Short- and long-term influence of beta-adrenergic antagonists after acute myocardial infarction

After coronary arterial occlusion, catecholamines are released from storage depots in the left ventricle and injured myocardial cells are exposed to relatively high concentrations of catecholamines during the evolutionary period in which cell injury is becoming progressively more severe. In addition, in experimental animal models, there is a substantial increase in beta-adrenergic receptor density without any alteration in affinity within 1 hour of permanent coronary arterial occlusion. Recent data suggest that alpha-adrenergic receptor density increases within 30 to 60 minutes after coronary arterial occlusion in experimental animal models. The administration of catecholamines during the early phases of evolving myocardial injury can result in heightened adrenergic biochemical responses in severely injured compared with normally perfused tissue in the hearts of experimental animals. Thus, there is adequate rationale for anticipating that beta-adrenergic antagonists would protect ischemic myocardium and potentially reduce the incidence of life-threatening arrhythmias in individuals with evolving acute myocardial infarction (AMI). Studies in animal models demonstrate that the administration of beta-adrenergic antagonists in the first few minutes after coronary artery occlusion may reduce the ultimate extent of myocardial necrosis. Clinical data from several different trials in which beta-adrenergic antagonists were administered to (1) protect ischemic myocardium and preserve ventricular function and (2) reduce the severity of serious ventricular arrhythmias in patients with AMI are reviewed. The effects of longer-term administration of beta-adrenergic antagonists in patients after AMI in prolonging life and reducing risk of reinfarction are presented.     

Short- and long- term prognosis after myocardial infarction

In 1971, altogether 266 acute coronary accidents in persons aged up to 65 years were recorded among the population of the City of Plzen. Of this number, 25% of men and 18% of women died during the prehospitalization phase. 203 persons were admitted to hospital: the development of their disease was followed up for three years in correlation with initial clinical and laboratory findings. Within these three years, the total mortality was 50% in men and 43% in women. Of the symptoms found within the first three days of hospitalization, the following ones appeared to be most significant prognostically: 1) sinus and ventricular arrhythmias, 2) congestive heart failure, 3) ECG changes, mainly pathological Q wave, left branch block, deeply negative T waves; 4) unfavourable for the three-years prognosis were histories of repetitive myocardial infarction, angina pectoris, hypertension, and diabetes mellitus; favourable for three-year prognosis were initial blood pressures 141--160/81--100 mmHg and heart rates 61--80/min. Such findings may serve for patients' classification for differentiated care in the postinfarction period.     

Short- and long-term comparative study of anistreplase versus streptokinase in acute myocardial infarction.

Streptokinase is well established as an effective thrombolytic. Anistreplase, a new thrombolytic drug, is a complex of streptokinase and acylated human plasminogen that can be administered by intravenous bolus and activates plasminogen at the clot site. Although both streptokinase and anistreplase are effected in treating myocardial infarction (MI), they have different pharmacologic properties. This study was designed to identify short- and long-term differences in their clinical effectiveness, safety in use, and survival rates in patients with acute MI. One hundred ten successive patients under seventy years of age admitted within three hours after onset of sustained chest pain suggestive of acute MI were randomized to receive either 30 units of anistreplase intravenously over five minutes or intravenous injection of 750,000 units of streptokinase over thirty to sixty minutes. Reperfusion was achieved in 34 of the 52 (65%) patients treated with anistreplase and in 41 of the 58 (71%) patients treated with streptokinase (p = NS). The two drugs were equally effective in preserving left ventricular ejection fraction, which was found to be significantly better in patients with anterior wall MI who had achieved reperfusion than it was in those who did not (p less than 0.02). One-month, twelve-month, and thirty-six-month survival rates were high (96% to 88%) with no significant difference between the two treatment groups. The authors conclude that the two drugs are equally effective thrombolytic agents but that anistreplase has the advantage that it can be administered as a bolus injection.     

