Gender differences in the management and outcome of acute myocardial infarction in unselected patients in the thrombolytic era

This study compares the clinical features, management, and outcome in men and women from a consecutive, unselected series of patients with acute myocardial infarction (AMI) who were admitted to a university cardiac center over a 3-year period. It is a retrospective observational study of 1,059 admissions with AMI identified through the Hospital In-Patient Enquiry (HIPE) registry, validated according to Minnesota Manual criteria, and followed for a period of up to 5 years (median 36 months). Women comprised 40% of all admissions, had a higher hospital mortality (24% vs. 16%, p<0.001), and were less likely to receive thrombolysis (23% vs. 33%, p<0.01), admission to coronary care (65% vs. 77%, p<0.001), or subsequent invasive or noninvasive investigations (55% vs. 63%, p<0.01). However, women with AMI were older than men with AMI (71 vs. 65 years, p<0.001). After adjusting for age, differences that remained significant were prevalence of hypertension (odds ratio [OR] 2.12, 95% confidence intervals [CI] 1.56 to 2.88) and cigarette smoking (OR 0.47, 95% CI 0.35 to 0.65), management in coronary care (OR 0.66, 95% CI 0.49 to 0.88), and hospital mortality (OR 1.48, 95% CI 1.07 to 2.04). Excess mortality occurred predominantly in women <65 years old (18% vs. 8%, OR [multivariate] 2.35, 95% CI 1.19 to 4.56), among whom multivariate analysis demonstrated a significantly lower thrombolysis rate (OR 0.48, 95% CI 0.27 to 0.86). In this group, lack of thrombolysis independently predicted hospital mortality (OR 5.37, 95% CI 1.45 to 19.82). Female gender was not an independent predictor of mortality following AMI (OR 1.42, 95% CI 0.90 to 2.26). Thus, among unselected patients, female gender is associated with, but not an independent predictor of, reduced survival after AMI. Gender differences in mortality are greatest in younger patients, who are less likely to receive thrombolysis and in whom lack of thrombolysis is independently associated with mortality after AMI.     

Hospitalization of discharged patients with acute myocardial infarction in the thrombolytic era

The objective of the work is to assess in discharged patients with AIM data on the period of hospitalization in the intensive care unit and the total period of hospitalization and how these were influenced by stratification into patients with complicated and uncomplicated AIM and patients with a low, medium and high risk. Data on hospitalization were analyzed in 2,527 discharged patients with AIM. The median of hospitalization at intensive care units was 5 days and the mean period of hospitalization 6.35 days. The significantly longer hospitalization (p < 0.001) in patients with complicated AIM (median 6 days) as compared with patients with uncomplicated AIM (median 5 days) impliesonly a one-day longer hospitalization in patients with complicated AIM. The median of total hospitalization was 17 days and the mean period of hospitalization 17.95 days. In the majority of patients the period of hospitalization was 15 - 21 days. More than 20% are hospitalized for more than 21 days. A significant difference of the total period of hospitalization in high risk patients and patients with a medium and low risk expressed in medians is only 2 days. The majority of patients in all three sub-groups of patients with AIM is dicharged between the 15th to 21st day of hospitalization. In the period of hospitalization at intensive care units and total hospitalizatiob of different sub-groups there is no substantial difference in their health status, incl. the danger of sudden cardiac death. By reducing the total period of hospitalization in discharged patients without complications it would be possible to save a considerable percentage of costs of hospitalization. The period of hospitalization must be fixed individually in every patient. In early dicharges it is important to consider also the psychosocial impact of discharge on the patient and his relatives.     

