Non-Q wave myocardial infarction.

Non-Q wave myocardial infarction is a distinct and changing clinical entity characterized by lower initial mortality and a higher rate of reinfarction compared to Q wave infarction. Clinical and pathologic data suggest that the syndrome results from transient or incomplete coronary occlusion resulting in an infarct which is smaller than when Q waves are present. High-risk patients can be identified during hospitalization, allowing for aggressive therapy aimed at revascularization. Relatively few clinical trials have examined initial therapy or secondary prevention in this group of patients. These studies are reviewed and management guidelines suggested.     

再发性心肌梗死危险因素的预测及预防

目的 识别再发性心肌梗死的高危人群并进行预防性治疗。方法 观察曾在该院住院、并进行随访的心肌梗死患者，分为再梗组和非再梗组，观察两组患者的临床特点。结果 初发急性心肌梗死年龄大、合并高血压、糖尿病、吸烟、梗死后心绞痛的患者发生再梗死的机宰大。结论 初发急性心肌梗死年龄大、合并高血压、糖尿病、吸烟、梗死后心绞痛的患者是再梗死的危险因素。预防包括：危险因素的干预、药物预防及介入治疗。     

静脉溶栓治疗100例老年急性心肌梗死患者的护理措施

目的探讨静脉溶栓治疗老年急性心肌梗死患者应采取的护理措施及其临床应用效果。方法按随机数字表法将我院2012年1月—2014年6月收治的100例老年急性心肌梗死患者分为对照组和观察组,每组50例。两组均行静脉溶栓治疗,对照组给予常规护理,观察组给予针对性护理,比较两组患者的并发症及血管再通率。结果对照组护理后发生严重心律失常9例,心力衰竭12例,再梗死10例;观察组护理后发生严重心律失常2例,心力衰竭2例,再梗死6例,观察组严重心理失常及心力衰竭的发生率明显低于对照组,比较差异具有统计学意义（P〈0.05）,再梗死发生率比较差异无统计学意义（P〉0.05）。对照组血管再通39例,占78%;观察组血管再通14例,占28%,组间比较差异具有统计学意义（P〈0.05）。结论老年急性心肌梗死患静脉溶栓治疗时实施针对溶栓的特殊护理可降低并发症发生率和死亡率,具有临床推广价值。     

Risk factors for long-term coronary prognosis after initial myocardial infarction: the Framingham Study

The role of standard coronary heart disease risk factors in predicting the long-term risk of recurrent coronary events in survivors of myocardial infarction is examined. Of 697 subjects (464 males and 233 females) who experienced an initial myocardial infarction during 30 years of follow-up in the Framingham Study, 459 returned for a baseline examination and were followed for up to 32 years (mean = 9.7 years) for incident reinfarction or coronary death. The Cox proportional hazards model was used to evaluate the relation of postinfarction risk factors with reinfarction and coronary death. Age-adjusted analyses showed the risk of reinfarction to be positively associated with blood pressure and serum cholesterol. Risk of coronary death was strongly associated with blood sugar level, systolic blood pressure, serum cholesterol, heart rate, diabetes, and interim reinfarction. In multivariable analyses, systolic pressure, serum cholesterol, and diabetes were predictive of reinfarction; relative weight was inversely associated with reinfarction. Systolic pressure, serum cholesterol, and the prevalence of diabetes persisted as independent predictors of coronary death. When adjustments were made for the effects of these variables, women were at only half the risk of coronary death compared with men. Higher baseline risk factors in women compared with men may obscure an important survival advantage in women. In persons recovered from an initial myocardial infarction, standard risk factors, particularly systolic pressure, serum cholesterol, and diabetes, remain important determinants of coronary prognosis over many years and warrant attention in preventing subsequent events.     

Non-pharmacological treatment of heart failure: implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy

The non-pharmacological therapy of heart failure, in particular an implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy or biventricular stimulation, improves symptoms and survival in patients with heart failure. An ICD is indicated in many patients with heart failure following cardiac arrest unless reversible causes are demonstrable. Selected patients with a left ventricular ejection fraction < or = 35% due to either ischaemic (>40 days after a myocardial infarction) or nonischaemic cardiomyopathy are candidates for ICD implantation as the primary prevention of sudden cardiac death. Patients who continue to have severe symptoms despite maximal pharmacotherapy, with a left ventricular ejection fraction < or = 35% and a wide QRS complex, are candidates for cardiac resynchronisation therapy to improve both symptoms and survival.     