Short- and medium-term outcome differences in women and men after primary percutaneous transluminal mechanical revascularization for acute myocardial infarction

Women presenting with acute myocardial infarction (AMI) have a higher mortality with conventional medical and thrombolytic therapy when compared with men. The outcome after primary percutaneous transluminal mechanical revascularization has not yet been fully investigated. This study was performed to compare the characteristics and the short- and medium-term outcomes of women and men with AMI treated with primary percutaneous revascularization. A total of 182 consecutive patients (62 women and 120 men) were included. Baseline clinical characteristics were similar except that women were older than men, presented more often in cardiogenic shock, and had smaller reference vessel diameters. Stents and abciximab were used equally, but abciximab was stopped more often in women before completion of the 12-hour infusion because of higher bleeding rates. Acute procedural success rates were similar (92% and 97%) but mortality was much higher in women, both at 30-day follow-up (100% vs 0.9%; p <0.05) and during a mean follow-up of 6.9 +/- 4.1 months (15% vs 4.4%; p <0.05). Women also experienced more unfavorable cardiovascular events (recurrent unstable angina or AMI, target vessel revascularization) than men. However, after control for baseline clinical differences in a multivariate analysis, gender was not an independent predictor of survival, whereas age, cardiogenic shock, and completion of a 12-hour abciximab infusion were.     

Exercise-induced symptomatic ischaemia predicts a poor long-term prognosis after acute myocardial infarction

STUDY OBJECTIVES: To evaluate the long-term prognostic significance of symptomatic ischaemia during exercise testing performed 3 weeks after acute myocardial infarction (AMI). DESIGN: A prospective study with long-term follow-up. SETTING: A Cardiac Rehabilitation Clinic in a University Hospital. SUBJECTS: A total of 446 patients were allowed to perform exercise testing 3 weeks after AMI and followed for 72 +/- 20 months. MEASUREMENTS AND RESULTS: Patients were divided into three groups according to whether they had no ECG evidence of ischaemia during exercise testing (334 patients), silent ischaemia (90 patients) or symptomatic ischaemia (22 patients). Cardiac death was significantly more frequent in patients with symptomatic ischaemia when compared with silent ischaemia (31.8% vs. 7.8%, P < 0.01) or when compared with no ischaemia (31.8% vs. 10.2%, P < 0.01). The three groups had a low cardiac mortality during the first 48 months of follow-up. The prognosis of patients with symptomatic ischaemia worsens markedly thereafter. The results of exercise testing did not predict recurrence of myocardial infarction. Coronary revascularization was performed in 34.4% of those without ischaemia, 47.8% of those with silent ischaemia and 45.5% of those with symptomatic ischaemia (P < 0.01). CONCLUSIONS: Patients with symptomatic ischaemia have a good prognosis during the first 4 years of follow-up. Their prognosis worsens thereafter as opposed to patients with or without silent ischaemia. This high-risk group of patients with symptomatic ischaemia deserves optimal management including revascularization when appropriate.     

Early and long-term prognosis after vasodilator therapy in the acute phase of myocardial infarction

Cautious administration of vasocilator agents with careful hemodynamic monitoring may improve cardiac function in many patients with severe pump failure and cardiogenic shock complicating myocardial infarction. However, the immediate prognosis tends to improve only in a specific subset of patients, that is, those with left ventricular stroke work index above 10 g.m/m2 and elevated left ventricular filling pressure. In the presence of very severe pump failure, cardiogenic shock, stroke work index of less than 10 g.m/m2 and grossly elevated left ventricular filling pressure, vasodilator therapy alone does not tend to improve in-hospital mortality. Furthermore, the long-term prognosis in the survivors with severe pump failure complicating myocardial infarction remains unfavorable. The poor prognosis of these patients is probably a result of the extensive myocardial necrosis sustained at the onset of infarction.     

Fatal outcome of acute myocardial infarction in men and women

An epidemiologic study of the outcomes of acute myocardial infarction, carried out according to the WHO Register of Acute Myocardial Infarction, demonstrated that overall mortality rates are similar for men and women between 20 and 69 years of age. Prehospital mortality was significantly higher in men, as compared to women, while the opposite was true for hospital mortality. Overall, prehospital and hospital mortality rates were relatively high in the younger patients, both male and female, an evidence of a more severe course of acute myocardial infarction at a younger age.     

