A survey of the medical and psychosocial status of 140 workers 32 months following myocardial infarct

We suspected there could be different social, psychological, and medical problems for women after a first myocardial infarction than those affecting men. 140 women (56.4 +/- 7 years) were interviewed by questionnaire 32 +/- 8.7 months after myocardial infarction; 83% (n = 119) responded (8.8% of the sample group had died), 12% suffered a reinfarction, and 11% underwent aortocoronary bypass surgery. For 84% of those responding it was harder to do their housework after myocardial infarction, but 73% did it without help. 51.5% showed a mood change that included increasing depression, anxiousness, and insecurity. In 12.5% of the women their relationship with their husband was adversely affected; in 6.6% their relationship with their children worsened. 83% (n = 89) saw their infarction as a result of stress. 45% could not relieve their stress after 32 months. A subjective feeling of stress decrease in 54% was achieved with a quieter life, in 39.5% by resigning their jobs, and in 6.5% by the death of the husband. Concerning somatic risk factors 74% of the smokers stopped smoking; oral contraceptives were discontinued in all cases. 90.5% (n = 97) of the women said they had their serum lipid values checked regularly, but these were only under control in 35%. We conclude the rehabilitation process does not end when patients leave a rehabilitation clinic. Patients should acquire household help, and their family situation should be discussed during their stay in the rehabilitation clinic. Concerning the somatic risk factors, women who survive myocardial infarction require better care and information.     

A school for patients with a history of myocardial infarct and their families: a method of group psychosocial intervention and an assessment of its effectiveness

A group method of psychosocial intervention (a "school") has been developed for post-myocardial infarction patients and their families in order to build up positive attitudes to medical recommendations. The efficiency of the school as well as the social and psychologic factors involved were assessed using the multifactorial scale of psychosocial changes, and 16PF, and "polar profiles" tests, and Leary's method, in 27 post-myocardial infarction patients (mean age 49.8 years) and their 12 wives. It was demonstrated that the patients' attitudes to medical recommendations became more positive, as compared to a control group; moreover, this positive quality persisted over long-term follow-up. Certain personality features (self-image, psychological makeup) affecting the patient's observance of medical advice were demonstrated which should be considered in planning the rehabilitation strategy for myocardial infarction patients. The results indicate that patients' wives should also be enrolled in the group effort.     

Effectiveness of physical training in patients who have had a myocardial infarct

A study of the effects of exercise on cardiovascular function of myocardial infarction survivors showed their physical stress tolerance to increase as a result of improved myocardial contractility and the optimum adjustment of hemodynamic and oxygen support of exercise. Therefore, exercise should be used more extensively as part of the rehabilitation effort following myocardial infarction.     

The unrecognized myocardial infarct in the aged--contribution to prognosis

The poor prognosis of myocardial infarction in old people is based almost completely upon clinical observations. But in the case of patients of advancing years it seems likely that the percentage of undiagnosed infarctions-whether due to atypical symptoms or to the fact that the patient is not admitted to hospital-is considerable. To estimate the level of this percentage a clinical-autoptical analysis of 124 decreased with transmural myocardial scars was carried out (mean age of death: 80 years). This reveals that 80% of all myocardials scars had not hitherto been diagnosed. Only 35% of the electrocardiograms showed definite scars, mostly in the case of patients with known myocardial infarction. 22% of deceased had complained about angina pectoris, again mostly patients with known myocardial infarction. In comparison with other studies of people in the same age group, the results are not surprising. This is only explained in part by old people's poor powers of recollection and their limited ability to communicate. These results indicate that the over all prognosis of acute myocardial infarction in old people, which often does not occur in hospital without being diagnosed should be viewed in a more favourable light than clinical results would suggest.     

Results of long-term conditioning in patients with myocardial infarction during phase III rehabilitation

The active kinesitherapy is an essential constituent of the whole rehabilitation process of patients with infarction. Despite the decrease due to the physiology of ageing and the progression of the coronary disease the physical functional capacity can be kept relatively constant also over many years. Thus the quality of the patients' lives can be favourably influenced. Whether the life expectancy alone can be improved at long date by the active conditioning, further on remains unclarified. Aimed differentiated medication, psychosocial measures, the consideration of secondary bronchopulmonary diseases and the well-timed selection for the coronary-surgical intervention must be included into the process of complex rehabilitation of patients with myocardial infarction. In these cases diagnostics and therapy of the somatic risk factors must particularly be taken into consideration during the whole process of rehabilitation in order to decrease the progressing of the basic disease.     

