Beta-Blocker Heart Attack Trial: impact of propranolol therapy on ventricular arrhythmias

The natural history of and the effect of propranolol on ventricular arrhythmias post-myocardial infarction were analyzed using data from the Beta-Blocker Heart Attack Trial (BHAT). The Beta-Blocker Heart Attack Trial was a multicenter, randomized, double-blind, placebo-controlled trial among 3,837 patients entered from 5 to 21 days after hospitalization for acute myocardial infarction. At baseline, prior to randomization, 3,290 (85.7%) patients underwent 24-hr ambulatory ECG monitoring which was repeated in approximately 25% of a randomly selected subset of the study population at 6 weeks. Ventricular arrhythmias were divided into eight different categories which defined the prevalence of ventricular arrhythmias in terms of frequency and/or complexity. Ventricular arrhythmias at baseline were associated with age, past history of myocardial infarction, and use of diuretics and digitalis. Paired data (baseline and 6-week) were available for 428 patients on propranolol and 412 on placebo. Propranolol markedly blunted the two- to threefold increase in ventricular arrhythmias that occurred from baseline to 6 weeks in the placebo group. Propranolol decreased the proportion of patients having ventricular arrhythmias during waking hours compared with sleep. These data show that propranolol has an antiarrhythmic effect and suggest that an antiarrhythmic mechanism may in part be responsible for the observed reduction in sudden cardiac death mortality in BHAT.     

Psychosocial risk factors and heart failure hospitalization: a prospective cohort study

Prospective studies on the role of psychosocial factors in heart failure development are virtually nonexistent. The authors aimed to address the effect of psychosocial factors on the risk of heart failure hospitalization in men and women free of cardiovascular disease. In 1991-1993, the 8,670 participants of the Copenhagen City Heart Study (Denmark) were asked comprehensive questions on major life events, work-related stress, social network, vital exhaustion, and sleep medication and were followed in nationwide registries until 2007, with less than 0.2% loss to follow-up. Almost one-fourth of the population reported some degree of vital exhaustion. The vital exhaustion score was associated with a higher risk of heart failure in a dose-response manner (P < 0.002), with high vital exhaustion being associated with a 2-fold higher risk of heart failure in both men (hazard ratio = 1.93, 95% confidence interval: 1.20, 3.10) and women (hazard ratio = 2.56, 95% confidence interval: 1.80, 3.65). Contrary to expectation, major life events, social network, and sleeping medication did not play an individual role for heart failure hospitalization. Because of the high prevalence of vital exhaustion in the population, even a modestly higher risk of heart failure associated with vital exhaustion may be of importance in the planning of future preventive strategies for heart failure.     

糖尿病合并冠心病急性心肌梗死的临床特点分析

目的探讨糖尿病合并冠心病急性心肌梗死的临床特点。方法对2007～2008年间住我院CCU病房的207名急性心肌梗死患者进行回顾性分析。结果糖尿病合并急性心肌梗死患者发生无痛性心梗、心衰和心源性休克的比例均增高。结论糖尿病患者有较高的冠心病危险因素,糖尿病并发冠心病时,冠心病的某些临床症状出现较晚或被掩盖,应引起临床医师的重视,在工作中应注意严格控制糖尿病患者的血糖、血脂、血压等危险因素,以期能预防或推迟冠心病的发生。     

Quantifying risk of adverse clinical events with one set of vital signs among primary care patients with hypertension

