Reciprocal electrocardiographic changes in acute myocardial infarction

If reciprocal electrocardiographic changes during acute myocardial infarction (AMI) are a result of ischemia of the wall opposite the AMI, a stress test is expected to induce similar changes in the corresponding electrocardiographic leads. Right atrial pacing was used as a myocardial stress method in 137 consecutive patients recovering from a transmural AMI, and the appearance of pacing-provoked ischemia before hospital discharge was correlated to the presence of absence of ST depression in the opposite wall during the initial 48 hours. Of the 137 patients, 83 (61%) had reciprocal changes; they were more common in inferior (87%) than in anterior (37%) AMI (p less than 0.01). Of 54 patients without reciprocal changes, only 5 (9%) had ST depression during predischarge pacing; however, of the 83 patients with reciprocal changes, 41 had pacing-induced ischemia (p less than 0.01) and 42 did not, indicating that in half of this group the reciprocal changes represent ischemia of the opposite wall. In the other half of the group, without ST depression during pacing, these changes may be a "mirror image" phenomenon. Follow-up showed that angina pectoris, positive treadmill test response 6 months later, or recurrent AMI all consequences of impaired myocardial blood supply, were significantly more frequent in patients with reciprocal changes. This group could be further separated according to the results of right atrial pacing, because angina pectoris or recurrent AMI were infrequent among those with reciprocal changes and negative pacing responses, but was frequent among those with reciprocal changes and positive pacing responses.(ABSTRACT TRUNCATED AT 250 WORDS)     

The predictive value of the electrocardiographic pattern of acute q-wave myocardial infarction for recurrent ischemia

Atotal of 140 consecutive patients with acute Q-wave myocardial infarction was evaluated to assess the relationship between different electrocardiographic patterns of evolution and the incidence of recurrent ischemia within 10 days of infarction. Patients were allocated to three groups according to the electrocardiogram at 12 h after admission: Group A: ST elevation of < 2 mm and negative T waves (75 patients); Group B: ST elevation of > 2 mm and negative T waves (35 patients); Group C: ST elevation of > 2 mm and positive T waves (30 patients). Patients in Group C had more anterior wall infarctions (82%) than Group A (40%) or Group B (58%) (p = 0.0001). Peak creatine kinase levels were lower in Group A (782 ± 115 IU) than in Groups B (1415 ± 257 IU) and C (1501 ± 287 IU) (p<0.0001). The occurrence of post-infarction recurrent ischemia was more frequent in Group A (79.2%) than in Groups B (33.3%) and C (14.8%) (p<0.0001). Patients in Group A had relatively smaller infarctions and a higher incidence of recurrent ischemia, whereas patients in Group C had larger infarctions and a lower incidence of recurrent ischemia. The electrocardiographic pattern 12 h after admission for acute myocardial infarction is helpful in identifying a subgroup at high risk of recurrent ischemia.     

Frequency and importance of silent myocardial ischemia identified with ambulatory electrocardiographic monitoring in the early in-hospital period after acute myocardial infarction

The incidence and clinical significance of silent myocardial ischemia occurring in the early period after acute myocardial infarction (AMI) was studied in 59 patients who had an uncomplicated early course after admission for AMI. Calibrated 2-lead ambulatory electrocardiographic monitoring performed for 39 +/- 2 hours starting 4 +/- 1 days after AMI identified silent myocardial ischemia, defined as greater than or equal to 1 mm ST-segment change lasting greater than or equal to 2 minutes, in 27 patients. These patients had 5 +/- 1 episodes lasting a median of 11 minutes/episode (range 2 to 36 minutes/episode). Patients with and without silent ischemia had comparable baseline demographics, were receiving similar anti-ischemic medications and had similar severity of coronary disease by angiography. No reinfarctions occurred during the in-hospital period. Fourteen of 27 patients (52%) with silent ischemia had greater than or equal to 1 in-hospital clinical ischemic event (pulmonary edema, n = 5, cardiac death, n = 1, and postinfarction angina, n = 11). In contrast, only 7 of 32 patients without silent ischemia (22%) had greater than or equal to 1 in-hospital event (pulmonary edema, n = 1, cardiac death, n = 1, and postinfarction angina, n = 6). The frequency of ischemic events was significantly greater in patients with silent ischemia compared to those without silent ischemia, p less than 0.02. Silent ischemia occurs frequently very early after AMI and identifies a group of patients who are at increased risk for adverse in-hospital clinical outcomes.     

