National Congress of the Spanish Society of Cardiology

The risk of coronary heart disease in subjects with Type2 diabetes is 2-4 times higher than in non-diabetic subjects of the same age. About 20% of patients with clinically established coronary heart disease have diabetes and the prognosis is much worse in diabetic than in non-diabetic patients. Trial evidence suggests that good blood glucose control reduces the risk of myocardial infarction in diabetic patients and improves prognosis after it. Trial evidence indicates that the benefit from antihypertensive treatment is at least as good in diabetic than in non-diabetic patients, and that diabetic patients with coronary heart disease or other form of atherosclerotic vascular disease should be treated with lipid-lowering drugs (usually with statins), if their LDL cholesterol levels on diet remain> 3.0 mmol/l (115 mg/dl). Trial evidence supports the use of aspirin in middle-aged or elderly diabetic patients. All diabetic patients should be advised to stop smoking.     

Trends in cardiovascular risk factor prevalence (1995-2000-2005) in northeastern Spain.

BACKGROUND: High prevalence of cardiovascular risk factors has been observed in Spain along with low incidence of acute myocardial infarction. Our objective was to determine the trends of cardiovascular risk factor prevalence between 1995 and 2005 in the 35-74-year-old population of Gerona, Spain. DESIGN: Comparison of cross-sectional studies were conducted in random population samples in 1995, 2000, and 2005 at Gerona, Spain. METHODS: An electrocardiogram was obtained, along with standardized measurements of body mass index, lipid profile, systolic and diastolic blood pressure, glycaemia, energy expenditure in physical activity, smoking, use of lipid-lowering and antihypertensive medications, and cardiovascular risk. Prevalence of diabetes, hypertension, and obesity was calculated and standardized for age. RESULTS: A total of 7571 individuals (52.0% women) were included (response rate 72%). Low-density lipoprotein cholesterol >3.4 mmol/l (130 mg/dl) (49.7%) and hypertension (39.1%) were the most prevalent cardiovascular risk factors. In 1995, 2000 and 2005, low-density lipoprotein cholesterol decreased in both men and women: 4.05-3.91-3.55 mmol/l (156-151-137 mg/dl) and 3.84-3.81-3.40 mmol/l (148-147-131 mg/dl), respectively. Increases were observed in lipid-lowering drug use (5.7-6.3-9.6% in men and 4.0-5.8-8.0% in women), controlled hypertension (14.8-35.4-37.7% in men and 21.3-36.9-45.0% in women); (all P-trends <0.01), and obesity (greatest for men: 17.5-26.0-22.7%, P-trends=0.020). Prevalence of myocardial infarction or possibly abnormal Q waves in electrocardiogram also increased significantly (3.9-4.7-6.4%, P-trends=0.018). CONCLUSIONS: The cardiovascular risk factor prevalence change in Gerona was marked in this decade by a shift of total cholesterol and low-density lipoprotein cholesterol distributions to the left, independent of the increase in lipid-lowering drug use, and better hypertension control with increased use of antihypertensive drugs.     

Relationship of glucose and insulin levels to the risk of myocardial infarction: a case-control study

OBJECTIVE: To assess the relationship between dysglycemia and myocardial infarction in nondiabetic individuals. BACKGROUND: Nondiabetic hyperglycemia may be an important cardiac risk factor. The relationship between myocardial infarction and glucose, insulin, abdominal obesity, lipids and hypertension was therefore studied in South Asians-a group at high risk for coronary heart disease and diabetes. METHODS: Demographics, waist/hip ratio, fasting blood glucose (FBG), insulin, lipids and glucose tolerance were measured in 300 consecutive patients with a first myocardial infarction and 300 matched controls. RESULTS: Cases were more likely to have diabetes (OR 5.49; 95% CI 3.34, 9.01), impaired glucose tolerance (OR 4.08; 95% CI 2.31, 7.20) or impaired fasting glucose (OR 3.22; 95% CI 1.51, 6.85) than controls. Cases were 3.4 (95% CI 1.9, 5.8) and 6.0 (95% CI 3.3, 10.9) times more likely to have an FBG in the third and fourth quartile (5.2-6.3 and >6.3 mmol/1); after removing subjects with diabetes, impaired glucose tolerance and impaired fasting glucose, cases were 2.7 times (95% CI 1.5-4.8) more likely to have an FBG >5.2 mmol/l. A fasting glucose of 4.9 mmol/l best distinguished cases from controls (OR 3.42; 95% CI 2.42, 4.83). Glucose, abdominal obesity, lipids, hypertension and smoking were independent multivariate risk factors for myocardial infarction. In subjects without glucose intolerance, a 1.2 mmol/l (21 mg/dl) increase in postprandial glucose was independently associated with an increase in the odds of a myocardial infarction of 1.58 (95% CI 1.18, 2.12). CONCLUSIONS: A moderately elevated glucose level is a continuous risk factor for MI in nondiabetic South Asians with either normal or impaired glucose tolerance.     