Biographical analysis and myocardial infarct: a study of myocardial infarction patients and 2 reference groups

In a retrospective case-referent study, 105 male myocardial infarction patients (age: 35-69), 105 hospital referents, and 105 neighbourhood referents, all of the same age, were interviewed with respect to exposure to some psychosocial risk indicators in their lives. These indicators include: Type A coronary-prone behavior pattern; the prevalence of stressful changes in childhood and adolescence, work and career, and family and social life; the syndrome of vital exhaustion and depression, which may precede myocardial infarction. The central question of this study is in what manner and in what connection these risk indicators may affect the lives of myocardial infarction patients. The results indicate that in general the prevalence of Type A behavior is twice as high in myocardial infarction patients as in both referent groups. On the other hand, this difference only reaches significance in younger patients (N = 30; age: 35-44). The prevalence of stressful life changes in myocardial infarction patients is characterized in particular by both the cohort-specific and the "non-normative" nature of these life changes. In young patients (N = 15; age: 35-39), all of whom but one are Type A, only some life changes associated with work and career occur significantly more often. In older patients (N = 30; age: 50-54, and 65-69) the latter problems are replaced by and intermingled with (chronic) conflicts in family and social life, that occur significantly more often. The myocardial infarction patients score significantly higher on the syndrome of vital exhaustion and depression than both referent groups. This syndrome is probably specific to myocardial infarction patients, and appears-unlike Type A behavior-not to be dependent on age. The results are discussed in terms of an "attributional" model that might explain the development of vital exhaustion and depression in the biography of myocardial infarction patients.     

Stage-by-stage rehabilitation of patients with myocardial infarct]

Continuous stage-wise rehabilitation was used in 102 patients who survived acute macrofocal myocardial infarction that was of a transmural type in nearly 60% of them. While hospitalized in a clinic, the patients underwent a 5-week physical activization course. Depending on the severity of the lesion the average duration of their hospitalization ranged from 34.2 to 43.1 days. Seventy patients (68.8%) were referred to the local cardiological sanatorium directly from the hospital. Subsequently all these patients were followed-up (up to 2 1/2 years) and treated on an out-patient basis in the cardiological service of the clinic. Among 88 patients who had worked before infarction, 72 persons (81.8%) returned to their professional activities after 4.9 months, on the average, following the development of myocardial infarction. Professional rehabilitation proved more effective in those who had received the sanatorium treatment after hospital, 87.1% of them returning to their jobs, and nearly 1 month sooner than those who had had no sanatorium treatment. Among the main clinical and instrumental methods of control of the state of myocardial infarction cases during the rehabilitation period the test with portioned physical exercises was also used. The examinations were repeated in 80 patients, in 50 of them -- on the 30th--35th day of the disease. The obtained data indicate that the threshold tolerance of the patients increases due to the stage-wise rehabilitation measures.     

Effect of intensive physical training on the hospital stage of the rehabilitation of patients with macrofocal myocardial infarct

Thirty-five patients with large-focal myocardial infarction were divided into the main (21) and the control (14) groups. The main-group patients were subjected to intensive exercise beginning with day 10-22 of the disease; its program was designed so as to match the data of bicycle ergometry checkups and included bicycle-ergometric riding and rationed walking. It was demonstrated that the main group patients showed better physical stress tolerance, improved myocardial functional potentials, better psychological outlook and smaller pulmonary venous congestion at the time of transfer to the sanatorium stage of rehabilitation. It is suggested that exercise be incorporated in the hospital rehabilitation complex for patients with large-focal myocardial infarction.     

Physical training 2 months after myocardial infarct

Two months after myocardial infarction, 30 patients were subjected to a 10-week physical training course. Following the training, their threshold capacity grew by 46%. The effect of training (increased threshold capacity, reduced double product at submaximum effort) persisted for 1 year after myocardial infarction. In 28 control-group patients, changes of threshold capacity and double product at submaximum effort were not significant over the first post-infarction year. A relatively early post-infarction physical training is not associated with complications and largely speeds up physical rehabilitation.     

Combined disorders of the central and regional hemodynamics and microcirculation in myocardial infarct

Central and regional hemodynamics was studied in 228 patients with acute myocardial infarction by a complex of radio-indication tests. It was established that the degree of changes in central hemodynamics correlates to a definite extent with the severity of myocardial involvement (size of the damaged zone). Regional hemodynamics did not always change parallel to the reduction in cardiac output. The character of circulation in the organs of patients with myocardial infarction depends greatly on the internal control factors and the degree of tonic tension of the regional vessels. Changes in the regional circulation in myocardial infarction lead to hypoxia of the organ and severe disturbances in its function. In most patients the intraorganic hemodynamics decrease gradient was 11/2-2 times more than the cardiac output reduction gradient. Hemodynamic changes in myocardial infarction at the level of different vessels are of a multicomponent and non-linear character. The extent and rate of restoration of intra-organic hemodynamics are greatly determined by the severity of myocardial infraction and the presence of complications.     