Gender,Recovery from Late Life Heart Attack and Medical Care

It has only recently been recognized that there are sigmfkant gender effects on heart disease and that women face increasing risks as they age. A longitudinal study of 246 older myocardial infarction (MI) patients included a 113 sample of women Findings indicate that over the first post-MI year, women had greater risk of death, cardiac distress and reinfarction. Cardiac symptoms of men declined while those of women increased. Several medical care and social disadvaatages were found among the post-MI women, including less aggressive cardiac care. Furthermore, since morbidity and mortality were related to medical care aad social disadvantages, the results support gender-age stratification theories.     

急诊科心肌梗塞临床救治分析

目的:观察分析急诊科心肌梗塞的临床救治方法及救治效果,总结其临床意义。方法:选取某医院72例心肌梗塞患者,遵照患者和(或)家属意见,分为静脉溶栓组与未溶栓组,各36例,静脉溶栓组采取急诊科静脉溶栓治疗,未溶栓组未给予静脉溶栓治疗,观察比较两组效果,进行统计学分析。结果:两组患者治疗后的血管再通率、心功能改善率及病死率比较存在明显差异(P<0.05),具有统计学意义。静脉溶栓组死亡原因为心室颤动1例,心源性休克1例;未溶栓组死亡原因为心室颤动4例,心源性休克2例,心脏破裂1例。结论:急诊科对心肌梗塞患者收治后应及早诊断,并尽快采取急诊溶栓治疗,减少并发症发生,改善心功能,以争取时间抢救患者生命,对全面提高治愈率,减少病死率具有重要的临床意义。     

Prognostic importance of somatic and psychosocial variables after a first myocardial infarction

The prognostic importance of somatic and psychosocial variables after a first myocardial infarction was studied in 201 consecutive Gothenburg, Sweden men below 61 years of age who had survived a first myocardial infarction between December 1976 and December 1978. The maximum follow-up time was 100 months. The prognostic importance of somatic, social, and psychological variables was related to the endpoints of death, nonfatal reinfarction, and total events. During follow-up, 48 deaths and 37 nonfatal recurrences occurred. Four variables, none of them significantly correlated with each other, were related to risk of an endpoint. Being single increased risk of death (p less than 0.01) and risk of all events (p less than 0.001), whereas an index reflecting infarct size was correlated to risk of death (p less than 0.001). A prognostic index based upon data available at three months after the myocardial infarction (angina pectoris, hypertension, serum aspartate aminotransferase (S-ASAT) maximum, and smoking) was correlated to risk of nonfatal reinfarction (p less than 0.05). Use of sedatives was also related to risk of reinfarction (p less than 0.05) and to risk of total event (p less than 0.05). The probability of death, reinfarction, and total event was estimated within two and five years after the infarction for all combinations of the variables that were related to risk of an endpoint. It was thus demonstrated that the predictive power increased over time and that the somatic and psychosocial variables independently added information.     

Omega-3 polyunsatured fatty acids role in postmyocardial infarction therapy

Largely initiated by studies among Eskimos in the early 1970s, great attention has been given to possible effects of omega-3 polyunsatured fatty acids (PUFA) in cardiovascular diseases. A series of positive effects on pathogenetic mechanisms of cardiovascular disease has been discovered from laboratory studies in cell cultures, animal models and in humans. omega-3 PUFA can reduce platelets and leucocytes activities as well as plasma triglycerides. Moreover they can have antiarrhythmic properties. Nowadays patients who experienced myocardial infarction have decreased risk of total and cardiovascular mortality by treatment with omega-3 PUFA (1 g daily). This effect is present irrespective of high or low fish intake or simultaneous intake of other drugs for secondary prevention of coronary heart disease. Mainly on the basis of GISSI Prevention trial results, dietary supplementation with omega-3 PUFA is now recommended as a new component of secondary prevention after myocardial infarction in national and international guidelines.     

