Long-term mortality following stroke, myocardial infarction and fractured neck of femur in Western Australia

Background: Population ageing will increase the burden of stroke, myocardial infarction (MI) and fractured neck of femur (FNF). These age‐dependent conditions are associated with increased mortality, although the pattern and extent of this increased mortality is poorly understood. The aim of this study was to compare mortality from stroke, MI and FNF. Methods: Retrospective inception cohort study of 2818 subjects more than the age of 60 years in Western Australia recorded in a linked database as having sustained a stroke, MI or FNF in the year 1990. Results: Early adjusted mortality rates associated with FNF were relatively low compared with stroke and MI. Medium‐term to longer‐term mortality associated with FNF was greater than MI, but stroke was associated with the highest long‐term adjusted mortality. Conclusion: The poorer medium‐term to longer‐term survival following stroke and FNF (relative to that following MI) may relate to a greater burden of comorbidity. Stroke and FNF may thus be markers of medical frailty.     

Alcohol consumption and risk of coronary heart disease in older adults: the Cardiovascular Health Study

OBJECTIVES: To evaluate several aspects of the relationship between alcohol use and coronary heart disease in older adults, including beverage type, mediating factors, and type of outcome. DESIGN: Prospective cohort study. SETTING: Four U.S. communities. PARTICIPANTS: Four thousand four hundred ten adults aged 65 and older free of cardiovascular disease at baseline. MEASUREMENTS: Risk of incident myocardial infarction or coronary death according to self-reported consumption of beer, wine, and spirits ascertained yearly. RESULTS: During an average follow-up period of 9.2 years, 675 cases of incident myocardial infarction or coronary death occurred. Compared with long-term abstainers, multivariate relative risks of 0.90 (95% confidence interval (CI)=0.71-1.14), 0.93 (95% CI=0.73-1.20), 0.76 (95% CI=0.53-1.10), and 0.58 (95% CI=0.39-0.86) were found in consumers of less than one, one to six, seven to 13, and 14 or more drinks per week, respectively (P for trend=.007). Associations were similar for secondary coronary outcomes, including nonfatal and fatal events. No strong mediators of the association were identified, although fibrinogen appeared to account for 9% to 10% of the relationship. The associations were statistically similar for intake of wine, beer, and liquor and generally similar in subgroups, including those with and without an apolipoprotein E4 allele. CONCLUSION: In this population, consumption of 14 or more drinks per week was associated with the lowest risk of coronary heart disease, although clinicians should not recommend moderate drinking to prevent coronary heart disease based on this evidence alone, because current National Institute on Alcohol Abuse and Alcoholism guidelines suggest that older adults limit alcohol intake to one drink per day.     

The predictability of risk factors with respect to incidence and mortality of myocardial infarction and total mortality. A 12-year follow-up of the Oslo Study,Norway

Abstract. Objectives. To study the prognostic value of several risk factors on incidence and mortality of myocardial infarction (MI) and total mortality in men. Design. Prospective cohort study of 12 years' follow-up. Setting. All men in Oslo aged 40–49 and a 7% sample of men aged 20–39 were invited for screening. Subjects. Of all 30025 invited men, of whom 25015 were aged 40–49, a total of 16209 men aged 40–49 attended the screening and risk factors were recorded for these men. Main outcome measures. Incidence of first MI (nonfatal and fatal), mortality of MI, total mortality. Results. When examining the rate ratio of the fifth to the first quintile of risk factors we found that systolic and diastolic blood pressures were stronger predictors for mortality than incidence of MI. The rate ratios (95% confidence interval) of systolic blood pressure were 3.73 (2.56, 5.44) and 2.56 (2.01, 3.25) respectively. For diastolic blood pressure the corresponding rate ratios were 4.14 (2.84, 6.04) and 2.78 (2.18, 3.54). Small differences in the rate ratios for these end-points were found for total serum cholesterol and triglycerides. Daily cigarette smoking versus non-cigarette smoking was a stronger predictor for MI mortality than incidence, with rate ratios of 3.16 (2.45, 4.24) and 2.34 (2.00, 2.79) respectively. The Cox proportional hazards regression analysis confirmed the above results. Conclusions. Total serum cholesterol and triglycerides predicted incidence and mortality of MI equally well. Whereas blood pressure and daily cigarette smoking predicted mortality of MI more strongly.     

