Beta-blocker use in elderly ED patients with acute myocardial infarction

BACKGROUND: Despite the effectiveness of early beta-blocker (BB) use in reducing mortality in acute myocardial infarction (AMI), they remain underutilized in the emergency department (ED) management of AMI. The elderly, with higher AMI mortality, and women, may be particularly vulnerable to underutilization of BB. OBJECTIVE: To determine the effect of age and gender on BB use in AMI in the ED. METHODS: A retrospective study of all ST-elevation AMI (STEMI) ED patients presenting to a community hospital ED from 2001 to 2003. Any contraindication to BB use (hypotension, bradycardia, AV block, active bronchospasm, and active congestive heart failure) was determined. Chi-square analysis was used to determine differences by gender and age. RESULTS: Three hundred eighty-five patients with STEMI were identified. Thirty-eight percent were women and 71% were over 60 years of age. Of the 270 (70%) who did not receive BB, 141 (52%) had contraindications to BB use. The total BB eligible group was 244 (63%). Of patients without contraindications to BB, 53% did not receive BB in the ED. By gender, 83 (54%) males and 46 (51%) females did not receive BB (P=.669). By age, 96 subjects (59%) over age 60 and 33 subjects (41%) under age 60 did not receive BB (P=.011). CONCLUSION: Despite convincing evidence of effectiveness, BB remain underutilized in ED management of AMI, especially in the elderly. There does not appear to be a gender difference in BB use. Education programs should be directed towards emergency physicians regarding BB use in AMI, especially in elderly ED patients.     

The use of cough-CPR in patients with acute myocardial infarction.

A case of a patient with an acute anterior myocardial infarction (MI) and ventricular fibrillation is presented. The patient was resuscitated after cough-cardiopulmonary resuscitation (C-CPR) was administered in the emergency department. The patient received thrombolytic therapy without complication. Cough-CPR is a technique not in widespread use. With the advent of thrombolytic therapy for patients with acute myocardial infarctions, a relative contraindication to thrombolytic therapy is present in patients who receive "standard CPR." The use of cough-CPR in witnessed dysrhythmias can alleviate this problem. Cough-CPR can also reduce the morbidity of resuscitations.     

Stroke in patients with acute myocardial infarction

The analysis has been performed of 40 cases of acute myocardial infarction with concomitant stroke versus 26 cases of acute myocardial infarction alone. Being a complication of acute myocardial infarction in 0.94% of the cases, the stroke was ischemic in 95% and hemorrhagic in 5% of the patients. Association of the two events accounted for lethal outcomes in 80% of the cases. The principal factors of the stroke risk in myocardial infarction are suggested. They involve: an advanced age, cardiac arrhythmias, cardiogenic shock, diabetes mellitus, recurrent or transmural myocardial infarction, previous acute episodes of disturbed cerebral circulation, essential hypertension and hyperglycemia.     

急性心肌梗死患者低钙血症情况分析

目的 探讨急性心肌梗死患者低钙血症的发生及其与预后的关系. 方法 对2003年1月至2006年12月哈尔滨医科大学附属第一医院CCU病房收治的1274例急性心肌梗死患者进行回顾性分析,常规方法测定血浆钙离子浓度,依据最低值进行分组,A组Ca2+≥2.20 mmol/L,B组Ca2+(2.00～2.19)mmol/L,C组Ca2+(1.90～1.99)mmol/L,D组Ca2+<1.90 mmol/L组,比较各组间病死率,并分析可能与之相关的因素.于入院后2～3 d内行床旁超声心动图检查. 结果 A组Ca2+≥2.20mmol/L,共668例(52.4%);B组(2.00～2.19)mmol/L,共476例(37.4%);C组(1.90～1.99)nnnol/L,共73例(5.7%);D组Ca2+<1.90 mmol/L,共45例(3.5%).A、B、C、D各组的死亡情况分别为17(2.5%)、37(7.8%)、15(20.5%)、8(17.8%),差异具有统计学意义(P<0.001);对急性心肌梗死后30 d住院期间死亡危险因素进行Logistic回归分析,血钙浓度是否低于2.2 mmol/L的OR值为0.501(P=0.044). 结论 低钙血症的发生是急性心肌梗死后30 d病死率的独立预测因子.     