Comparative Prognostic Significance of Simultaneous Versus Independent Resolution of ST Segment Depression Relative to ST Segment Elevation During Acute Myocardial Infarction

Objectives. We sought to determine the prognostic significance of simultaneous versus independent resolution of ST segment depression that occurs concomitant with ST segment elevation during acute myocardial infarction (AMI).Background. ST segment depression in leads other than those showing ST segment elevation during AMI is a common phenomenon. Whether this indicates adverse outcomes remains controversial. We hypothesized that the timing of ST segment depression resolution relative to ST segment elevation resolution might differentiate between a high risk group and a low risk group of patients.Methods. Continuous 12-lead ST segment monitoring was performed after thrombolytic therapy for AMI in 413 patients, 261 of whom met technical criteria for analysis. Blinded analysis of ST segment depression resolution patterns was used to group patients as follows: 1) no ST segment depression at any time (control group); 2) ST segment depression resolving simultaneously with ST segment elevation (simultaneous group); and 3) ST segment depression persisting after ST segment elevation resolution (independent group). These patterns were correlated with the outcomes—recurrent angina, reinfarction, heart failure and death—using chi-square analysis and the Fisher exact test for categoric variables and the Wilcoxon rank-sum test for continuous variables.Results. The incidence of recurrent angina, reinfarction and heart failure was similar among the three groups. In-hospital mortality, however, was significantly higher in the independent group (13%) than either the simultaneous group (1%, p < 0.001) or the control group (0%, p = 0.002).Conclusions. Continuous analysis of ST segment resolution identifies, among patients with AMI with concomitantly occurring ST segment elevation and depression, a subgroup with increased in-hospital mortality. The pathogenic mechanism of increased mortality is not currently known.     

Treatment of recurrent ischemia after thrombolysis and successful reperfusion for acute myocardial infarction: effect on in-hospital mortality and left ventricular function

To determine the effect of treatment of recurrent ischemia after reperfusion for acute myocardial infarction on in-hospital mortality and left ventricular function recovery and to identify patients at highest risk of serious consequences in the event of recurrent ischemia in this setting, 405 consecutively treated patients were studied retrospectively. All patients received intravenous thrombolytic therapy within 6 h of ST segment elevation-documented infarction and had angiographic confirmation of their reperfusion status performed within 120 min of treatment. Three hundred three patients had successful reperfusion with or without rescue angioplasty and had no recurrent ischemia (group 1), 74 patients had initially successful reperfusion but subsequent recurrent ischemia (group 2) and 28 patients had failed reperfusion (group 3). The in-hospital mortality in groups 1 to 3 was 2.0%, 14.9% and 32.1%, respectively (p less than 0.001) and the change from baseline to prehospital discharge left ventricular ejection fraction was 1.2 +/- 9.3%, -0.8 +/- 8.7% and -4.3 +/- 5.3%, respectively (p = NS). Within the recurrent ischemia group (group 2), multiple regression analysis found absence of cardiogenic shock at presentation (p = 0.002) and successful treatment initiated within 90 min of recurrent ischemia (p = 0.045) to be the only variables independently correlated with in-hospital survival. Later successful reperfusion was not associated with improved hospital survival. The timing and success of treatment did not affect recovery of global or regional left ventricular function in the patients with paired angiographic studies.(ABSTRACT TRUNCATED AT 250 WORDS)     

急性心肌梗死墓碑形ST段抬高的临床意义

目的探讨急性心肌梗死（acute myocardial infarction，AMI）墓碑形ST段抬高的临床意义。方法将86例AMI患者以ST段抬高的特征分为两组，墓碑形抬高组36例、其他形抬高组50例。观察两组的一般临床资料（年龄、有否合并糖尿病），并比较两组AMI的发生部位、PCI前心梗后心绞痛、并发症及死亡的发生率、首次CK值、各项心电指标及PCI后心肌缺血再灌注损伤的发生率。结果两组各项临床指标及心电图指标差异均有统计学意义；墓碑形ST段抬高组PCI后心肌缺血再灌注损伤的发生率亦明显高于其他形ST段抬高组。结论墓碑形ST段抬高患者梗死部位特殊而广泛、并发症多、死亡率高、易出现心肌缺血再灌注损伤，对此类患者应高度重视并积极预防心肌缺血再灌注损伤的发生。     