Short- and long-term prognostic importance of complete bundle-branch block complicating acute myocardial infarction

Among 1013 consecutive patients with acute myocardial infarction (AMI), 104 (10%) developed complete bundle-branch block (BBB). The clinical characteristics and the short- and long-term prognosis were similar in the 53 patients with right and the 51 patients with left BBB. Compared to the 909 patients without this conduction disturbance, these 104 patients were older (64 +/- 9 vs. 58 +/- 10 years, p less than 0.001), more frequently women (26 vs. 17%, p less than 0.05), had a larger infarct (peak CK 1672 +/- 1124 vs. 1356 +/- 1089 IU/l, p less than 0.001), more frequently anterior (60 vs. 37%, p less than 0.001). They had a higher incidence of Killip class greater than 1 (63 vs. 38%, p less than 0.001), pericarditis (40 vs. 23%, p less than 0.001), atrial fibrillation or flutter (22 vs. 12%, p less than 0.01), ventricular fibrillation (15 vs. 9%, p less than 0.05), and atrioventricular block (23 vs. 11%, p less than 0.001). Both hospital mortality (32 vs 10%, p less than 0.001) and 3-year posthospital mortality (37 vs. 18%, p less than 0.001) were much higher among patients with complete BBB. Transient BBB had the same deleterious prognosis as BBB persistent at discharge (mortality 33 vs. 39%, NS). The prognostic importance of BBB was more prominent during the first 6 months after infarction (mortality between 6 and 36 months: 18% with BBB vs. 11% without BBB, NS).     

Immediate and long-term prognosis of acute myocardial infarction in the aged

The immediate prognosis and long-term survival of 132 consecutive not-monitored cases of acute myocardial infarction has been estimated in a 7-yr prospective study of a defined community of persons aged 65 and above.The prognostic implication of the demographic characteristics and of certain antecedent biological-physiological attributes of the subjects, as well as the impact of several severe initial manifestations in the acute attack, have been evaluated. In some respects the results are in harmony with other series of predominantly younger people, although the absolute long-term survival of this cohort was appreciably less favourable.     

Short- and long-term outcomes of patients with electrocardiographic left ventricular hypertrophy after fibrinolysis for acute myocardial infarction

There is conflicting evidence with regard to the value of electrocardiographic left ventricular hypertrophy (LVH) in myocardial infarction. Of 5,951 patients in the ASSENT-3 trial, 273 (5%) had LVH on baseline electrocardiograms and had significantly higher mortality rates at 30 days (11% vs 6%, p = 0.001) and 1 year (13% vs 8%, p = 0.007). After adjustment for differences in baseline parameters, LVH remained an independent predictor of 30-day (hazard ratio 2.3, 95% confidence interval 1.4 to 3.9) and 1-year (hazard ratio 1.8, 95% confidence interval 1.1 to 2.8) mortality rates. Thus, electrocardiographic LVH is a prognostic tool in identifying short- and long-term mortality rates in patients who have ST-elevation myocardial infarction and receive fibrinolysis.     

Short- and long-term mortality for patients undergoing primary angioplasty for acute myocardial infarction

OBJECTIVES: The goal of this study was to learn more about the risk factors and short- and long-term outcomes for primary angioplasty. BACKGROUND: Primary angioplasty (direct angioplasty without antecedent thrombolytic therapy) has been an effective alternative to thrombolytic therapy for patients with acute myocardial infarction (AMI). However, most reported studies have been compromised by small sample sizes and short observation times. METHODS: New York's coronary angioplasty registry was used to identify New York patients undergoing angioplasty within 6 h of AMI between January 1, 1993 and December 31, 1996. Statistical models were used to identify significant risk factors for in-patient and long-term survival and to estimate long-term survival for all patients as well as various subsets of patients undergoing primary angioplasty. RESULTS: The in-hospital mortality rate for all primary angioplasty patients was 5.81%. When patients in preprocedural shock (who had a mortality rate of 45%) were excluded, the in-hospital mortality rate dropped to 2.60%. Mortality rates for all primary angioplasty patients at one year, two years and three years were 9.3%, 11.3% and 12.6%, respectively. Patients treated with stent placement did not have significantly lower risk-adjusted in-patient or two-year mortality rates. CONCLUSIONS: Primary angioplasty is a highly effective option for AMI.     