The association between hyperglycaemia on admission and 180-day mortality in acute myocardial infarction patients with and without diabetes.

AIM: To evaluate the association between hyperglycaemia on admission, previously known diabetes and 180-day mortality in acute myocardial infarction (AMI) patients. METHODS: The study population consisted of 779 consecutive AMI patients from the Myocardial Infarction Registry in Estonia who had an admission venous plasma glucose level recorded and who were admitted to the Tartu University Clinics within a period of 2 years. Logistic regression analysis was used to estimate crude and adjusted odds ratios (OR) with 95% confidence interval (95% CI). RESULTS: In patients without a history of diabetes, glucose level was < or = 11.0 mmol/l in 556 patients (group 1) and > 11.0 mmol/l in 109 patients (group 2). Of those with diabetes, glucose level was < or = 11.0 mmol/l in 30 patients (group 3) and > 11.0 mmol/l in 84 patients (group 4). Non-diabetic hyperglycaemic patients underwent more resuscitations outside of hospital (group 2, 31.2% vs. group 1, 2.0% vs. group 3, 6.7% vs. group 4, 6.0%, P < 0.0001) and had a higher 180-day mortality compared with other groups (group 2, 47.7% vs. group 1, 14.1% vs. group 3, 26. 7% vs. group 4, 29.8%, P < 0.0001). After adjustment for potentially confounding factors, hyperglycaemic non-diabetic (OR 4.35, 95% CI 1.79-10.59), but not diabetic (OR 1.79, 95% CI 0.62-5.15) status, remained an independent predictor of 180-day mortality. CONCLUSIONS: AMI patients with hyperglycaemia on admission, independent of a history of diabetes, represent a high-risk population for 180-day mortality. The worst outcome occurs in non-diabetic hyperglycaemic patients. Further studies are warranted to clarify the questions of hyperglycaemia treatment in AMI patients.     

Hospital mortality of acute myocardial infarction in the thrombolytic era

OBJECTIVE: To examine the management and outcome of an unselected consecutive series of patients admitted with acute myocardial infarction to a tertiary referral centre. DESIGN: A historical cohort study over a three year period (1992-94) of consecutive unselected admissions with acute myocardial infarction identified using the HIPE (hospital inpatient enquiry) database and validated according to MONICA criteria for definite or probable acute myocardial infarction. SETTING: University teaching hospital and cardiac tertiary referral centre. RESULTS: 1059 patients were included. Mean age was 67 years; 60% were male and 40% female. Rates of coronary care unit (CCU) admission, thrombolysis, and predischarge angiography were 70%, 28%, and 32%, respectively. Overall in-hospital mortality was 18%. Independent predictors of hospital mortality by multivariate analysis were age, left ventricular failure, ventricular arrhythmias, cardiogenic shock, management outside CCU, and reinfarction. Hospital mortality in a small cohort from a non-tertiary referral centre was 14%, a difference largely explained by the lower mean age of these patients (64 years). Five year survival in the cohort was 50%. Only age and left ventricular failure were independent predictors of mortality at follow up. CONCLUSIONS: In unselected consecutive patients the hospital mortality of acute myocardial infarction remains high (18%). Age and the occurrence of left ventricular failure are major determinants of short and long term mortality after acute myocardial infarction.     

Long-term prognostic importance of total cholesterol in elderly survivors of an acute myocardial infarction: the Cooperative Cardiovascular Pilot Project