Implications for patient triage from survival and left ventricular functional recovery analyses in 500 patients treated with coronary angioplasty for acute myocardial infarction

The in-hospital course of 500 consecutive patients treated with coronary angioplasty for acute myocardial infarction was reviewed in relation to their clinical and angiographic presentation and angioplasty outcome to determine which patients benefit most from successful angioplasty in this setting. Patient age was 56 +/- 11 years (mean +/- SD) and 78% were men; 46% had anterior myocardial infarction, 49% received concomitant intravenous thrombolytic therapy, left ventricular ejection fraction was 47 +/- 11% and median time to angioplasty was 4.7 h (range 1 to 24). Angioplasty was successful in 78% of patients and partially successful in 7% of patients; the overall in-hospital mortality rate was 10.2%. Multivariate analysis found six independent correlates (p less than 0.05) of in-hospital mortality: left ventricular ejection fraction less than or equal to 30%, lack of postangioplasty infarct artery patency, age greater than 65 years, recurrent ischemia after successful angioplasty, emergency bypass surgery and arterial pressure on admission to the catheterization laboratory less than 100 mm Hg. After consideration of these predictors of survival in multivariate analyses, angioplasty success still was independently correlated with improved in-hospital survival for patients with cardiogenic shock (p = 0.002) and anterior myocardial infarction (p = 0.007). A trend toward an independent beneficial effect of successful angioplasty on survival was also noted in patients with inferior wall infarction and precordial ST segment depression (p = 0.063) and for all patients who were hypotensive on admission to the catheterization laboratory, regardless of the infarct site (p = 0.057).(ABSTRACT TRUNCATED AT 250 WORDS)     

溶栓后早期转运PCI与保守治疗/补救转运PCI治疗STEMI患者的比较

目的：本研究回顾分析比较急性心肌梗塞（AMI）患者在基层医院行溶栓治疗后,早期转运到上级医院行经皮冠状动脉介入治疗（PCI）和继续在当地予保守治疗然后作转运PCI的优劣。方法：315例AMI患者在发病12h内,于基层医院接受溶栓治疗,其后183例直接转诊行PCI（A组）,132例在当地继续保守治疗,67例因再次出现心肌缺血症状行补救性转运PCI（B组）。比较两组1年内全因死亡、再梗死、难治性心肌缺血发生率及30d内严重出血和脑卒中发生率,以及治疗前后左室射血分数（LVEF）改变情况。结果：与B组比较,A组1年内全因死亡率（6.8%比1.6%）、再梗死发生率（17.4%比3.3%）、难治性心肌缺血发生率（22.7%比4.4%）均明显降低（P均〈0.05）,而LVEF改善情况A组明显优于B组[（58.7±12.4）%比（47.6±11.9）%,P〈0.05]。结论：溶栓后的ST段抬高性心肌梗死患者应尽早转运到上级医院接受PCI治疗,以取得更好疗效。     

Cardiac care unit admission criteria for suspected acute myocardial infarction in new-onset atrial fibrillation

Management of new-onset atrial fibrillation (AF) varies between institutions and individual physicians. Because AF often occurs in elderly patients and is associated with coronary artery disease, patients presenting for the first time are often selected for admission to the coronary care unit to exclude the possibility of acute myocardial infarction (AMI). A review of 245 patients with AF admitted to an intensive care unit revealed 45 cases that were of new onset. AMI was diagnosed in 5 (11%) on the basis of elevated serum creatine kinase-MB levels. Evaluation of 56 clinical variables available during initial assessment indicated that infarction patients could be distinguished from others by the presence of left ventricular hypertrophy (p less than 0.01), electrocardiographic evidence of old myocardial infarction (p less than 0.01), typical cardiac chest pain (p less than 0.01), and duration of cardiac symptoms less than 4 hours (p less than 0.05). The presence of 2 or more of these features identified all AMI patients and 7 others at high risk for serious cardiac complications. The findings indicate that new-onset AF in the absence of clinical predictors suggesting myocardial ischemia or AMI does not warrant routine admission to the coronary care unit.     