Sleep apnea in patients with acute myocardial infarction

OBJECTIVE: To document sleep apnea in the acute phase of myocardial infarction. If apnea occurs in patients with myocardial infarction, hypoxemia induced by apnea might exaggerate insufficiency of oxygen supplied to the damaged myocardium. DESIGN: Prospective controlled study. SETTING: Critical care unit of a teaching hospital. PATIENTS: Forty-nine patients, average age 64 yrs (range 49 to 91). MEASUREMENTS AND MAIN RESULTS: Patient measurements were recorded on a polygraph using an apnea-monitor, pulse oximeter, pulmonary artery pressure monitor, and an ECG. All of the patients observed showed frequent apneic episodes. The apnea was especially frequent when the cardiac index was low. Capillary oxygen saturation of less than 90% (suggesting systemic hypoxia) was observed in 21 patients concomitantly with apnea. Occasionally, arrhythmias followed these episodes (premature supraventricular contractions [n = 10], premature ventricular contraction [n = 4], and ventricular tachycardia [n = 2]). CONCLUSIONS: This study suggests that sleep apnea is common in the setting of acute myocardial infarction. It may be a factor predisposing to, or even causing, sudden death in patients with acute phase of myocardial infarction.     

Racial differences in the use of cardiac procedures in patients with acute myocardial infarction

BACKGROUND: Although numerous studies have shown that Black patients are less likely than White patients to undergo cardiac procedures, most of these studies did not consider clinical and demographic factors that could account for observed racial differences. OBJECTIVE: To determine if there are racial differences in the use of coronary angiography and revascularization procedures in patients with acute myocardial infarction, while controlling for multiple potentially important demographic and clinical variables. METHODS: In this retrospective cohort study, data were obtained from medical records of 642 consecutive Black and White patients with acute myocardial infarction at a regional cardiac referral center in southern New England. RESULTS: Blacks were significantly less likely than Whites to undergo angiography (p =.004; adjusted odds ratio =.36; 95% confidence interval =.18 -.72) and revascularization procedures (p =.006; adjusted odds ratio =.21; 95% confidence interval =.07 -.64). In the subgroup admitted directly to the hospital (n = 465), rather than transferred in from outlying hospitals, there were no racial differences in the use of angiography, but Blacks were significantly less likely to undergo revascularization procedures (p =.004; adjusted odds ratio =.18; 95% confidence interval =.06 -.58). CONCLUSIONS: In patients hospitalized with acute myocardial infarction, there are substantial racial differences in the use of angiography and revascularization procedures that cannot be explained by clinical or demographic factors.     

Cocaine use and acute myocardial infarction

Cocaine use in the United States is widespread, affecting more than 30 million Americans. Although many of these persons do not seek healthcare, the overriding cause for hospitalization is cocaine-associated chest pain. Because only a minority of these patients suffer myocardial injury, it is important to exclude even rarer life-threatening causes for chest pain, such as aortic dissection or pneumothorax. Following that, a thorough knowledge of the pathophysiology and existing literature helps to provide cost-effective care, which focuses resources on those patients most likely to suffer complications. Regardless of the severity of complications, referral to cocaine detoxification programs, counseling, social support, and outpatient follow-up care for modification of cardiac risk factors is a fundamental component of long-term patient care.     

结肠癌术后突发急性广泛前壁心肌梗死合并室颤致心搏呼吸骤停成功救治一例

急性心肌梗死(myocardial infarction)即急性心肌缺血性坏死,大多是在冠脉血供急剧减少或中断,相应心肌出现严重而持久的急性缺血导致心肌坏死,美国35～ 84岁人群发病率男性为71‰,女性为22‰,每年约有150万人发生急性心肌梗死[1-2].随着我国老龄化的加重,外科围手术期出现急性心肌梗死的情况越来越多见[3],但出现反复心室颤动致心搏呼吸骤停而获得抢救成功病案较少[4],结肠癌根治术后出现急性广泛前壁心肌梗死并发室颤抢救成功的案例更是罕见.     