Treating to New Targets (TNT) Study: does lowering low-density lipoprotein cholesterol levels below currently recommended guidelines yield incremental clinical benefit?

The Treating to New Targets (TNT) trial is a parallel-group study that has randomized 10,003 patients from 14 countries to double-blind treatment with either atorvastatin 10 or 80 mg. During the double-blind period, low-density lipoprotein (LDL) cholesterol levels are expected to reach approximate mean values of 100 mg/dl (2.6 mmol/L) for the low-dose atorvastatin group and 75 mg/dl (1.9 mmol/L) for the high-dose group. Randomized patients are expected to be followed for an average of 5 years. The primary end point is the time to occurrence of a major cardiovascular event, defined as coronary heart disease death, nonfatal myocardial infarction, resuscitated cardiac arrest, or stroke. The large patient numbers in the TNT study and long follow-up should ensure that there is adequate power to definitively determine if reducing LDL cholesterol levels to approximately 75 mg/dl (1.9 mmol/L) can provide additional clinical benefit.     

Reduction in serum total cholesterol and risks of coronary events and cerebral infarction in Japanese men: the Kyushu Lipid Intervention Study.

Lowering serum total cholesterol is shown to decrease the risk of coronary heart disease (CHD) in Western countries,but evidence is limited regarding cerebral infarction (CI). The present study used the Kyushu Lipid Intervention Study to examine the risks of CHD events and CI in relation to reduction in serum total cholesterol. Subjects were 4,615 men aged 45-74 years with serum total cholesterol of 220 mg/dl (5.68 mmol/L) or greater who had no history of CHD events or stroke. CHD events and CI numbered 125 and 92, respectively, in a 5-year follow-up. After adjustment for potential confounding factors, the relative risks of CHD events and CI for 15% or greater reduction in total cholesterol, compared with less than 5% reduction, were 0.78 (95% confidence limit [CL]0.46-1.32) and 0.39 (95% CL 0.22-0.69), respectively. As compared with on-treatment cholesterol levels of 240 mg/dl (6.20 mmol/L)or higher, the risk of CHD events was approximately 50% lower across 3 categories below 240 mg/dl (6.20 mmol/L), and that of CI was 70%lower at 2 categories below 220 mg/dl (5.68 mmol/L). Lowering serum total cholesterol below 220 mg/dl (5.68 mmol/L) seems desirable with regard to the prevention of CI.     

Individuelle Therapieziele bei Diabetespatienten mit koronarer Herzkrankheit und Herzinsuffizienz

Patients with diabetes are at increased risk for the development of coronary artery disease and myocardial infarction with a reduced prognosis due to a prothrombotic milieu and diabetes-associated complications. Therapeutic targets in these patients are blood pressure levels below 140/90?mmHg, LDL levels below 70?mg/dl and HbA_1c goals of 6.5?C7.0% (7.7?C8.5?mmol/l) with avoidance of hypoglycemic events. In acute myocardial infarction, blood glucose levels should be close to normal with levels between 100?C150?mg/dl and patients should receive either drug-eluting stents or cardiac surgery in cases of complex lesions. In addition, patients with diabetes mellitus develop diabetic cardiomyopathy which is associated with a reduced overall prognosis. Treatment of heart failure in individuals with diabetes mellitus does not differ from the therapy of non-diabetic individuals. However, sufficient glucose control is an important goal in these patients with HbA_1c goals of 6.5?C7.0% (7.7?C8.5?mmol/l), again without hypoglycemic events.     