Hospital mortality of acute myocardial infarction in the thrombolytic era

OBJECTIVE: To examine the management and outcome of an unselected consecutive series of patients admitted with acute myocardial infarction to a tertiary referral centre. DESIGN: A historical cohort study over a three year period (1992-94) of consecutive unselected admissions with acute myocardial infarction identified using the HIPE (hospital inpatient enquiry) database and validated according to MONICA criteria for definite or probable acute myocardial infarction. SETTING: University teaching hospital and cardiac tertiary referral centre. RESULTS: 1059 patients were included. Mean age was 67 years; 60% were male and 40% female. Rates of coronary care unit (CCU) admission, thrombolysis, and predischarge angiography were 70%, 28%, and 32%, respectively. Overall in-hospital mortality was 18%. Independent predictors of hospital mortality by multivariate analysis were age, left ventricular failure, ventricular arrhythmias, cardiogenic shock, management outside CCU, and reinfarction. Hospital mortality in a small cohort from a non-tertiary referral centre was 14%, a difference largely explained by the lower mean age of these patients (64 years). Five year survival in the cohort was 50%. Only age and left ventricular failure were independent predictors of mortality at follow up. CONCLUSIONS: In unselected consecutive patients the hospital mortality of acute myocardial infarction remains high (18%). Age and the occurrence of left ventricular failure are major determinants of short and long term mortality after acute myocardial infarction.     

Delayed thrombolytic treatment of older patients with acute myocardial infarction.

OBJECTIVE: To determine demographic and clinical factors associated with delayed thrombolysis in patients with acute myocardial infarction. DESIGN: A retrospective cohort. SETTING: 37 Minnesota hospitals during the time periods October 1992-July 1993 and July 1995-April 1996. PATIENTS: We reviewed the medical records of 776 older patients aged 65 or older hospitalized with an admission diagnosis of acute myocardial infarction, suspected acute myocardial infarction, or rule-out acute myocardial infarction, who were treated with a thrombolytic agent. MEASUREMENT: We used multivariate logistic regression models to examine the association between selected study characteristics and time between hospital presentation and administration of thrombolytic treatment. Early thrombolysis was defined as less than 60 minutes after hospital presentation and late thrombolysis as 60+ minutes. RESULTS: Of 776 study patients, 57.5% (n = 446) received early thrombolysis. Of the remaining 330 patients receiving late treatment, 12.1% (n = 94) were thrombolyzed more than 2 hours after hospital presentation. After controlling for other factors, the odds of delayed thrombolysis among patients aged 75 or older were 1.48 compared with younger individuals (95% CI, 1.17-1.88). The odds of delayed thrombolysis among patients with severe comorbidity were 1.46 (95% CI, 1.10-1.94) compared with individuals without severe comorbidity. Predictors of early thrombolytic treatment included hospital arrival via emergency transport (ORdelay = 0.46; 95% CI, 0.34-0.63) and chest discomfort at admission (ORdelay = 0.40; 95% CI, 0.18-0.86). CONCLUSIONS: The present study indicates that patients of advanced age and with severe comorbidity are more likely to experience delayed thrombolytic treatment after hospital presentation. These are the patients who suffer the highest morbidity from acute myocardial infarction and for whom expeditious treatment may enhance therapeutic benefit.     

Management of patients after thrombolytic therapy for acute myocardial infarction

The coronary artery thrombus that causes acute myocardial infarction can be lysed, and reperfusion can be achieved, in the first few hours after infarction. However, the infarct vessel will reocclude in 15-30% of patients, and this event is frequently associated with pain, reinfarction, arrhythmias, or death. The risk of reocclusion is greatest in patients with high-grade residual stenosis after thrombolysis. Percutaneous coronary angioplasty may be performed safely after thrombolytic therapy. Angioplasty effectively decreases the degree of residual stenosis, and may thereby reduce the risk of reocclusion and consequent ischemic events. However, a substantial proportion of patients with acute infarction are not suitable candidates for angioplasty. Coronary artery bypass surgery has also been safely performed within several days after thrombolytic therapy. Further studies are needed to determine which patients will benefit most from this aggressive approach to acute myocardial infarction.     