Secondary prevention of coronary heart disease in older British men: extent of inequalities before and after implementation of the National Service Framework

BACKGROUND: Deficiencies in implementation of secondary prevention of coronary heart disease (CHD) have been identified. We explored the extent of medication use for secondary prevention of CHD since the introduction of the National Service Framework (NSF) for CHD and the influence of patient age, social class, region and time since diagnosis in older British men. METHODS: Prospective study in 24 British towns using patient information on medication use in 1998-2000 and 2003. Subjects were men with medically recorded diagnosis of myocardial infarction or angina, aged 62-85 years in 2003. Prevalence of medication use (aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers) in 1998-2000 and 2003 was ascertained. RESULTS: Prevalence of use of all drugs increased in 2003 and was markedly higher in patients with a history of myocardial infarction than angina. Older age was related to lower prevalence of drug use, particularly statins. In 2000, older subjects (74-85 years) were 60% [95% confidence interval (CI) = 41-72 per cent] less likely to receive statins compared with younger subjects (62-73 years); this pattern changed very little between 2000 and 2003. Although social class appeared to have little relation to drug use, the prevalence of use of all medications decreased with increasing time since diagnosis. CONCLUSIONS: Although the uptake of medications for secondary prevention in CHD patients increased since the NSF in 2000, marked age inequalities in statin use were present both in 1998-2000 and 2003. Further action is needed to reduce these inequalities, because older patients are at particularly high risk of recurrent and fatal CHD.     

Trial of pioglitazone for the secondary prevention of cardiovascular events in patients with diabetes mellitus type 2: insufficient evidence

The PROactive study was a multicentre, multinational, double-blind, placebo-controlled randomised trial that was intended to show a benefit of pioglitazone in the secondary prevention of cardiovascular disease in patients with diabetes. However, the result for the primary composite endpoint was not significant. The most important secondary endpoint (time to death, myocardial infarction or cerebrovascular accident) did show a significant reduction of 16%, but any potential benefit was outweighed by a major increase in the incidence ofhospitalisation for heart failure in the pioglitazone-treated group. Moreover, in this secondary prevention trial, there was marked undertreatment with statins while no effect of pioglitazone was observed in those who did receive a statin. Finally, no adjustment was made for the poorer glycaemic control in the placebo group. Based on these data, broadening the indication for pioglitazone in patients with diabetes cannot be recommended.     

Secondary prevention in coronary heart disease

After myocardial infarction, beta-blockers, aspirin and (in selected patients) ACE inhibitors all reduce substantially the risk of further myocardial infarction or coronary death. With regard to life-style changes, giving up cigarette smoking reduces coronary risk by about 50%. Weight reduction and regular exercise are advised, although the effect of these measures on prognosis is uncertain. Recently, two major trials, the Scandinavian Simvastatin and West of Scotland Pravastatin studies, have radically changed ordinary medical practice. In these trials HMG CoA reductase inhibitor (statin) treatment reduced coronary events by 30–40%, reduced all-cause mortality, and proved safe and well-tolerated. The accepted policy now is to treat all patients with coronary heart disease, who have a cholesterol concentration 5.5 mmol/l or higher, with a statin. Where does this leave cholesterol-lowering dietary advice in secondary prevention? The benefits of statin treatment were attained by reducing serum cholesterol by an average of 25%. Diet change rarely attains such a fall in cholesterol and should therefore be used only as an adjunct to drug therapy. When recommending a lipid-lowering diet there is a danger that patients may be denied highly-effective drug treatment because of the «threshold» effect. A decision on the need for cholesterol reduction should be made before diet change is advised. Once the decision is made the target is a 25% cholesterol reduction, which will require drug therapy in addition to diet changes.     

Long-term anticoagulant treatment after acute myocardial infarction. The Warfarin Re-Infarction Study.

High levels of fibrinogen and clotting factor VII are associated with an increased risk for subsequent death and cardiovascular disease in apparently healthy individuals. Furthermore, pathoanatomic studies and coronary angiography have confirmed a relationship between coronary thrombus formation and acute Q-wave infarction. Effective antithrombotic agents may prevent or limit thrombus formation and events related to thrombosis. The Warfarin Re-Infarction Study (WARIS) studied the effect of warfarin in survivors of acute myocardial infarction. Patients aged 75 years or less were randomized in a double-blind, placebo-controlled study to test whether long-term treatment with warfarin reduces the risk of death, reinfarction, and thromboembolic morbidity. A total of 1918 patients were screened for participation; 1214 were recruited. The mean follow-up was 37 months. Analyzed on an intention-to-treat basis, 123 (20%) in the placebo group died, versus 94 (15%) in the warfarin group, a risk reduction of 24% (P = 0.026). Considering patients on treatment or within 28 days after discontinuing the test medication, 92 in the placebo group died, as compared with 60 of the warfarin-treated patients, a risk reduction of 35% (P = 0.005). Relapsing myocardial infarction (fatal and nonfatal) was reduced by 43% (P = 0.0001). The incidence of cerebrovascular attacks was lower in the warfarin group (16 patients) than the placebo group (41 patients), a highly significant reduction of 61% (P = 0.0003). Serious bleeding occurred in 11 patients taking warfarin, an incidence of 0.6% per year. In conclusion, long-term anticoagulant therapy may be recommended after acute myocardial infarction.     