BACKGROUND: Hypertension is often uncontrolled. One reason might be physicians' reticence to modify therapy in response to single office measurements of vital signs. METHODS: Using electronic records from an inner-city primary care practice, we extracted information about vital signs, diagnoses, test results, and drug therapy available on the first primary care visit in 1993 for patients with hypertension. We then identified multivariable predictors of subsequent vascular complications in the ensuing 5 years. RESULTS: Of 5,825 patients (mean age 57 years) previously treated for hypertension for 5.6 years, 7% developed myocardial infarctions, 17% had strokes, 24% developed ischemic heart disease, 22% had heart failure, 12% developed renal insufficiency, and 13% died in 5 years. Controlling for other clinical data, a 10-mmHg increase in systolic blood pressure was associated with 13% increased risk (95% confidence interval [CI], 6%-21%) of renal insufficiency, 9% (95% CI, 3%-15%) increased risk of ischemic heart disease, 7% (95% CI, 3%-11%) increased risk of stroke, and 6% (95% CI, 2%-9%) increased risk of first stroke or myocardial infarction. A 10-mmHg elevation in mean blood pressure predicted a 12% (95% CI, 5%-20%) increased risk of heart failure. An increase in heart rate of 10 beats per minute predicted a 16% (95% CI, 2%-5%) increased risk of death. Diastolic blood pressure predicted only a 13% (95% CI, 4%-23%) increased risk of first stroke. CONCLUSIONS: Vital signs-especially systolic blood pressure-recorded routinely during a single primary care visit had significant prognostic value for multiple adverse clinical events among patients treated for hypertension and should not be ignored by clinicians.     

Atrial fibrillation in the Malmö diet and cancer study: a study of occurrence,risk factors and diagnostic validity

The validity of atrial fibrillation (AF) diagnoses in national registers for use as endpoints in prospective studies has not been evaluated. We studied the validity of AF diagnoses in Swedish national hospital discharge and cause of death registers and the occurrence of and risk factors for AF in a middle-aged Swedish population using these registers. Our study included the 30,447 individuals (age 44–73) who attended baseline visits in 1991–1996 of the Malmö Diet and Cancer study. Individuals with a first AF diagnosis were identified by record linkage with national registers. A subset of cases was randomly selected for validation by examination of electrocardiograms and patient records. Electrocardiograms were available in 98% of the validation sample (95% definitive AF, 3% no AF). The 2% with ECGs unavailable had probable AF. Baseline AF prevalence was 1.3%, higher in men and increased with age. During 11.2 years of follow-up 1430 first AF diagnoses occurred. Risk factors were age, hypertension, BMI, diabetes, history of heart failure, history of myocardial infarction and, in men but not women, current smoking. The strongest risk factors were history of heart failure (hazard ratio men 4.5, women 8.7) and myocardial infarction (hazard ratio men 2.0, women 1.8). The largest population attributable risks were observed for hypertension (men 38%, women 34%) and obesity (men 11%, women 10%). In conclusion, case misclassification of AF in national registers is small, indicating feasibility of use in prospective studies. Hypertension and obesity account for large portions of population risk in middle-aged individuals with low prevalence of manifest cardiac disease.     

Diabetes and coronary heart disease risk in Mexican Americans.

Mexican Americans have a high prevalence of diabetes relative to non-Hispanic whites, but paradoxically experience a lower prevalence of myocardial infarction and lower cardiovascular mortality (at least in men). To determine whether Mexican Americans might be more resistant to the atherogenic effects of diabetes than non-Hispanic whites, we examined the associations between diabetes and myocardial infarction and selected coronary heart disease (CHD) risk factors in these two ethnic groups. The study population consisted of 5149 Mexican Americans and non-Hispanic whites who were 25 to 64 years old and recruited from the San Antonio Heart Study, a population-based study of cardiovascular risk factors and diabetes conducted between 1979 and 1988. Diabetic men were more than twice as likely to have an electrocardiography (ECG)-documented myocardial infarction than were nondiabetic men, while diabetic women were more than three times as likely to have a myocardial infarction than were nondiabetic women. In both sexes the association between myocardial infarction and diabetes was nearly identical between the two ethnic groups. In both ethnic groups diabetes was also more strongly associated with conventional CHD risk factors (e.g., triglycerides, systolic blood pressure, and high-density-lipoprotein cholesterol) in women than in men. Furthermore, these associations were at least as strong, if not stronger, in Mexican Americans as in non-Hispanic whites. Thus, these data provide no evidence to suggest that Mexican Americans are resistant to the lipid-altering effects of diabetes. We conclude that the protective effect against CHD conferred by Mexican American ethnicity may be obscured in part by the high prevalence of diabetes in this ethnic group.     