Long-term prognosis of young patients after myocardial infarction in the thrombolytic era

Background: Myocardial infarction (MI) in young adults is a rare event. In the Framingham study, the 10-year incidence rate of MI per 1,000 was 12.9 in men 30–34 years old. Overall, 4–8% of patients with acute MI are ≤ 40 years old. Hypothesis: It was the purpose of this study to assess the in-hospital and long-term morbidity and mortality in patients ≤40 years old with acute myocardial infarction compared with older patients in the thrombolytic era. Methods: A consecutive series of 75 patients aged ≤40 years (mean 35.0 ± 4.8) with acute myocardial infarction was compared with an equally sized group of patients aged >40 years (mean 65.1 ± 9.8). Results: Thrombolysis or direct percutaneous transluminal coronary angioplasty was performed in 52 versus 24% (p = 0.0004) and 5.3 versus 2.7% (p = NS) in younger and older patients, respectively. Significantly fewer young patients had multivessel disease (28 vs. 64%, p < 0.004). No in-hospital mortality was observed in patients with reperfusion therapy irrespective of age. After a mean followup time of 47 ± 35 months, cardiac mortality was 0 and 11% (p < 0.03), respectively, in young and older patients with, and 3 versus 24% (p < 0.02) without reperfusion therapy, respectively. In addition, significantly fewer patients in the younger age group developed recurrent angina pectoris (12 vs. 39%, p = 0.0004) or congestive heart failure (9 vs. 34%, p = 0.0005) irrespective of reperfusion therapy. Conclusion: Our observations demonstrate that long-term prognosis after myocardial infarction in young patients is excellent in the thrombolytic era.     

Smoking and prognosis after acute myocardial infarction in the thrombolytic era (Israeli thrombolytic national survey)

Objectives. This study sought to compare the relation between smoking and the 30-day and 6-month outcome after acute myocardial infarction in an Israeli nationwide survey.Background. Studies before and during the thrombolytic era reported similar or lower early mortality after acute myocardial infarction in smokers than in nonsmokers. This finding is intriguing and may be misleading because numerous epidemiologic studies have clearly shown that smoking is an independent risk factor for atherosclerosis, myocardial infarction and death.Methods. The study cohort comprised 999 consecutive patients with an acute myocardial infarction from a prospective nationwide survey conducted during January and February 1994 in all coronary care units operating in Israel. The prognosis of 367 patients (37%) who were smokers (current smokers and those who smoked up to 1 month before admission) was compared with that of 632 nonsmokers (past smokers or those who never smoked).Results. Smokers were on average 10 years younger and were more frequently men and patients with a family history of coronary heart disease and inferior infarction and less frequently patients with a previous infarction or a history of angina, hypertension and diabetes than nonsmokers. Smokers also had a lower incidence of congestive heart failure on admission or during the hospital period. Thrombolytic therapy (49% vs. 40%, p < 0.01) and aspirin (89% vs. 80%, p < 0.001) were administered more frequently in smokers than nonsmokers. The crude 30-day (6.0% vs. 15.7%) and cumulative 6-month (7.9% vs. 21.5%) mortality rates were significantly lower (p < 0.0001 for both) in smokers than nonsmokers, respectively. However, after adjustment for age, baseline characteristics, thrombolytic therapy and invasive coronary procedures, the lower 30-day (odds ratio [OR] 0.75, 95% confidence interval [CI] 0.43 to 1.29, p = 0.30) and 6-month (hazard ratio 0.84, 95% CI 0.54 to 1.30, p = 0.42) mortality rates in smokers and nonsmokers were not significantly different. The model had a power of 0.80 for OR 0.50, with alpha 0.1.Conclusions. In our nationwide survey, the seemingly better prognosis of smokers early after acute myocardial infarction was no longer evident after adjustment for baseline and clinical variables and may be explained by their younger age and a more favorable risk profile. Smokers develop acute myocardial infarction a decade earlier than nonsmokers. Efforts to lower the prevalence of smoking should continue.     

Stroke and acute myocardial infarction in the thrombolytic era: clinical correlates and long-term prognosis

Thirteen (1.8%) of 708 patients with acute myocardial infarction treated with recombinant tissue-type plasminogen activator in the Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) I, II and III trials developed a stroke. Four strokes were hemorrhagic and nine were nonhemorrhagic. Of five prespecified risk factors for intracranial hemorrhage (age greater than 65 years, history of hypertension, history of prior cerebrovascular disease, aspirin use and acute hypertension), two patients had two risk factors and one patient had one risk factor. However, 80% of patients without intracranial hemorrhage had at least one risk factor and 31% had two risk factors. No patient with a prior stroke or transient ischemic attack (all greater than 6 months previously) had an intracranial hemorrhage. Of three prespecified risk factors for nonhemorrhagic stroke (atrial fibrillation, prior cerebrovascular disease and large anterior wall infarction), only the occurrence of a large anterior myocardial infarction (with ejection fraction less than 45%) was a predictor (p = 0.0015). The in-hospital death rate was 25% for patients with hemorrhagic stroke versus 11% for patients with a non-hemorrhagic stroke and 6% for those patients without a stroke. Furthermore, the hospital stay was greater than 50% longer in patients who had a stroke than in those who did not. Thus, intracranial hemorrhage remains an unpredictable risk in patients treated with thrombolytic therapy and cerebral infarction is related to anterior myocardial infarction and poor left ventricular function. Both types of stroke are associated with substantial morbidity and mortality.     