The effects of time-released garlic powder tablets on multifunctional cardiovascular risk in patients with coronary artery disease

The double-blinded placebo-controlled randomized study has been performed in 51 coronary heart disease (CHD) patients to estimate the effects of time-released garlic powder tablets Allicor on the values of 10-year prognostic risk of acute myocardial infarction (fatal and non-fatal) and sudden death, with the respect of secondary CHD prevention. It has been demonstrated that 12-month treatment with Allicor results in the significant decrease of cardiovascular risk by 1.5-fold in men (p < 0.05), and by 1.3-fold in women. The above results were equitable also in terms of relative risks. The main effect that played a role in cardiovascular risk reduction was the decrease in LDL cholesterol by 32.9 mg/dl in men (p < 0.05), and by 27.3 mg/dl in women. Thus, the most significant effects were observed in men, while in women the decrease of cardiovascular risk appeared as a trend that might be due presumably to the insufficient sample size. Since Allicor is the remedy of natural origin, it is safe with the respect to adverse effects and allows even perpetual administration that may be crucial for the secondary prevention of atherosclerotic diseases in CHD patients.     

Aldosterone antagonism in heart failure

Aldosterone, a neurohormone known to affect electrolytes, has recently been implicated as playing a major role in the progression of heart failure, particularly in patients with systolic dysfunction. Major clinical trials designed to analyze clinical outcomes using an aldosterone antagonist have been done in two groups with heart failure. The first was the Randomized Aldactone Evaluation Study, which was done in symptomatic chronic advanced heart failure patients and showed that an aldosterone antagonist, spironolactone, reduced mortality significantly compared with placebo. Very few of these patients were on standard therapy with beta blockade. Another study, the Eplerenone Post myocardial infarction Heart failure Efficacy and SUrvival Study (EPHESUS), done in post-myocardial infarction patients with heart failure, demonstrated a significant reduction in mortality and hospitalizations for patients randomized to the aldosterone antagonist eplerenone. These trial results provide the background for aldosterone antagonist therapy in chronic advanced heart failure patients as well as post-myocardial infarction heart failure patients with reduced ejection.     

Myocardial infarction in an urban population: worse long term prognosis for patients from less affluent residential areas

STUDY OBJECTIVE: The objective in this follow up study from the Malm? myocardial infarction register has been to assess whether long term survival following discharge after first myocardial infarction has any relation with the socioeconomic environment and to assess to what extent intra-urban differences in mortality from ischaemic heart disease can be accounted for by covariance with long term survival following discharge after acute myocardial infarction. DESIGN: Register based surveillance study. SETTING: Seventeen residential areas in the city of Malm?, Sweden. PARTICIPANTS: The cohort contains all 2931 male and 2083 female patients with myocardial infarction who were discharged for the first time between 1986-95 from Malm? University Hospital. MAIN RESULTS: During the on average 4.9 years of follow up 55% of the patients died. The sex adjusted and age adjusted all cause mortality rate/1000 patient years ranged between residential areas from 85.5 to 163.6. The area specific relative risk of death after discharge was associated with a low socioeconomic score, r=-0.56, p=0.018. Major risk factors for cardiovascular disease were more prevalent in areas with low socioeconomic score and low rates of survival. Of the intra-urban differences in mortality from ischaemic heart disease, 41% could be accounted for by differences with regard to the survival rate after discharge. CONCLUSIONS: The results are compatible with the hypothesis that the socioeconomic environment plays an important part in the survival rate of patients with myocardial infarction. To assess the preventive potential, the extent to which socioeconomic circumstances covary with severity of disease, respectively with the use and compliance with secondary preventive measures, needs to be evaluated.     

Cardiovascular disease--linking pathology and epidemiology.