Influence of emotional stress and behavior during acute myocardial infarction on prognosis

Seventeen cases of acute myocardial infarction (AMI) with emotional stress (group A) and 54 cases with basically stable emotion (group B) were compared with respect to three major complications (arrhythmia, cardiac insufficiency of grade 3 and 4 and cardiogenic shock) and therapeutic effect. The results showed that the incidences of the three complications in group A were significantly higher than those in group B (P less than 0.05), and the clinical condition was more serious in the former group. Response to narcotics showed that number of patients requiring more than 3 injections of either dolantine 50 mg or morphine 5 mg was significantly greater in group A than in group B (P less than 0.001). Sigma ST was not found to be significantly different between the two groups. However, the duration of elevation of ST segment was significantly longer in group A than in group B (P less than 0.01). It is suggested that relief of myocardial ischemia is slow in group A. There were five patients in group A with extended infarct size and died during the acute stage. None in the group B showed extension of infarction. The mortality rate in group A significantly higher than that in group B (53% VS 3.7%, P less than 0.001) and it bears no relation with sex, age and the site of infarction on admission. The greater the emotional upheaval the more unfavorable the prognosis. It is shown that excessive emotional stress is an important risk factor of AMI and aggressive measures are required to prevent worsening of the condition.     

Unstable angina: ST segment depression with positive versus negative T wave deflections--clinical course, ECG evolution, and angiographic correlation

Thirty-two consecutive patients who initially had horizontal or downward-sloping ST segment depression confined to the precordial leads were studied. Patients were divided into two groups: group A included 21 patients with horizontal or downward-sloping ST depression with peaked positive T waves, and group B comprised 11 patients with peaked negative T waves and downward or horizontal ST depression. The incidence of acute myocardial infarction (AMI) was similar (group A 38.1% vs group B 36.4%; p greater than 0.05). In-hospital mortality was much more significant in group B (p = 0.03). Coronary arteriography was performed in 31 patients. Of the 10 patients in group B who were catheterized, seven (70%) had left main occlusion. Of the 21 patients in group A, none had a significant left main lesion (p = 0.001), although eight (38.1%) had single-vessel disease (p = 0.05). Thus the ECG pattern of horizontal or downward-sloping ST depression passing into a peaked negative T wave identifies a subgroup of high-risk patients in whom the prognosis is poor once AMI occurs. Early catheterization is recommended when this ischemic pattern is apparent on the ECG.     

Inferior ST segment depression during acute anterior myocardial infarction: clinical and angiographic correlations

This study was performed to determine whether inferior ST segment depression during early stages of acute transmural anterior myocardial infarction identifies patients with multivessel coronary artery disease and additional inferior ischemia. Coronary and left ventricular angiography were performed within 3.4 months in 33 patients with acute transmural anterior infarction. Initial electrocardiograms, 2 to 5 hours after onset of chest pain, revealed significant ST segment depression (greater than or equal to 0.1 mV) in at least two of leads II, III and a VF in 15 patients (45%) (group B); in 18 patients (group A) this finding was absent. Compared with group A, patients in group B had greater anterior ST elevation (1.2 versus 0.7 mV, p less than 0.025); higher serum peak creatine kinase (2,475 versus 1,147 IU/liter, p less than 0.005); higher Killip scores (2.1 versus 1.3, p less than 0.001); more in-hospital complications (60 versus 17%, p less than 0.05); lower mean left ventricular ejection fraction (34 versus 55%, p less than 0.001); more frequent regional left ventricular dysfunction in anterolateral (91 versus 44%, p less than 0.05), posterolateral (36 versus 0%, p less than 0.05) and inferior (100 versus 6%, p less than 0.005) regions; greater wall motion abnormality scores (10.0 versus 5.5, p less than 0.005); higher frequency of concomitant left circumflex or right coronary artery disease, or both (80 versus 28%, p less than 0.01); more frequent postinfarction angina (100 versus 39%, p less than 0.001) and lower New York Heart Association functional classification scores (1.7 versus 2.4, p less than 0.05) at 6 month follow-up. The time course of inferior ST depression differed from that of anterior ST elevation. Thus, inferior ST depression was maximal in the first 48 hours and decreased (p less than 0.05) thereafter. In contrast, ST elevation in leads V1 to V6 and I appeared to decrease (p = NS) between days 4 and 7. However, inferior ST depression "mirrored" ST elevation in lead aVL, which also decreased (p less than 0.05) after 48 hours. Thus, inferior ST depression during anterior infarction is associated with more extensive infarction, greater morbidity and higher frequency of multivessel coronary disease. Such inferior ST depression might reflect not only "reciprocal change," but also ischemia in adjacent lateral and remote inferior regions.     