Differences in thrombolytic treatment and in-hospital mortality between women and men after acute myocardial infarction

There is evidence for gender differences in the treatment and outcome of acute myocardial infarction (AMI). However, little data exist about these differences in patients from the Arab Middle East. Therefore, we studied the influence of patient gender on the presentation, the use of thrombolytic therapy, and in-hospital mortality after AMI in Kuwaiti nationals. This is a retrospective study of all consecutive Kuwaiti patients admitted to the coronary care unit of a university hospital with the diagnosis of AMI between June 1994 and May 1997. A total of 89 women and 267 men were included. Women were older than men and had significantly higher rates of diabetes (72% vs 46%), hypertension (58% vs 33%) and hypercholesterolemia (80% vs 53%). Women were less likely to receive thrombolytic therapy (40% vs 62%, p=0.001). Fewer women were eligible for thrombolytic therapy (50% vs 66%, p<0.05). Of those who were eligible for thrombolysis there was no sex difference in receiving such treatment. The in-hospital mortality among women younger than 70 years was 2.5 times higher than among men in the same age group, while there was no difference in mortality between women and men aged 70 years and older. We conclude that women and men with AMI have different clinical characteristics and outcomes following AMI. There was no gender bias for the use of thrombolytic therapy. The higher in-hospital mortality in younger women, i.e. less than 70 years, compared to younger men, indicates that younger women with AMI should be considered as a high-risk group.     

Behavioral and physiologic determinants of long-term prognosis after myocardial infarction

We studied the accuracy of predictions of long-term prognosis after infarction in a sample of 118 non-smoking, post-coronary males using: behavioral indices only; physiologic risk factors only; and a combination of behavioral indices and physiologic risk factors. To isolate valid behavioral indices, we measured 49 signs and symptoms of a lifestyle characterized by chronic struggle from videotapes of subjects undergoing a structured interview. Of these, 15 had a univariate relationship to recurrent cardiac events, and four--intensity, self-involvement, periorbital pigmentation and arousal while driving--had a multivariate relationship. Of six physiologic risk factors, one--the Peel Index--was related to recurrent cardiac events. Separately, each model achieved approximately 70% accuracy in classifying subjects into their future reinfarction status; jointly, predictive accuracy increased to 75%. The results suggest that living a lifestyle of chronic struggle increases risk for recurrent myocardial infarction, independently of the risk incurred by standard physiologic risk factors. The need for precise assessment of individual signs and symptoms of this lifestyle and implications for secondary prevention are discussed.     

Comparison of sexual activity of women and men after a first acute myocardial infarction

Studies of gender differences in the sexual activity of men and women after a first acute myocardial infarction (AMI) have produced conflicting results. The present study was performed to determine whether there are gender differences (1) in the quantity and quality of sexual activity after a first AMI, and (2) in the relations between selected demographic and medical variables and sexual activity after AMI. Four hundred sixty-two men and 51 women with a first AMI were interviewed once before discharge and again 3 to 6 months after AMI. Patients' demographic and medical background and their frequency of and satisfaction with sexual behavior were obtained from the interviews and from medical charts. Analyses of variance showed that women reported significantly less frequency of and satisfaction with sexual activity than men before and after AMI. Both women and men reported significantly less sexual activity and less satisfaction with sexual activity after AMI than before AMI. The decrease in frequency of and satisfaction with sexual activity after AMI was similar for women and men. The relations between selected demographic and medical variables such as age, education, and perceived health before the first AMI and the frequency of and satisfaction with sexual activity of the women and men did not appear to be affected differently by the AMI. A first AMI appears to reduce the frequency of and satisfaction with sexual activity of women and men similarly 3 to 6 months after AMI.     