BACKGROUND: Coronary heart disease (CHD) in the form of myocardial infarction first came to attention early in the 20th century. Mortality from CHD increased dramatically after the First World War and had assumed epidemic proportions, particularly in the USA, by 1945. The ensuing research stemmed almost exclusively from the lipid infiltration hypothesis for atheroma. METHODS: Using epidemiological methods, pathological evidence for the thrombotic component of CHD was demonstrated by Morris as early as 1951. Morris's main work was based, first, on routine autopsy records at the London (now Royal London) Hospital and, second, on the National Necropsy Survey relating physical activity at work to pathological findings. RESULTS: The indications from Morris's work that thrombosis contributes as much to clinical CHD as atheroma were in due course strengthened by the findings of clinical trials of aspirin, prospective studies incorporating measures of haemostatic function and further studies of pathology. CONCLUSIONS: Recognition of the thrombotic contribution to CHD does not materially alter approaches to prevention through lifestyle modifications but does have major implications for pharmacological measures. Thus, aspirin and thrombolytic therapy are mandatory in the acute stage of suspected myocardial infarction while aspirin is also part of accepted practice in the longer term in secondary prevention. The value of warfarin is being rediscovered, often at a lower and therefore safer intensity of anticoagulation than previously considered necessary. The effect that warfarin may have on the vessel wall as well as on occlusion of the lumen is helping to reconcile the two major hypotheses for the pathology of CHD. Much of our current knowledge about the origins, management and prevention of CHD stems from Morris's early studies linking pathology and epidemiology.     

Reperfusion therapy for patients with an acute myocardial infarct with ST-segment elevation: fibrinolysis versus transport to a cardiac center for primary angioplasty

Although fibrinolytic therapy for acute myocardial infarction is widely used and can be administered prior to hospitalisation, it is only successful in restoring full early coronary patency in about 60% of patients and has a 0.5% to 1% risk of severe side effects. Primary percutaneous coronary angioplasty carried out as an alternative to fibrinolysis avoids the risk of fibrinolytic therapy and restores patency in nearly 90% of cases. Data from randomised trials of primary angioplasty versus fibrinolytic therapy in acute myocardial infarction reveal that angioplasty results in a significant reduction in mortality. Furthermore, primary angioplasty can be improved by means of a new pre-angioplasty drug therapy (so-called facilitated primary angioplasty). Transport to a cardiac centre for primary angioplasty (of which there are 14 in the Netherlands) is feasible and safe. Although the time to treatment is delayed by a further 90 minutes, it tends to save lives and prevent strokes and it also significantly reduces the incidence of reinfarction. Interestingly, the time gained to treatment with prehospital fibrinolytic therapy compared to in-hospital therapy gave an outcome similar to that found upon comparing transport and primary angioplasty. Rescue procedures (angioplasty) within 24 hours are necessary in about 30% of patients who are initially treated with lytic therapy. These results support prehospital triage for fibrinolysis or transport to a cardiac centre, where early angioplasty can be performed if clinically indicated. A trial to determine the policy of choice is at present being conducted in the Netherlands.     

Myocardial Infarction Registry--2010. Experience and first results in Hungary

Authors present the methodology and first data of Hungarian Myocardial Infarction Register Pilot Study started 1st of January, 2010. The aim of the study is to collect epidemiological data on myocardial infarction, to examine the natural history of the disease and to investigate the main characteristics on patient care in the pilot area. The program is using standardized diagnostic criteria and predefined electronic data record forms (eCRF). The pilot area consists of 5 districts in the capital, and Szabolcs-Szatmár-Bereg county. The area has 997 324 inhabitants. Eight cardiology departments, 5 with heart catheterization facility (C) in Budapest, four hospitals with one C in Szabolcs-Szatmar-Bereg county have been responsible of the patients' care. After starting the program 16 other hospitals joined the program from different parts of Hungary. Between 1st of January 2010 and 1st of May 2011 4293 patients were registered, among them 52.1% with ST segment elevation myocardial infarction (STEMI), 42.1% with non-ST segment elevation myocardial infarction (NSTEMI), while 3% of the patients had unstable angina, and 2.8% of the cases had other diagnosis or the hospital diagnosis was missing in the eCRF. Authors compare the patients care with STEMI in five districts of Budapest and Szabolcs-Szatmár-Bereg county. In Budapest 79.7% of the 301 STEMI patients were treated in C and 84.6% of them were treated with primary percutaneous intervention (pPCI). In Szabolcs-Szatmár-Bereg county 402 patients were registered with STEMI, 62.9% of them were treated in C, where 77% of them were treated with pPCI. The drugs (beta blockers, ACE inhibitors, statins) important for secondary prevention were given more often to patients treated in the capital, however no difference was found in the platelet aggregation inhibitors therapy. Hospital mortality of STEMI patients was 8% in the capital, and 10% in Szabolcs- Szatmár-Bereg county. Authors conclude that the web based myocardial infarction register is feasible and important to have reliable data on patient care and a necessary quality control tool. Authors propose to broaden this pilot program and to start a nationwide myocardial infarction register.