OBJECTIVES: To determine the long-term prognostic importance of in-hospital total serum cholesterol in elderly survivors of acute myocardial infarction (AMI). DESIGN: Retrospective medical record review. SETTING: Acute care, nongovernmental hospitals in Alabama, Connecticut, Iowa, and Wisconsin. PARTICIPANTS: Four thousand nine hundred twenty-three Medicare beneficiaries from four states aged 65 and older discharged alive with a principal diagnosis of AMI between June 1, 1992, and February 28, 1993, who had a measurement of total serum cholesterol during hospitalization. MEASUREMENTS: Primary endpoint of all-cause mortality within 6 years of discharge. RESULTS: Of the 7,166 hospitalizations meeting study inclusion criteria, 4,923 (68.7%) had total cholesterol assessed, and 22% had a cholesterol level of 240 mg/dL or greater. Of AMI hospitalization survivors with cholesterol of 240 md/dL or greater, 17.2% died within 1 year and 47.9% died within 6 years, compared with 17.4% (P =.73) and 48.7% (P =.98) of those with a cholesterol level less than 240 mg/dL. The adjusted hazard ratio for elevated total serum cholesterol measured during hospitalization for all-cause mortality in the 6 years after discharge was 0.97 (95% confidence interval (CI) = 0.87-1.09). The unadjusted 1- and 6-year mortality rates for those with total cholesterol less than 160 mg/dL were 22.2% and 55.5%, respectively, not significantly different from mortality for patients with cholesterol of 160 mg/dL or greater, even after adjustment. CONCLUSION: Among elderly survivors of AMI, elevated total serum cholesterol measured postinfarction is not associated with an increased risk of all-cause mortality in the 6 years after discharge. Furthermore, this study found no evidence of an increased risk of all-cause mortality in patients with low total cholesterol. Further studies are needed to determine the relationship of postinfarction lipid subfractions and mortality in older patients with coronary artery disease (CAD).     

The association between C-reactive protein on admission and mortality in patients with acute myocardial infarction

OBJECTIVE: In patients presenting with acute myocardial infarction the pathophysiologic and prognostic value of serum C-reactive protein is not well defined. This study assessed the association between serum C-reactive protein levels on admission and mortality in patients admitted because of acute myocardial infarction. DESIGN: Retrospective cohort study. SETTING: Tertiary care centre. PATIENTS: A total of 729 patients with acute myocardial infarction admitted within a period of 3 years. MAIN OUTCOME MEASURES: C-reactive protein levels on admission, cardiovascular risk factors and survival within the observational period. RESULTS: Within the 3-year observational period, 118 patients died of a cardiovascular cause. With increasing serum C-reactive protein levels (<0.5, 0.5 to <2, 2 to <5, 5-10 and >10 mg dL-1) mortality also increased (14%, 19%, 20%, 39% and 28%, respectively). When controlling for the confounding effect of age, thrombolytic treatment, the time interval between onset of pain and admission, smoking, diabetes mellitus, hypercholesterolemia, hypertension, and elevated creatine kinase on admission in a multivariate Cox regression model, there was only a weak and nonsignificant association between increased serum C-reactive protein and the risk of death. CONCLUSIONS: Patients with elevated concentrations of serum C-reactive protein admitted to the hospital because of acute myocardial infarction are at an increased risk of dying. This association is however, largely explained by other baseline variables, in particular by an estimate of the duration of myocardial ischaemia. If C-reactive protein measured by means of an ultra-sensitive assay is more suitable for risk stratification of unselected patients with acute myocardial infarction, needs further study.     

Factors associated with development of stroke long-term after myocardial infarction: experiences from the LoWASA trial

OBJECTIVE: To describe factors associated with the development of stroke during long-term follow-up after acute myocardial infarction (AMI) in the LoWASA trial. PATIENTS: Patients who had been hospitalized for AMI were randomized within 42 days to receive either warfarin 1.25 mg plus aspirin 75 mg daily or aspirin 75 mg alone. DESIGN: The study was performed according to the probe design, that is open treatment and blinded end-point evaluation. SETTING: The study was performed in 31 hospitals in Sweden. The mean follow-up time was 5.0 years with a range of 1.7-6.7 years. RESULTS: In all, 3300 patients were randomized in the trial, of which 194 (5.9%) developed stroke (4.2% nonhaemorrhagic, 0.5% haemorrhagic and 1.3% uncertain. The following factors appeared as independent predictors for an increased risk of stroke: age, hazard ratio and 95% confidence interval (1.07; 1.05-1.08), a history of diabetes mellitus (2.4; 1.8-3.4), a history of stroke (2.3; 1.5-3.5), a history of hypertension (2.0; 1.5-2.7) and a history of smoking (1.5;1.1-2.0). Most of these factors were also predictors of a nonhaemorrhagic stroke whereas no predictor of haemorrhagic stroke was found. CONCLUSION: Risk indicators for stroke long-term after AMI were increasing age, a history of either diabetes mellitus, stroke, hypertension or smoking.     