Clustering of risk factors for cardiovascular disease among women in Southern Brazil: a population-based study

The association between clustering of risk factors and self-reported cardiovascular disease among women was investigated in a cross-sectional study using a multistage population-based sample. Participants were interviewed at home about diabetes mellitus, physical activity, and diet pattern. Hypertension was defined as blood pressure > or =140/90mmHg or use of anti-hypertensive medication. Cardiovascular disease included self-reported myocardial infarction, heart failure, coronary artery bypass surgery, and stroke. A sample of 1,007 women from Porto Alegre, Southern Brazil, mostly white (73%), 44.8 +/- 0.8 years old, and with 9.3 +/- 0.3 years of schooling was investigated. Hypertension, diabetes mellitus, obesity, low fruit and vegetable intake, and lack of vigorous or moderate physical activity were clustered into a combination of risk factors, which were independently associated with self-reported cardiovascular disease. The main cluster included hypertension and diabetes, accounting for an independent risk ratio of 8.5 (95%CI: 3.0-24.5). Clustering of cardiovascular risk factors is strongly associated with self-reported cardiovascular disease among women.     

Prevalence of heart disease--United States, 2005

Heart disease has been the leading cause of death in the United States for the past 80 years and is a major cause of disability. Heart disease also results in substantial health-care expenditures; for example, coronary heart disease is projected to cost an estimated 151.6 billion dollars in direct and indirect costs in 2007. Although some self-reported national data are available, state-specific prevalence data for heart disease have not been reported previously. In addition, although racial/ethnic, geographic, and sex differences in death rates for heart disease have been documented, less information has been available regarding the prevalence of persons living with heart disease. To estimate the prevalence of myocardial infarction (MI) and angina/coronary heart disease (CHD) in each of the 50 states, the District of Columbia (DC), Puerto Rico, and the U.S. Virgin Islands (USVI), CDC analyzed self-reported data from the 2005 Behavioral Risk Factor Surveillance System (BRFSS). This report summarizes the results of that analysis and provides the first state-based prevalence estimates of these heart diseases. The results indicated that substantial geographic, racial/ethnic, educational, and sex disparities existed in the prevalence of MI and angina/CHD. To lower the incidence of heart disease and meet the overall Healthy People 2010 goal to eliminate health disparities, public health programs should target disproportionately affected populations.     

Effect of carbon monoxide on cardiovascular disease.

Carbon monoxide exposure from heavy smoking or heavy atmospheric carbon monoxide pollution depresses myocardial function in patients with coronary heart disease, aggravates angina pectoris, aggravates intermittent claudication of the calf or thigh, increases myocardial ischemia in patients with clinical and subclinical coronary heart disease, and contributes to an increased incidence of nonfatal and fatal myocardial infarction and sudden death from coronary heart disease. Carbon monoxide contributes to the increase in nonfatal and fatal myocardial infarction and in sudden death from coronary heart disease in cigarette smokers by (a) carboxyhemoglobin interfering with myocardial oxygen delivery at the time nicotine has caused an increase in myocardial oxygen demand, aggravating an episode of myocardial ischemia, (b) the negative inotropic effect of carboxyhemoglobin aggravating an attack of myocardial ischemia, (c) carboxyhemoglobin reducing the threshold for ventricular fibrillation during an episode of myocardial ischemia, and (d) carboxyhemoglobin increasing platelet stickiness, thereby, increasing a thrombotic tendency. Furthermore, experimental data indicate that exposure to carbon monoxide in concentrations found in heavy tobacco smokers or in persons with heavy occupational exposure to carbon monoxide plays a role in the pathogenesis of cardiovascular disease.     