Cardiovascular responses to early exercise in inferior wall ST acute myocardial infarction

The heart rate and blood pressure responses to standardized exercise tests were studied in a group of patients with electrocardiographic evidence of inferior wall acute myocardial infarction (AMI). The tests were done on a bicycle ergometer at 8 to 10 days and 10 to 12 weeks after AMI. At 8 to 10 days after AMI, those with ST AMI (n = 12) had a significantly reduced heart rate response to exercise compared with patients with Q-wave AMI (n = 25). This difference was not evident at 10 to 12 weeks. The systolic blood pressure response in patients with ST AMI was lower than that of Q-wave AMI patients during the first exercise test, although the difference did not attain statistical significance but was significantly lower than the responses of both groups at the second test. The patients with ST AMI had smaller amounts of myocardial damage than those with Q-wave AMI as indicated by plasma creatine kinase values (p less than 0.01). These differences in the heart rate responses appeared to result from the preferential activation of nonmyelinated afferent fibers in the subepicardial region of the inferior wall of the myocardium.     

The conservative coronary angioplasty strategy after thrombolysis for acute myocardial infarction: immediate and short-term results.

The in-hospital and short-term follow-up results of a conservative coronary angioplasty approach in 354 consecutive patients treated after thrombolysis for acute myocardial infarction were compared with results obtained in 408 control noninfarcted patients treated for the classical indication of myocardial ischemia. Only 20% of the study patients underwent angioplasty during the initial hospitalization period and the clinical success rate was 93% versus 95% in the control group (p = NS). No significant differences in the total number of in-hospital untoward events were observed (10.2% and 7.6%, respectively). During a 7.4 +/- 1.5 month follow-up period, the total number of adverse events was only 16.9% in the study patients but it was 27.8% in the control group (p < 0.001). There were no significant differences in death, myocardial infarction, or coronary surgery as individual events, but repeat angioplasty was less frequent in the study group (14.0% versus 21.5%, p < 0.01). Thus in-hospital results in patients undergoing angioplasty on a deferred basis after thrombolysis for myocardial infarction were largely comparable with those results obtained in noninfarcted patients. Moreover, short-term clinical follow-up events were reduced when compared with the control group, an observation apparently largely related to the subgroup without clinical evidence of residual ischemia.     

Prognostic significance of a low peak serum creatine kinase level in acute myocardial infarction

To assess the prognostic significance of a low peak creatine kinase (CK) level, 723 consecutive patients admitted with acute myocardial infarction (AMI) within 16 hours after onset of symptoms were studied. Thrombolytic therapy was not attempted during the study. Patients were dichotomized according to their peak CK levels, determined from a cluster analysis of peak CK distribution among the population of patients who died within 3 years after hospital discharge. The 139 patients with low peak CK (less than or equal to 650 IU/liter) (group 1) were compared to the 584 patients with high peak CK (greater than 650 IU/liter) (group 2). Patients in group 1 were older and had a higher incidence of previous AMI, angina pectoris before AMI and non-Q-wave AMI. Despite a lower incidence of in-hospital complications and a nonsignificantly lower hospital mortality rate (4 vs 9%) the group 1 three-year posthospital mortality rate was higher (26 vs 17%; p less than 0.02), especially in the subgroup of patients with a Q-wave infarct (mortality 31% in group 1 vs 16% in group 2; p less than 0.001). Among the 491 patients who had a first Q-wave AMI, 55 had a peak CK less than or equal to 650 IU/liter. Compared to the 436 patients with a higher peak CK, these 55 patients had a higher incidence of early postinfarction angina (31 vs 14%; p less than 0.01), a similar hospital mortality (4 vs 7%) but a higher 3-year posthospital mortality (23 vs 12%; p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Indications, results of therapy and factors which influence survival in patients treated with intra-aortic balloon counterpulsation