Platelet tests in the prediction of myocardial infarction and ischaemic stroke: evidence from the Caerphilly Prospective Study

A platelet test that is predictive of myocardial infarction (MI) and/or stroke would enable the targeting of anti-platelet drugs towards high-risk patients. The predictive power of several platelet tests for MI and for stroke was examined in 2000 older men in the Caerphilly Cohort Study of Heart Disease, Stroke and Cognitive Decline. The tests were: aggregation to adenosine diphosphate (ADP) in platelet-rich plasma (PRP); aggregation to ADP in whole blood measured using an impedance method and a test of platelet aggregation induced in whole blood by high-shear flow. Around 200 MIs and 100 ischaemic strokes occurred during a 10-year follow-up. Neither primary nor secondary aggregation in PRP was predictive of MI. However, the fifth of men in whom the primary response to ADP was least, showed the highest risk of a subsequent stroke [relative odds (RO) 1.64; 95% confidence interval (CI) 1.12-2.43]. Aggregation in whole blood was not predictive of MI but, again, the fifth of men with the least platelet response showed the highest stroke incidence (RO 1.79; 95% CI 1.06-3.00). Retention of platelets in the high-shear test was not predictive of either event.     

Mortality in sepsis: Comparison of outcomes between patients with demand ischemia,acute myocardial infarction,and neither demand ischemia nor acute myocardial infarction

Introduction

Elevation in cardiac troponins is common with sepsis despite unclear impact.

Hypothesis

We investigated whether demand ischemia(DI) resulted in variable outcomes compared to acute myocardial infarction(AMI) and those with neither DI nor AMI in sepsis.

Methods

We analyzed data from the 2011‐2014 National Inpatient Sample among patients admitted for sepsis. We compared outcomes among patients with DI i) versus AMI and ii) versus neither DI nor AMI, respectively using propensity matching. Primary study end‐point was in‐hospital mortality.

Results

We studied 666,154 patients, with mean age 63.7 years and 50.8% female participants. Overall, 94.7% of the included patients had neither DI nor AMI, 4.4% had AMI and 0.83% had DI. Between 2011 and 2014, we observed an increasing trend for DI but decreasing trend for AMI in sepsis. Patients with DI experienced higher rates of atrial and ventricular arrhythmias, had longer length of stay and higher cost of stay compared to patients with neither demand ischemia nor AMI. Despite higher hospital mortality at baseline with DI, post‐propensity matching revealed no difference in hospital mortality between patients with DI and those with neither (26.9% vs. 27.0%, adjusted odds ratio 0.99, 95% confidence intervals 0.92‐1.07;p=0.87). Patients with DI experienced lower hospital mortality compared to those with AMI pre (28.5% vs. 48.3%;p<0.001) and post‐propensity matching (41.1% vs. 29.1%, aOR 0.58, 95% CI 0.54‐0.63;p<0.001).

Conclusion

Among patients with sepsis, those with DI had similar adjusted in‐hospital mortality compared to those with neither DI nor AMI. Patients with AMI had the highest in‐hospital mortality among all groups.     

不同年龄段ST段抬高型心肌梗死男女患者院内病死率的性别差异

目的研究不同年龄段ST段抬高型心肌梗死(STEMI)患者不同性别院内病死率的差异。方法入选1994年1月1日至2006年12月31日首都医科大学宣武医院心脏科收治住院的STEMI患者1189例,其中男性869例,女性320例,年龄23~91岁。根据年龄分为3组:A组(65岁)571例;B组(65~74岁)419例;C组(≥75岁)199例。收集患者年龄、性别、2型糖尿病、血脂、血压等方面的临床资料。结果 A组中,与男性STEMI患者比较,女性(3.1%vs.8.3%)院内病死率升高,差异具有统计学意义(P0.05)。在B组中,与男性STEMI患者比较,女性院内病死率升高(11.9%vs.20.1%)。C组中,男性与女性STEMI患者病死率差异无统计学意义(P0.05)。三组中,随着年龄增长,女性对男性院内病死率的优势比(OR)亦呈逐步下降趋势(2.861 vs.1.875 vs.1.143)。通过多因素分析,校正混杂因素后,在A组,年龄(OR=1.154,95%CI:1.052~1.264),高血压(OR=7.685,95%CI:2.276~25.946)为STEMI患者院内病死的独立危险因素,急诊再灌注治疗(OR=7.685,95%CI:0.007~0.098)为STEMI患者院内病死的保护因素。在B组,女性(OR=1.875,95%CI:1.088~3.232)是STEMI患者院内病死的独立危险因素。结论女性STEMI患者院内病死率较男性高,年龄越大其差异越小。在65岁人群中,年龄,高血压为STEMI患者院内病死的危险因素,急诊再灌注治疗为保护因素;在65~74岁人群中,女性为STEMI患者院内病死的危险因素。     