Holiday effect in myocardial infarct]

Aimed measures of the organisation of the combat against infarction demand also the observation of temporary frequencies. On the basis of the evaluation of certificates of death of the month December of the years 1969 to 1973 of the GDR with differentiation according to so-called prehospital dead (persons who died at home and on the way to the hospital) and patients who died in the hospital with high significance an unwarrantedly high prehospital mortality during the period from Christmas to the end of the year (25th to 31st December) was established compared with the preceding week (18th to 24th December). Since in contrast to this the hospital cases and the cases "on the way" do not show any significant differences main tasks for the beginning of improvements concerning health policy may be deduced, all the more since the so-called holiday effect, expressed by a high home/clinic-relation of patients who died of myocardial infarction, could be restricted to 6 counties of the GDR on account of the analysis of further localities. From the results the tendency of a retrogression of the holiday effect is to be read off in the course of years. In the discussion an explantation of this peculiarity is attempted, and practicable conclusions for the removal and thus for the improvement the infarct situation are formulated.     

Submaximal stress test and lactate dynamics following acute myocardial infarct in elderly patients

Eighty patients were physically conditioned after definite myocardial infarction (WHO definition). The percentage of patients older than 60 years was 28%. Physical conditioning as part of the non-drug therapy of acute myocardial infarction is of great importance also to older patients. The older patient impaired in his/her performance becomes physically more capable by an individually adapted conditioning and can socially better be re-integrated. A suitable parameter for the demonstration of the efficiency of physical conditioning in older patients is the lactate dynamics.     

Site and type of acute myocardial infarct in relation to myocardial infarct size--dynamics of global ejection fraction in acute myocardial infarct

By the ejection fraction global (EFg) statements concerning the remaining function of the myocardium in acute myocardial infarction and thus individually concerning the prognosis (classification of risk groups) become possible. For the valuation of the dynamics of the EFg in a period up to 6 months after an acute myocardial infarction the EFg was multifariously controlled. Only patients with first myocardial infarction in localization on the anterior wall and Q-wave showed a significant dynamics of the EFg between the measurements acute and third week as well as acute and 6th month (absolutely 5.2%). --In re-infarction/Q-wave this could be confirmed also for the localization of the posterior wall in the period acute till third week. For the localization on anterior and posterior wall a dynamics of the EFg could also be calculated for the period acute and 6th month. Thereby the absolute increase of the EFg was between 4.0 and 4.6%. The dynamics of the EFg in the region of the anterior wall was 5.2% for the first infarction and only 4% for the reinfarction. Thus it is below the dynamics of the EFg in an effective thrombolytic therapy.     

Personality characteristics and the late prognosis of myocardial infarct (results of a 5-year follow-up)

Prospective five-year follow-up of patients with ischemic heart disease who had suffered from macrofocal myocardial infarction between the age of 29 and 54 and who had been previously examined by a psychologist was conducted. Within the five-year period, myocardial infarction recurred in 29 patients (it was fatal in 10), sudden death occurred in 13 patients. Total mortality was 25.5%. The incidence of recurrent myocardial infarction, the frequency of sudden death, and the total mortality of ischemic heart disease were 3, 2.3 and 3 times higher, respectively, in patients classed according to the personality features as type I which is close to type A (63 persons) than in patients (27 persons) possessing premorbidly personality features close to type B (type II). The importance of premorbid personality features in the remote prognosis in myocardial infarction is suggested.     

Clinico-biochemical principles of healing of myocardial infarct]

Individual glyco- and mucoproteins and collagen metabolites were determined in dynamics in 297 patients with transmural, macrofocal nontransmural, and microfocal myocardial infarction. It is shown that these laboratory findings enable one to appraise the course of myocardial infarction healing. This may serve as one of the criteria for the elaboration of individualized rehabilitation programs.     