Wives of patients with acute myocardial infarction are at an increased risk of developing coronary artery disease

BACKGROUND: The present study was carried out to investigate risk factors for developing coronary artery disease in wives of patients with acute myocardial infarction. SUBJECTS AND METHODS: Risk factors for developing coronary artery disease were investigated in 50 wives of patients who developed an acute myocardial infarction (group A) and were compared with those of 50 wives of normal healthy men (group B). The average age was 50.20 +/- 1.56 years (mean +/- SD) and 50.20 +/- 1.53 years for group A and group B respectively. The parameters assessed were: plasma cholesterol (TC), high density lipoprotein cholesterol (HDL-C), triglycerides (TG), low density lipoprotein cholesterol (LDL-C), systolic and diastolic blood pressure, smoking habits and body mass index (BMI). RESULTS: The levels of LDL-C in the wives of patients with myocardial infarction were higher than those of the wives of normal healthy men (167.8 +/- 5.84 mg/dl and 148.4 +/- 4.85 mg/dl, respectively, P < 0.01). Moreover, HDL-C concentrations were lower in the wives of the patients (51.34 +/- 0.92 mg/dl) than in the wives of the healthy men (58.14 +/- 1.39 mg/dl), (P < 0.001). Finally, TG levels were higher in the wives of the patients (132.2 +/- 7.9 mg/dl) than in the wives of the normal healthy men (96.9 +/- 5.94 mg/dl) (P < 0.01). CONCLUSIONS: Although plasma lipid levels themselves were not excessively high, the wives of patients with an acute myocardial infarction are at a higher risk of developing coronary artery disease than the wives of normal healthy men, in the long term, due to higher levels of LDL-C and TG as well as lower levels of HDL-C.     

Stopping smoking and long-term mortality after acute myocardial infarction.

A prospective follow-up study was carried out to investigate the relation between smoking and risk of death after an acute myocardial infarction. The study consisted of male patients under the age of 65 years, who had had an acute myocardial infarction between 1972 and 1975 in North Karelia, Finland. Of these patients, 888 survived the first six months after the acute infarction and were followed-up for three years after the infarction with regard to their deaths. The cumulative all-causes mortality rate of the patients who were still smoking six months after the acute myocardial infarction was 1.7 times that of the patients who had stopped smoking within the first six months. There was a dose-response relation between the number of cigarettes smoked daily and the mortality. The impact of smoking was greatest in the subgroups of patients with an otherwise good prognosis. We estimated that 28 per cent of the deaths in the whole group of initial smokers was attributable to continuing smoking after the infarction. On the basis of these findings we suggest that the anti-smoking advice should be an important part of the modern comprehensive care of patients with an acute myocardial infarction.     

Hyperhomocysteinaemia and premature coronary artery disease in the Chinese.

OBJECTIVES: To examine the prevalence of hyperhomocysteinaemia and compare it with the classic risk factors and vitamin status in Hong Kong Chinese patients with premature atherosclerotic coronary artery disease. DESIGN: Case-control study. SETTING: General hospital and community. SUBJECTS: Forty five patients (39 males) with significant coronary artery disease confirmed by angiography (32 post myocardial infarction) and 23 healthy volunteers (17 male), all aged less than 55 years. INTERVENTION: Standardised methionine-loading test. MAIN OUTCOME MEASURES: Coronary artery disease, risk factors. RESULTS: More patients than controls had fasting hyperhomocysteinaemia (10/45 v 2/23, P = 0.122), post-methionine hyperhomocysteinaemia (17/45 v 1/23, P = 0.008), and an abnormal response to methionine (15/45 v 1/23, P = 0.015). A history of smoking was more frequent in patients (3/23 v 25/45, P = 0.002). Sixteen of 17 patients with hyperhomocysteinaemia but only nine of 28 with normohomocysteinaemia were smokers (P = 0.0002). Fasting plasma cholesterol concentrations (mean (SD)) were higher in hyperhomocysteinaemic patients (6.41 (1.58) mmol/l) than in controls (5.53 (0.90) mmol/l) (P = 0.042). Serum vitamin B-12 was not reduced and serum folate was higher in hyperhomocysteinaemic patients (35 (4) nmol/l) than normohomocysteinaemic patients (26 (9) nmol/l) (P = 0.009). CONCLUSIONS: Although the prevalence of hyperhomocysteinaemia in Hong Kong Chinese is similar to that in white subjects, hyperhomocysteinaemia is not an independent risk factor for coronary artery disease and is associated with smoking. This may be of some consequence in view of the change to a more Western diet with more animal protein, and therefore methionine, coupled with a high frequency of cigarette smokers in this region. The causes of the hyperhomocysteinaemia are multifactorial but in this pilot study a deficiency of folate and/or vitamin B-12 did not seem to be one of them.