Development and prognosis of non-Q-wave myocardial infarction in the thrombolytic era

Background Data on non-Q myocardial infarctions (MI) are derived primarily from prethrombolytic era studies. Previous trials demonstrated different development rates and none reported on clinical outcomes. Methods Our goal was to determine the incidence and prognosis of non-Q-wave MI among patients with ST-segment elevation receiving thrombolysis. A retrospective analysis of 5 randomized controlled trials was made. The main outcome measures included rates of (1) transformation of ST-segment elevation to Q- and non-Q-wave MI and (2) inhospital and 1-year mortality and reinfarction among patients who subsequently develop a Q or non-Q MI postthrombolysis as compared to controls. Results Non-Q wave development was greater among patients receiving thrombolysis versus placebo/control (3.1% absolute difference, 95% CI 1.2%-5.0%). Among patients receiving thrombolysis, those who developed a non-Q MI experienced significantly lower inhospital and 1-year mortality (absolute differences −3.8% [95% CI −5.2% to −2.4%] and −6.4% [95% CI −9.9% to −3.0%], respectively) and reinfarction (absolute differences −2.9% [95% CI −4.3% to −1.6%] and −3.5% [95% CI −6.1% to −0.9%], respectively) rates, compared with those who evolved a Q MI. Inhospital and 1-year mortality was also significantly lower when compared to placebo/control patients who developed a non-Q MI (absolute differences 4.6% [95% CI −8.2% to −1.1%] and −7.5% [95% CI −12.5% to −2.5%], respectively). Conclusions Patients receiving thrombolysis more often develop a non-Q-wave MI and have a better prognosis than either those who develop a Q MI postthrombolysis or a non-Q MI after standard medical therapy. (Am Heart J 2002;144:243-50.)     

高龄急性心肌梗死患者静脉溶栓治疗的临床观察

目的：探讨高龄（≥75岁）急性心肌梗死（AMI）患者静脉溶栓治疗的疗效和安全性。方法：将61例高龄AMI患者随机分为溶栓组和常规治疗组，溶栓组30例，在常规治疗基础上采用尿激酶（UK）静脉溶栓＋口服阿斯匹林（ASA）。常规治疗组31例，除不用UK外，其余治疗均与溶栓组相同。结果：血管再通率溶栓组为66．7％（20／30），常规治疗组为12．9％（4／31），两组血管再通率比较，差异有显著性（P＜0．05）。溶栓组住院4周病死率为3．3％，常规治疗组为22．6％，两组比较差异亦有显著性（P＜0．05）。溶栓组未见严重出血等并发症。结论：UK＋ASA治疗高龄AMI可以提高冠脉再通率，降低病死率和改善预后。     

Prognosis of acute myocardial infarction in the thrombolytic era: medical evaluation is still valuable