Heart wall rupture as a grave complication of acute myocardial infarct

The rupture of the heart wall is a severe complication of the acute myocardial infarction. We found it in 3.5% of the deceased patients with an acute myocardial infarction. The average age of these patients was 71 years. 75% of the patients died during the first five days after the event of the myocardial infarction. Apart from elderly patients with myocardial infarction such ones with a transmural myocardial infarction in the region of the left ventricle, an enlargement of the heart and signs of an insufficiency of the left heart, with a hypertension and diabetes mellitus seemed to be endangered. These patients need the most exact control and observation and in case of suspicion (symptomatology of angina pectoris which is continuing to exist) of a developing rupture of the heart wall and aimed diagnostics (echocardiography) and therapy must be begun immediately.     

Organization of rehabilitative treatment of patients with myocardial infarct]

Purposeful continuous comprehensive rehabilitation of myocardial infarction patients is impossible without centralization. The authors share their long-term experience in arranging and running such a centralized stage-wise system of rehabilitation and secondary prophylaxis. All the stages (specialized hospital department -- post-hospital center -- sanatorium -- outpatient dispensary center) are manned with cardiologists, specialists in kinesitherapy and functional diagnosis, psychologists. All the measures are coordinated by persons responsible for the particular stages of rehabilitation. When the patients return to their professional activities, the state of their cardiovascular system is controlled at work, and ECG is recorded during the working hours. The well-coordinated work of all the links of this rehabilitation system permitted to achieve 91.7% restoration of the capacity for work in patients of a pre-retirement age who have survived myocardial infarction. In order to make scientifically substantiated conclusions on the effect of rehabilitation and secondary prophylaxis on the prognosis of the patients joint efforts of several centers are necessary, as well as standardizing all the studies, unification of the criteria of assessment of the patients' state and of the efficacy of the measures taken. This would serve as a foundation for the creation of a rehabilitation system suitable for the practical health services.     

Psychological development up to the 1st year following acute myocardial infarct in relation to physical and social rehabilitation

In 64 patients with definitive myocardial infarction the development of the neurotic-functional disturbances up to the 12th month after myocardial infarction depending upon the duration of the rehabilitation phase I, the physical functional capacity, the cardiovascular morbidity and the professional rehabilitation was examined by means of the standardized questionnaire of complaints and the questionnaire of behaviour after Hess and H?ck. The great proportion of psychic disturbances (questionnaire of complaints = 39%, questionnaire of behaviour = 33%) after admission of the patients from the intensive care unit had reduced spontaneously by 1/3 both in a 5-6 weeks and in a 3 weeks duration of the phase I without fully decreasing to the level of the average population. In these cases patients with low watt energy up to the 3rd month showed more frequently neuroses, whereas cardiovascular complications, the enlargement of the left ventricle and the unsolved situation of the professional rehabilitation increased the number of neuroses in rehabilitands in phase III. The investigations confirmed the connection of physical and social with psychic rehabilitation, particularly the use of the further shortening of the early mobilisation in suitable patients for their psychic stability. But the results of the study also emphasize the necessity of the early beginning psychotherapy, in order to prevent neurotic developments after myocardial infarction.     

Physical rehabilitation of patients with myocardial infarct during the restorative period]

In the in-patient rehabilitation department of the Leningrad cardioheumatological dispensary 276 patients with large-focal and transmural myocardial infarction were kept under observation. The programme of physical rehabilitation envisaged the employment of kinesitherapy with increasing workload, dosaged walking up to 2--3 km, mounting the stairs within 3--5 floors. The reaction to the prescribed exercises was determined by the figures of pulse rate, arterial pressure and electroacrdiographic indices. The patients were transferred to the rehabilitation department from the city hospitals and clinics 3 1/2 to 8 weeks after the infarction, depending on the severity of the lesion. In 87% of the patients the term of treatment in the rehabilitation department ranged from 20 to 30 days, the rest of the patients were discharged at a later date. Over half of the patients fulfilled the complete programme of physical rehabilitation, the rest -- in an incomplete form.     

Microfocal myocardial infarct as a variant of exacerbation of ischemic heart disease

The results of long-term (3- to 4-year) follow-up of 180 patients with microfocal myocardial infarction are analysed. The difference in the course and prognosis of primary and recurrent microfocal myocardial infarction is determined. It is shown that microfocal myocardial infarction as a form of exacerbation of ischemic heart disease is characterized by a complex of syndromes differing from the typical picture of marcrofocal myocardial infarction. As compared to macrofocal myocardial infarction, the course of the disease after microfocal myocardial infarction is characterized by more frequent exacerbations of coronary insufficiency and a greater tendency toward the development of recurrent myocardial infarction. In some cases, microfocal myocardial infarction heralds the development of macrofocal myocardial infarction with a severe course and high mortality rate, which provides the grounds for the conclusion that patients with microfocal myocardial infarction have a lower coronary reserve.