急诊经皮冠状动脉介入治疗与远端血栓保护装置PercuSurge Guardwire联合治疗急性心肌梗死

目的评价远端血栓保护装置PercuSurge Guardwire在急性心肌梗死(AMI)的高危急诊经皮冠状动脉介入(PCI)治疗中预防远端血栓栓塞并发症的临床疗效及安全性.方法 92例AMI患者为研究对象,其中47例在急诊PCI过程中联合应用PercuSurge Guardwire装置(PercuSurge组),平均年龄(61.4±7.1)岁;另45例进行常规无PercuSurge Guardwire保护的急诊PCI(对照组),平均年龄(64.9±8.3)岁.比较两组急诊PCI术后即刻冠状动脉TIMI血流及院内、30天主要心脏不良事件发生率.结果全部病例均成功植入血管支架并放置PercuSurge Guardwire保护装置.平均阻滞球囊直径(4.5±0.5) mm,平均阻滞时间(8.7±5.9)min.PercuSurge组术后TIMI 3级血流率显著高于对照组(95.74与86.67%,P＜0.05),无血流事件发生率显著降低(0%与6.67%,P＜0.05).并发症包括血管夹层1例(2.13%),远端小血管血栓栓塞1例 (2.13%).随访全部患者,PercuSurge组院内及30天心脏不良事件发生率均显著低于对照组(分别为2.13%与13.33%,2.13%与8.89%,P值均小于0.05).结论联合应用 PercuSurge Guarwire远端保护装置在AMI患者的急诊PCI过程中可安全有效地预防远端血栓栓塞并发症的发生,显著提高术后TIMI 3级血流率,显著降低无血流事件发生率,从而显著降低患者院内及30天主要心脏不良事件发生率.     

Sexuality in acute myocardial infarction patients

We as nurses in the Coronary Unit we do not see the sexuality of the patients sufficiently addressed neither by us nor by the patients themselves. In this article we are trying to analize the reasons and to emphasize the need to include this subject in our Nursing Problem List.In it we explaine the fears and the wrong ideas that we have identified in our patients. The sexual function is not affected by a myocardial infarction but psychological factors, age, drugs and other associated diseases might be a reason.A quiet enviroment, a fit training plan and looking for personalise proper alternatives may help the patient to start a satisfactory sexual life again.     

Prevalence of right ventricular myocardial infarction in patients with acute inferior wall myocardial infarction

The objective was to evaluate the prevalence of right ventricular myocardial infarction (RVMI) in patients with acute inferior wall myocardial infarction (IWMI) admitted to the National Institute of Cardiovascular Diseases, Karachi, Pakistan. Between August 2000 and May 2001, a total of 100 patients with acute IWMI were enrolled. History of all patients was taken, and thorough clinical examination was performed to asses the presence of signs of right ventricular infarction. Standard 12-lead electrocardiogram was recorded immediately on arrival of patients along with right precordial leads. All patients were considered for thrombolytic therapy in the absence of any contraindication and were managed with standard treatment strategies. Complications arising during the course of admission were recorded and compared between the two groups. There were 86 (86%) males and 14 (14%) females. Mean age was 56.3 +/- 13.13 years (range 33-83 years). The prevalence of RVMI in IWMI was 34%. Smoking and diabetes were more prevalent in RVMI group, while hypertension and family history of ischemic heart disease were more common in isolated IWMI. Ninety per cent of patients received thrombolytic therapy. In-hospital mortality (23.5%) was higher in RVMI group than isolated IWMI (18.1%). Other major complications were also higher in RVMI group than isolated IWMI. Right ventricular infarction was found in approximately one-third of IWMI. Right ventricular infarction was associated with considerable morbidity and mortality, and its presence defines a higher risk subgroup of patients with inferior wall left ventricular infarction.     