A prospective study of parental history of myocardial infarction and coronary heart disease in women

Among 121,964 women aged 30-55 years in 1976, 117,156 who were initially free from coronary heart disease provided information on a number of coronary risk factors including parental history of myocardial infarction and were followed prospectively. In 1976, 31,101 (26.5%) reported that at least one parent had suffered a myocardial infarction. Questionnaires in 1978 and 1980 identified women who had developed nonfatal myocardial infarction (n = 132) and angina pectoris (n = 101). Fatal coronary heart disease cases (n = 42) were ascertained by searches of state vital records. The age-adjusted relative risk of nonfatal myocardial infarction for women with a parental history of myocardial infarction less than or equal to 60 years of age compared with women with no family history was 2.8 (95% confidence limits (CL) 1.8, 4.3). For those with a parental history of myocardial infarction greater than 60 years of age, the age-adjusted relative risk of nonfatal myocardial infarction was 1.0 (CL 0.5, 1.8). The age-adjusted relative risks of fatal coronary heart disease were 5.0 (CL 2.7, 9.2) for parental history before age 61 and 2.6 (CL 1.1, 5.8) for parental history after age 60. The corresponding relative risks of angina pectoris were 3.4 (CL 2.2, 5.2) and 1.9 (CL 1.2, 3.2), respectively. These associations were only slightly altered by adjustment for history of hypertension, diabetes, high cholesterol, use of oral contraceptives, menopause, postmenopausal hormone use, obesity, or smoking, in individual stratified analysis or in multivariate analyses. These data support the hypothesis that parental history of myocardial infarction has an independent effect on risk that is not explained solely by individual risk factors.     

Occupational magnetic field exposure and myocardial infarction incidence

BACKGROUND: Studies on healthy volunteers have seen reduced heart rate variability after exposure to extremely low-frequency electric and magnetic fields (EMF). Because reduced heart rate variability has been linked to cardiovascular disease risk, it has been hypothesized that exposure to EMF might increase the risk of cardiovascular disease. One epidemiologic study has shown increased mortality from cardiovascular conditions in utility workers with elevated exposure to magnetic fields, but several other epidemiologic studies have failed to confirm this result. We tested the hypothesis that occupational EMF exposure increases the risk of myocardial infarction in a large population-based case-control study of myocardial infarction, with detailed information on potential confounders. METHODS: We used data from the SHEEP study, which is a population-based case-control study of acute myocardial infarction in Stockholm. Occupational EMF exposure was based on job titles 1, 5, and 10 years before diagnosis. We used 2 approaches to classify exposure: first, specific individual job titles with presumed elevated EMF exposure, and second, classification of subjects according to a job-exposure matrix. RESULTS: We found no increased risk of myocardial infarction in subjects classified as having elevated EMF exposure. For the highest exposure category of > or = 0.3 microT according to the job-exposure matrix, the adjusted relative risk was = 0.57 (95% confidence interval = 0.36-0.89). CONCLUSIONS: The results of this study do not support the hypothesis that occupational EMF exposure increases the risk of myocardial infarction.     

The role of aldosterone-antagonists in the treatment of congestive heart failure

The role of aldosterone-antagonists in the treatment of congestive heart failure. Despite the advances of the treatment of congestive heart failure, nearly half of the patients diagnosed with this disease five years ago are alive today. Experimental and human studies have demonstrated, that under special pathologic condition, the heart extracts aldosterone, and aldosterone extraction in the heart stimulates increased collagen turnover culminating in ventricular remodeling. Aldosterone blockade has been shown to be effective in reducing total mortality and hospitalization for heart failure in patients with systolic left ventricular dysfunction due to chronic heart failure (RALES study with spironolactone) and in patients with systolic left ventricular dysfunction post acute myocardial infarction (EPHESUS study with eplerenone). These clinical studies have shown that mineralocorticoid receptor activation remains important despite the use of angiotensin converting enzyme inhibitor or angiotensin receptor blocking agent and a beta blocker. In the ACC/AHA (and in the European and Hungarian) guidelines for the evolution and management of chronic heart failure, the indication of spironolactone was defined of Class Ila, Level of Evidence: B in CHF of stage C. The eplerenone (in US: INSPRA) was approved for the management of CHF patients after myocardial infarction with ejection fraction < 40%. Eplerenone, compared with spironolactone, is associated with a lower incidence of gynecomastia and other sex hormone-related adverse effect (breast pain, menstrual abnormalities). The spironolactone should not be used in patients with a creatinine above 220 mikromol/l. Despite the guidelines recommendation, spironolactone has been widely used in patients without consideration of their functional class or ejection fraction, without optimization of background treatment with ACE inhibitors and beta-blockers.     