BACKGROUND AND AIM: During nearly 40 years of intraaortic balloon counterpulsation (IABP) application in advanced medical therapy more and more indications for this treatment have been proposed. Despite increasing experience with IABP, the clinical effects of IABP use are still unclear. The aim of this study was to determine results of IABP use and factors which influence survival in cardiogenic shock (CS) caused by different clinical disorders when treated with IABP. METHODS: 73 patients (mean age 58.3+/-12.6 years, 54 males) undergoing IABP were included in the study. Data were collected retrospectively. After analysis of the whole population a subgroup of patients admitted due to acute myocardial infarction (AMI) was evaluated. The in-hospital and overall mortality rates were assessed. RESULTS: In-hospital death occurred in 31 (42.5%) patients. Over half of these patients (n=17; 54.8%) died during first 7 days from admission. The main reason for IABP introduction was CS due to acute coronary syndrome (ACS) at admission in 62 (84.9%) patients. The in-hospital mortality in patients with AMI complicated by CS was 40.7%. The features which significantly influenced survival in patients with AMI were age--patients who died were older (64+/-8.9 vs. 58.6+/-9,1; p=0.0285), and ST segment changes--there was lower mortality rate in a subgroup with ST elevation AMI (18 vs. 6 patients, p=0.003). We also observed slightly higher incidence of anterior wall AMI in survivors than in non-survivors (p=0.06). CONCLUSION: Our study presents several disorders which may be treated with IABP. Acute MI still remains the most frequent indication for IABP insertion. In the present study, AMI survivors and non-survivors, differed mainly in age, ST segment changes and infarction site. Non ST segment elevation AMI was associated with worse prognosis.     

Clinical significance of precordial ST segment depression during acute inferior myocardial infarction

To investigate the mechanisms and clinical significance of precordial (V1-V4) ST segment depression during acute inferior myocardial infarction, stress thallium-201 scintigrams and coronary angiograms were obtained within four to eight weeks after the onset of myocardial infarction in 37 patients experiencing their first acute inferior myocardial infarction. Among 18 patients with precordial ST depression (group 1), 11 with concomitant disease of the left anterior descending artery (LAD) had positive results on exercise test, whereas in seven patients without LAD lesion, only two had positive exercise test (p less than 0.01). In 19 patients without precordial ST depression (group 2), 11 had severe stenosis in the LAD. However, among these 11 patients, only two had positive exercise tests. Patients with precordial ST depression demonstrated a higher frequency of positive exercise tests than those without it (p less than 0.01). On stress thallium-201 scintigraphy, a perfusion defect involving the inferior wall was present in all patients, but additional anterior wall ischemia was present in only five of the 18 patients in group 1. These five patients had chest pain on exercise tests and a severe stenosis greater than 90% in the LAD. There was no significant difference in the frequency of additional posterolateral wall infarction between groups 1 and 2. In 18 patients in group 1, sigma ST (total degrees of ST segment depression in leads V1, V2, V3, and V4 in the acute stage) was significantly greater in 11 patients with LAD lesion than in seven without (p less than 0.05), and sigma ST greater than five mm was observed in 12 of 13 patients who had additional anterior wall ischemia and posterolateral wall infarction on stress thallium-201 scintigraphy (p less than 0.05). Myocardial revascularization, such as aortocoronary bypass surgery or percutaneous transluminal coronary angioplasty (PTCA), was performed in six of the 18 patients in group 1 in the chronic stage, but in only one of the 19 patients in group 2. Thus, in patients with initial acute inferior myocardial infarction, those with precordial ST depression seemed to be a high-risk group. It was suggested that, during the early stage of myocardial infarction, this abnormality on electrocardiograms is related to the summation of effects of anterior wall ischemia and posterolateral wall infarction. Furthermore, the sigma ST evaluation is useful in differentiating a mirror image of inferior wall infarction from anterior wall ischemia and posterolateral wall infarction as the mechanism of precordial ST depression.     