急性心肌梗塞早期QT间期离散度、JT间期离散度增加与近期预后的关系

测定１０７例急性心肌梗塞（ＡＭＩ）患者第三心肌梗塞日的ＱＴ间期离散度（ＱＴｄ）和ＪＴ间期离散度（ＪＴｄ）．并以１００例正常人作对照。结果显示：ＡＭＩ组ＱＴｄ、ＪＴｄ较对照组显著增大（均Ｐ＜０．００１）。住院期间死亡组（３Ｏ例）ＱＴｄ与ＪＴｄ较存活组（７７例）明显增大（均Ｐ＜０．００１）。提示以ＱＴｄ、ＪＴｄ增大来评价ＡＭＩ患者的近期预后有一定意义。     

心肌缺血预适应对老年急性心肌梗死患者近期病死率的影响

目的探讨心肌缺血预适应对老年急性心肌梗死（AMI）患者近期病死率的影响．方法对照分析33例有心肌缺血预适应老年AMI患者（A组）与22例无心肌缺血预适应老年AMI患者（B组）的临床资料。结果A组肌酸磷酸激酶（CPK）与肌酸磷酸激酶同功酶MB（CK-MB）峰值、泵功能障碍发生率及近期死亡率均显著低于B组（P＜0．05～0．01）。结论CPK与CK-MB峰值的降低，提示心肌缺血预适应有缩小心肌梗死范围的作用；由于梗死范围缩小，故泵功能障碍发生率降低，这是使有心肌缺血预适应老年AMI患者近期病死率降低的主要原因。     

Gender differences in the decline of mortality rates of acute myocardial infarction in West Germany

In Germany in 1994, 86915 people died from acute myocardialinfarction; 56·3% of these cases were male. The correspondingmortality rates per 100000 were 1l6·1 in men and 87·9in women. The male-female mortality ratio in 1994 was most pronouncedfor males aged 45–54 years with a relative risk of 5·7(95% CI, 5·2 to 6·2). The mean age of death was70·5 years in men and 78·6 years in women, reflectinga difference of 8·1 years. In both genders, mortality rates of acute myocardial infarctionin the former Federal Republic of Germany (West Germany) startedto decline in 1980. This decline summed up to –37·8%(95% CI, –38·9 to –36·8) in men and–25·7% (95% CI, –27·1 to –24·3)in women until 1994. The difference in gender-specific declinewas significant. The steepest decline was achieved for men inthe 25–44 year age group and for middle-aged women of45–64 years. An increase could be observed for both gendersover 85 years. The mean age of death from myocardial infarction,however, increased in the same time period by 2 years in menand 4 years in women.     

Uric acid and risk of myocardial infarction,stroke and congestive heart failure in 417 734 men and women in the Apolipoprotein MOrtality RISk study (AMORIS)

Objectives. Few studies have simultaneously analysed the influence of elevated serum uric acid (UA) on acute myocardial infarction (AMI), ischaemic and haemorrhagic stroke (IS, HS) and congestive heart failure (CHF) in large healthy populations. We, here, examine UA as a risk factor for AMI, stroke and CHF by age and gender in the Apolipoprotein MOrtality RISk (AMORIS) Study. Design. Prospective study (11.8 years, range 7–17) of fatal and nonfatal acute myocardial infarction, stroke and CHF through linkage with Swedish hospital discharge and mortality registers. Settings. Measurements of uric acid in 417 734 men and women from health check‐ups in Stockholm area. Results. There was a gradual increase in risk of AMI, stroke and CHF by increasing UA levels. Women had a stronger relationship between UA and both AMI and IS than men. Predictions of AMI were at least as powerful in the elderly as in the young, but not so for IS. Associations were markedly attenuated when adjusted for total cholesterol, triglycerides, hospital hypertension and diabetes status. The association between UA and HS was U‐shaped in both genders. CHF was more strongly related to UA than AMI and stroke and less affected by the adjustment factors. Conclusions. Already moderate levels of UA appear to be associated with an increased incidence of AMI, stroke and CHF in middle‐aged subjects without prior cardiovascular disease. These associations seem to increase gradually from lower to higher levels of UA. UA may be an important complementary indicator of cardiovascular risk in the general population.     