Risk factors for asymptomatic abdominal aortic aneurysm: systematic review and meta-analysis of population-based screening studies

BACKGROUND: The incidence of and mortality from ruptured abdominal aortic aneurysm (AAA) is increasing. There is uncertainty regarding the indicators which could be used to identify groups at high risk. This issue has been addressed in a systematic review of population-based screening studies. METHODS: MEDLINE and EMBASE were searched, reference lists scanned and manual searches made of eight journals. The search was restricted to four languages (English, German, French and Italian). Population-based studies investigating risk factors associated with screening-detected AAA were included. The following risk factors were considered: sex, smoking, hypertension, diabetes, a history myocardial infarction, and peripheral vascular disease. RESULTS: Fourteen cross-sectional studies met our inclusion criteria. Most studies screened people aged 60 years or older. The prevalence of AAA ranged from 4.1% to 14.2% in men and from 0.35% to 6.2% in women. Male sex showed a strong association with AAA (OR 5.69), whereas smoking (OR 2.41), a history of myocardial infarction (OR 2.28) or peripheral vascular disease (OR 2.50) showed moderate associations. Hypertension was only weakly associated with AAA (OR 1.33) and no association was evident with diabetes (OR 1.02). CONCLUSIONS: The efficacy of screening men aged 60 years or older and women of the same age who smoke or have a history of peripheral or coronary artery disease should be evaluated in randomized controlled trials.     

Secondary prevention after myocardial infarction

The management of acute myocardial infarction has been revolutionized in the past decade. Advances in pharmacological and mechanical reperfusion therapy have improved the survival of patients who experience myocardial infarction. Although revascularisation techniques have been shown to reduce infarct size and in-hospital mortality, patients recovering from myocardial infarction are still at increased risk for reinfarction, congestive heart failure, and sudden death. Despite impressive technological advances, lifestyle modification and pharmacological interventions remain the key components of secondary prevention after myocardial infarction. Although the concept of secondary prevention of reinfarction and death has been investigated vigorously for several decades, preventive therapy has been seriously underused by physicians. The aim of this paper is to provide a comprehensive, evidence-based overview of secondary prevention postmyocardial infarction clinical trials, in the hope of improving the utilization of effective therapies in patients with coronary heart disease.     

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.     

心脏结构及功能指标的联合轨迹与慢性心衰预后的关联

目的 探讨心脏结构及功能指标纵向变化轨迹群对慢性心力衰竭(chronic heart fail-ure,CHF)预后存在的潜在价值.方法 纳入2012年1月—2019年1月在山西省两所三级甲等医院住院并符合标准的277例患者,利用多次住院的心脏结构及功能指标,建立基于群组的多轨迹模型,识别具有相似轨迹变化的患者群体.使...     

Moexipril and left ventricular hypertrophy

Angiotensin-converting enzyme (ACE) inhibitors today are the standard therapy of patients with myocardial infarction and heart failure due to their proven beneficial effects in left ventricular remodeling and left ventricular function. ACE inhibitors have also been demonstrated to lead to regression of left ventricular hypertrophy (LVH). It is believed that the mechanism of action of LVH regression with ACE inhibitors arises from more than simple blood pressure reduction. LVH is an important risk factor for cardiovascular disease morbidity and mortality independent of blood pressure. Moexipril hydrochloride is a long-acting, non-sulfhydryl ACE inhibitor that can be taken once daily for the treatment of hypertension. Moexipril has now also been demonstrated to have beneficial effects on LVH and can lead to LVH regression.     