1827例急性心肌梗死患者梗死部位的相关分析

目的　调查不同部位急性心肌梗死患者梗死的发病特点。方法　通过回顾病史 ,将符合诊断标准的住院患者按照不同发病部位分组 ,分别记录发病特点 ,了解不同发病部位的构成比 ,不同发病部位的男女构成比以及发病部位与病死率的关系。结果　符合条件的病例共 182 7例 ,前壁急性心肌梗死 (前壁、前间壁和广泛前壁 )占总发病的 4 5 8% ,其次是下壁急性心肌梗死组占 2 6 7%。在所有部位急性心肌梗死病例中 ,男性发病比例 (6 4 0 %～ 88 3% )与女性 (11 7%～ 36 0 % )相比均有很大差别 (P <0 0 5 )。各部位急性心肌梗死的病死率为 8 7%～ 2 0 6 %。除急性前壁合并下壁组心肌梗死病例病死率差异有显著性外 (P <0 0 5 ) ,其他部位急性心肌梗死患者的病死率与急性心肌梗死平均住院病死率相比差异未见显著性(P >0 0 5 )。结论　急性心肌梗死以前壁或下壁为主 ,男性仍是发生急性心肌梗死的主要人群 ,急性前壁和合并下壁心肌梗死的病死率显著高于急性心肌梗死平均病死率。     

Newer fibrinolytic agents in patients with acute myocardial infarction

Summary Fibrinolytic agents with higher specificity for fibrin in the thrombi and little systemic activation of the fibrinolytic system have been developed and tested in preliminary clinical trials of patients with acute myocardial infarction. The largest published experience available has been with recombinant tissue plasminogen activator, which seems to be more effective than streptokinase in lysing coronary thrombi. The acylated streptokinase-plasminogen complex BRL 26921 and pro-urokinase also gave promising preliminary results. All these agents, however, were accompanied by unexpectedly high incidence of systemic activation of the fibrinolytic system and by hemorrhagic complications with frequencies similar to those accompanying streptokinase. Hence, their superior clinical efficacy must be clearly proven before they are substituted for a more widely available and less expensive drug, such as streptokinase.     

Beta-blocker use in the emergency department in patients with acute myocardial infarction undergoing primary angioplasty

Our objectives were to evaluate the frequency of β-blocker administration in the setting of acute myocardial infarction (AMI) where angioplasty is the primary treatment, and to investigate Emergency Physician’s (EPs) attitudes toward β-blockers. We performed a retrospective chart review of all patients who presented with symptoms and electrocardiogram (EKG) criteria consistent with AMI in the defined study period. Charts were reviewed for β-blocker administration and other treatments. A survey was subsequently distributed to all EPs to determine self-reported reasons for withholding β-blockers. There were 91 patients identified. Of those who did not have contraindications, 99% (89/90) received aspirin, 97% (88/91) received heparin, 94% (84/89) received nitrates, but only 28% (19/68) received β-blockers. Ninety-six percent of β-blocker-eligible patients received them as inpatients. Eighty-six percent (44/52) of EPs completed the survey. Physicians felt strongly about avoiding β-blockers in patients with asthma exacerbation, severe congestive heart failure, and high degree AV block. Bradycardia was the most frequent reason for withholding β-blockers. In this series of patients presenting with AMI, β-blockers were greatly underutilized. The self-reported reasons of EPs for withholding β-blocker therapy did not explain why 72% (49/68) of patients without contraindications did not receive β-blockers.     

Disopyramide kinetics in patients with acute myocardial infarction.

The kinetic behavior of disopyramide was studied in 20 patients with suspected myocardial infarction: in 13 of these, the diagnosis was subsequently confirmed. All received a 400-mg oral loading dose of disopyramide base followed by an oral maintenance regimen of either 100 or 200 mg 4 times daily. The elimination half-life (t1/2beta) was longer (p less than 0.05) in patients with confirmed infarction than in patients with unconfirmed infarction [38.0 +/- 3.7 hr (mean +/- SEM) compared to 24.3 +/- 0.8 hr, and 21.2 +/- 2.1 hr compared to 7.2 +/- 2.4 hr for the 100- and 200-mg maintenance dose regimens, respectively]. The t1/2beta was dose dependent for infarct and noninfarct patients. Two of the patients with confirmed infarction failed to reach trough plasma levels equal to or exceeding the lower end of the manufacturer's recommended therapeutic range (3.3 mug/ml) during the study. For the remaining 11 patients the time taken to achieve trough plasma levels of 3.3 mug/ml varied from 18 to 170 hr; hence plasma disopyramide concentration in these patients was suboptimal at a time when the risk of arrhythmias is high. Modification of existing oral loading dose regimens is therefore required for optimization of oral disopyramide therapy.