Comparison of management and 30-day mortality of acute myocardial infarction in men versus women in Estonia

OBJECTIVE: There is conflicting information about gender differences in clinical features, management and outcome after acute myocardial infarction (AMI). The objective of the study was to compare the baseline characteristics, management and 30-day mortality of AMI in men and women in Estonia. METHODS: This study included consecutive unselected patients from the Myocardial Infarction Registry (MIR) in Estonia, who were admitted to a university hospital between January 2001 and February 2002. Logistic regression analysis was used to estimate crude and adjusted odds ratios (OR) with 95 percent confidence intervals (95% CI). RESULTS: The study included 228 men and 167 women. Women were older than men (73.49 +/- 10.95 vs. 65.63 +/- 12.60, p < 0.000), and had more comorbidities. After age-adjustment, the higher prevalence of comorbidities, like diabetes (age-adjusted odds ratio [OR] 2.48, 95% confidence intervals [CI] 1.45-4.24), hypertension (OR 1.78, 95% CI 1.15-2.76) and history of congestive heart failure (OR 2.14, 95% CI 1.32-3.46) in women was preserved. Women were more frequently treated with diuretics (OR 2.68, 95% CI 1.69-4.25) and less frequently with statins (OR 0.61, 95% CI 0.39-0.96), after age-adjustment. Although thrombolytic therapy, coronary angiography and angioplasty were performed less frequently in women, these differences disappeared after age-adjustment. Female gender was not an independent predictor of 30-day mortality after AMI, crude OR was 1.39, 95% CI 0.80 to 2.41, adjustment for age and other covariates reduced OR to 0.98, 95% CI 0.44 to 2.20. CONCLUSIONS: Among AMI-patients, age but not gender is an important determinant of care and early mortality.     

Short- and long-term clinical effects of primary directional coronary atherectomy for acute myocardial infarction

We performed primary directional coronary atherectomy (DCA) without antecedent thrombolytic therapy in 21 of 67 patients with acute myocardial infarction within 24 hr of onset between June 1993–March 1994. Reperfusion with primary DCA was successful in 18 patients (85.7%, group D). Results were compared with those of primary balloon angioplasty patients treated between June 1992–May 1993 (group P). Minimum lumen diameter (MLD) values both immediately after reperfusion and in predischarge angiograms were significantly larger in group D than in group P, but were similar in late follow-up angiograms. Although a larger MLD in group D than in group P contributed to the prevention of reocclusion of the coronary artery before discharge in DCA patients, a high rate of restenosis at late follow-up canceled the beneficial effects of primary DCA. © 1996 Wiley-Liss, Inc.     

Impact of obesity on long-term prognosis following acute myocardial infarction

OBJECTIVE: To evaluate the impact of obesity on mortality in patients with acute myocardial infarction. METHODS: This study comprises 6676 consecutive patients with acute myocardial infarction screened for entry into the Danish Trandolapril Cardiac Evaluation (TRACE) study. At baseline, body mass index (BMI) and waist to hip ratio (WHR) were measured. Survival status was determined after 8-10 years. RESULTS: BMI was used to divide patients into 4 groups: underweight, normal weight, overweight and obese. The normal weight group was used as reference for the other groups. WHR was divided in quartiles and the lowest quartile was used as reference for the three other quartiles. The prevalence of overweight (BMI 25-29.9 kg/m(2)) and obesity (BMI>30 kg/m(2)) were 48% and 13% in males and 31% and 13% in females. Obese patients were younger, less often smokers and more frequently suffered from diabetes and hypertension. In both men and women, there was no association between obesity assessed as BMI and mortality [men: adjusted RR=0.99 (0.85-1.14, p=0.3); women: adjusted RR=0.90 (0.74-1.10, p=0.2)]. Men with WHR in the upper quartile had an increased mortality [adjusted RR=1.21 (1.07-1.37, p<0.01)]. Increasing WHR in women showed a trend of increased mortality, although this was not significant [adjusted RR=1.13 (0.95-1.34, p=0.2)]. CONCLUSION: In patients with acute myocardial infarction overall obesity as assessed by body mass index is inversely related to mortality. However, abdominal obesity appears to be an independent predictor of all-cause mortality in men and perhaps also in women.