妊娠期高血压疾病产妇产后合并心力衰竭危险因素分析及防治对策

目的探究妊娠期高血压疾病产妇产后合并心力衰竭(以下简称心衰)的危险因素及防治对策。方法回顾性分析2016年1月至2019年11月贺州市人民医院收治的578例妊娠期高血压疾病产妇的临床资料,根据产后是否合并心衰,分为合并心衰组(64例)和未出现心衰组(514例)。对两组年龄、体质量指数、生育史、心脏病史等资料进行对比分析,将其中有统计学差异的指标进行多因素Logistic回归分析,并分析其应对策略。结果单因素分析:两组心脏病史、糖尿病史、吸烟史、贫血、熬夜、感染、情绪激动、高脂血症、高尿酸血症、肾功能不全、左心室肥厚发生情况、氨基末端脑钠肽前体(N-terminalpro-brain natriuretic peptide,NTproBNP)水平、妊娠期高血压疾病类型、高血压病史时间、血压控制情况比较,差异有统计学意义(P<0.05)。Logistic回归分析:存在心脏病史、糖尿病史、吸烟史、贫血、熬夜、感染、情绪激动、高脂血症、高尿酸血症、肾功能不全、左心室肥厚、高NT-proBNP水平、子痫前期或子痫、血压控制较差等是妊娠期高血压疾病产妇产后合并心衰的独立危险因素,差异有统计学意义(P<0.05)。结论结合妊娠期高血压疾病产妇产后合并心衰的危险因素,改善心脏负荷,避免交感神经过度兴奋,积极治疗原发病,改掉不良习惯,重点监护子痫前期孕妇,降低妊娠期高血压疾病产妇产后心衰的风险。     

慢性肺源性心脏病患者急性心肌梗死特征及临床分析

目的探索慢性肺源性心脏病患者并发急性心肌梗死的临床特征。方法将笔者所在科室2007年3月～2010年9月期间收治的54例慢性肺源性心脏病伴发AMI患者与48例单纯AMI患者的临床诊疗资料进行回顾性对照分析。结果在室性早搏及传导阻滞方面，慢性肺源性心脏病组较非慢性肺源性心脏病组有着较高的发生率，均P〈0．05；在并发心律失常及心力衰竭方面，慢性肺源性心脏病组的发生率显著高于非慢性肺源性心脏病组，P〈0.05；两组患者在其他并发症的发生率方面比较差异无统计学意义，P〉0．05。结论慢性肺源性心脏病患者突发心律失常、急性左心衰或心源性休克时，应高度重视伴发AMI的可能性。     

Early detection and management of the high-risk patient with elevated blood pressure

Severe or important blood pressure elevations are associated with the risk of cardiovascular disease. However, a significant proportion of myocardial infarctions and strokes occur in subjects with only slight elevations or even with normal blood pressure. Both the coexistence of other cardiovascular risk factors, such as diabetes or dyslipidemia, or those recently recognized, such as elevations of C-reactive protein or abdominal obesity and metabolic syndrome, or the presence of target organ damage, such as microalbuminuria, left ventricular hypertrophy, mild renal dysfunction or increased intima-media thickness, all indicate the existence of a high cardiovascular risk in mild hypertensives or in subjects with normal or high-normal blood pressure. Unfortunately, these high-risk patients are often not recognized and thus under-treated. The 2003 European Societies of Hypertension and Cardiology guidelines emphasize the importance of a complete risk assessment and stratification in subjects at all blood pressure categories. The search for other cardiovascular risk factors and target organ damage should be encouraged. Identification of these high-risk patients may allow an earlier indication for antihypertensive treatment and for correction of all cardiovascular risk factors. The objective would be to impair the progression or to induce the regression of silent vascular damage before a clinical event develops.