ST段抬高型心肌梗死患者血小板计数/淋巴细胞与冠状动脉病变程度及短期预后的相关性

【摘要】目的 探讨ST段抬高型心肌梗死患者血小板计数/淋巴细胞比值（PLR）水平的变化与冠状动脉病变程度的相关性及PLR对两个月全因死亡率的预测价值。 方法 我院选取2013年4月到2015年4月期间行急诊经皮冠状动脉介入治疗的120例ST段抬高型心肌梗死患者，根据冠状动脉病变的SYNTASX积分评价，将120例患者分为严重冠状动脉病变组和非严重冠状动脉病变组，严重冠状动脉病变组（SYNTASX积分>25）72例，非严重冠状动脉病变组（SYNTASX积分≤25）48例。根据PLR三分位将120例患者分为高PLR组（PLR≥210）42例，中PLR组（210>PLR>90）21例，低PLR组（PLR≤90）57例。分析PLR水平的变化与冠状动脉病变程度的相关性及PLR对两个月全因死亡率的预测价值。结果 在72例患者的严重冠状动脉病变组和有48例患者的非严重冠状动脉病变组中，非严重冠状动脉病变组的血小板计数和PLR明显低于严重冠状动脉病变组的血小板计数，数据有统计学意（P<0.05)。非严重冠状动脉病变组的淋巴细胞计数和高密度脂蛋白胆固醇明显高于严重冠状动脉病变组的淋巴细胞计数和高密度脂蛋白胆固醇，数据有统计学（P<0.05)。非严重冠状动脉病变组中多支血管病变比例，替罗非班使用率，血栓抽吸使用率，两个月全因累积死亡率，明显低于严重冠状动脉病变组，差异具有统计学意义（P<0.05)。SYNTAX的风险比为1.4，95%可信区间为（1.2,1.9），其与患者两个月全因死亡有关联性（P<0.05）。PLR的风险比为1.2，95%可信区间为（1.3,2.0），其与患者两个月全因死亡有关联性（P<0.05）。结论 PLR与ST段抬高型心肌梗死患者的冠状动脉病变程度密切相关，对于患者预后具有一定的预测价值，患者可以通过PLR值了解自己的病情并及时治疗。     

Coagulation factor XIII polymorphisms and the risk of myocardial infarction and ischaemic stroke in young women

The inconsistent findings among association studies that have examined the relationship between factor XIIIA Val34Leu and thrombosis may be owing to (1) population differences in the prevalence of other risk factors that modify the association with Val34Leu, or (2) linkage disequilibrium with other functional factor XIIIA polymorphisms. We therefore performed genotyping for factor XIIIA Val34Leu, Tyr204Phe and Pro564Leu in a population-based study of myocardial infarction (MI) and ischaemic stroke among white women <45-years of age and 345 demographically similar controls, and examined potential interactions with other risk factors. The presence of the factor XIIIA Leu34 allele was associated with a slight decreased risk of MI [odds ratio (OR) = 0.80] that was most pronounced among women with traditional cardiovascular risk factors. Paradoxically, women carrying two copies of the Leu34 allele had a nearly fourfold increased risk of ischaemic stroke relative to the Val34/Val34 genotype. Heterozygosity for factor XIIIA Phe204 was associated with a milder increased risk of ischaemic stroke, and analysis of a kindred with congenital dysfibrinogenaemia suggested that co-inheritance of the factor XIIIA Phe204 allele may increase susceptibility to ischaemic stroke. Our results suggest that the factor XIIIA Val34Leu variant may be associated with a decreased risk of MI among young women with other risk factors. The relationship of factor XIIIA polymorphisms to cerebrovascular disease requires further study.