Electrocardiographic manifestations and in-hospital prognosis of transient acute myocardial ischemia at rest

From January 1970 to June 1985, transient electrocardiographic changes at rest were documented in 652 patients admitted to our coronary care unit. Patients were stratified according to the type of electrocardiographic alteration at rest: 295 had ST-segment elevation (group 1), 106 T-wave changes (group 2) and 251 ST-segment depression (group 3). Patients in group 3, compared with groups 1 and 2, were more likely to have symptoms of coronary artery disease dating back many years (p less than 0.01 and p less than 0.01, respectively), a previous myocardial infarction (p less than 0.05 and difference not significant), a positive exercise test (p less than 0.01 and p less than 0.01), transient ST-T changes occurring in a higher number of electrocardiographic leads (p less than 0.01 and p less than 0.01), multivessel disease (p less than 0.001 and p less than 0.01) and poor ventricular function (p less than 0.01 and p less than 0.05). Despite these differences, the occurrence of acute myocardial infarction and cardiac death during hospitalization was much more frequent in group 1 compared with groups 2 (p less than 0.02) and 3 (p less than 0.05). However, death occurred in those patients who had poor ventricular function and severe atherosclerosis. A greater susceptibility of group 1 patients to severe vasoconstriction documented by the ergonovine test and by the occurrence of spontaneous spasm seems to account for different in-hospital outcome.     

Increased cardiac mortality in women compared with men in patients with acute myocardial infarction

OBJECTIVE: It has been reported that women with acute myocardial infarction (AMI) have a higher short-term mortality rate than men, but the reason is not known. The profile in relation to age, gender and risk factors was evaluated to compare AMI and unstable angina pectoris (UAP). METHODS: Findings from 984 patients including 580 patients with AMI (129 women, 451 men) and 404 patients with UAP (131 women, 273 men) were analyzed by the South Osaka Acute Coronary Syndrome Study Group (SACS). The primary endpoint of the study was in-hospital death. The primary endpoints of interest (cardiac death) were fatal recurrent myocardial infarction, death from congestive heart failure, and sudden death. RESULTS: Cardiac death during hospitalization within 30 days in AMI was higher in women than in men (12.4% vs 6.7%, p < 0.05). On the other hand, in UAP there was no significant difference between women and men (1.5% vs 0.7%, NS). The incidence of cardiac death in AMI was significantly higher for patients 75 years old and older (19.0%) than for patients less than 55 years old (4.2%), 55-64 years old (3.5%) and 65-74 years old (4.7%) (p < 0.001, respectively). CONCLUSIONS: Cardiac death was higher for women compared with men in patients with AMI. The worse prognosis for the AMI women patients was likely to be derived from less performance of percutaneous coronary intervention, and a high incidence of severe myocardial infarction. Further research should be focused on the analysis of various clinical backgrounds.     

Risk stratification in patients with first non-Q wave infarction: limited value of the early low level exercise test after uncomplicated infarcts. The Multicenter Post-Infarction Research Group

Risk stratification using clinical and historical variables plus early low level exercise testing was performed in 141 patients with a first non-Q wave myocardial infarction. The 111 patients who performed the exercise test had a 3.6% cardiac mortality rate in the first year compared with 13.3% in the 30 patients who could not exercise (p = 0.063), and a 1 year incidence rate of recurrent cardiac events (cardiac death or recurrent nonfatal myocardial infarction) of 10.8% compared with 23.3% (p = 0.127). Patients who developed ischemia (ST depression or angina) during the test had an increased incidence of cardiac events in the year after the infarction (odds ratio greater than 3, p less than 0.05). When patients were subgrouped by the presence or absence of pulmonary congestion, the discriminatory value of the exercise test was seen to reside primarily in the cohort with pulmonary congestion. For example, ST depression during exercise in this group identified patients with a 71% incidence of cardiac events in the year after the infarction compared with 5.3% for those without ST depression (odds ratio 45, p = 0.002). In the patients without pulmonary congestion, the exercise test had no discriminatory value. It is concluded that early low level exercise testing has a limited role after an uncomplicated non-Q wave infarction, but is useful in patients with clinical markers of higher risk.