BACKGROUND: Modern and sophisticated technology for the management of myocardial infarction has progressively devalued medical evaluation. HYPOTHESIS: This study was undertaken to assess the importance of the findings of medical evaluation at hospital presentation, in patients with acute myocardial infarction. METHODS: Data from 590 thrombolytic-treated myocardial infarction patients were analyzed. The patients were grouped according to their clinical status on arrival at hospital. A modified Forrester classification--subset II was divided according to the absence (IIa) or presence (IIb) of symptoms--was applied. Short- (14 days) and long-term (up to 10 years) survival was analyzed and 19 independent variables were included in the multivariate models. RESULTS: Short-term survival was 95.6% for subset I, 83.3% for subset IIa, 60% for subset IIb, 54.6% for subset III, and 34.8% for subset IV (P<0.001). By multiple regression analysis, lower clinical subsets (P<0.001), fewer coronary arteries with disease (P=0.006), younger age (P=0.014), absence of reinfarction (P=0.034), longer interval between streptokinase infusion and coronary arteriography (P=0.016), and higher left ventricular ejection fraction (P=0.037) demonstrated significant and independent correlation with short-term survival. Long-term survival for the total population was 71+/-3.6% for subset I, 54.4+/-8.5% for subset IIa, 20.8+/-9.4% for subset IIb, 54.5+/-15% for subset III, and 0% for subset IV (P<0.001). Using Cox regression analysis, lower clinical subsets (P<0.001), younger age (P<0.001), higher global left ventricular ejection fraction (P<0.001), and fewer coronary arteries with disease (P=0.021) correlated independently and significantly with long-term survival. When excluding data from patients who died before the short-term follow-up (n=532), lower clinical subsets remained an important predictor of long-term survival (P<0.001). CONCLUSION: Clinical classification at hospital presentation is a powerful predictor of short- and long-term survival post-myocardial infarction.     

静脉溶栓治疗老年急性心肌梗死患者的体会

目的探讨老年（≥75岁）急性心肌梗死患者静脉溶栓的疗效及安全性。方法将62例老年急性心肌梗死患者随机分为溶栓组和常规治疗组；溶栓组32例。采用尿激酶静脉溶栓加皮下注射小剂量低分子肝素钙。常规治疗组30例，除不用尿激酶及小剂量低分子肝素钙外，其余治疗均与溶栓组相同。结果冠状动脉再通率溶栓组为65．6％（21／32），常规治疗组为16．7％（5／30），两组比较差异具有显著性（P〈0．05）；溶栓组病死率6．3％（2／32），而常规治疗组病死率为23．3％（7／30），两组比较具有显著差异性（P〈0．05）；两组无严重出血并发症，出血并发症比较差异无显著性（P〉0．05）。结论 尿激酶静脉溶栓治疗老年急性心肌梗死可以提高冠状动脉再通率，降低死亡率和改善预后，是可行性治疗措施。     

静脉溶栓治疗老年急性心肌梗死的临床分析

目的 探讨老年(≥75岁)急性心肌梗死患者静脉溶栓的疗效及安全性. 方法 将62例老年急性心肌梗死患者随机分为溶栓组和常规治疗组;溶栓组32例,采用尿激酶静脉溶栓加皮下注射小剂量低分子肝素钙.常规治疗组30例.除不用尿激酶及小剂量低分子肝素钙外,其余治疗均与溶栓组相同.结果 冠状动脉再通率溶栓组为65.6%(21/32),常规治疗组为16.7%(5/30),两组比较差异具有显著性(P<0.05);溶栓组病死率6.3%(2/32),而常规治疗组病死率为23.3%(7/30),两组比较具有显著差异性(P<0.05);两组无严重出血并发症,出血并发症比较差异无显著性(P>0.05). 结论 尿激酶静脉溶栓治疗老年急性心肌梗死可以提高冠状动脉再通率,降低死亡率和改善预后,是可行性治疗措施.     

Selection of patients with acute myocardial infarction for thrombolytic therapy

PURPOSE: To critically review the current recommendations regarding the eligibility of patients with myocardial infarction for thrombolytic therapy. DATA IDENTIFICATION: Relevant studies published from January 1980 to January 1990 were identified through a computerized search of the English-language literature using MEDLINE and by a manual search of the bibliographies of all identified articles. STUDY SELECTION: All randomized, controlled trials of intravenous thrombolysis in acute myocardial infarction and unstable angina were reviewed. Smaller, observational studies and previous review articles were included when relevant to the discussion. DATA EXTRACTION: Key data were extracted from each article, including the proportions of patients eligible for thrombolysis, the reasons for exclusion from thrombolytic therapy, and the clinical outcomes of patients treated and of those excluded from treatment. The validity of certain exclusion criteria was examined using subgroup analysis from the large, randomized mortality trials of intravenous thrombolysis and observations from smaller, nonrandomized studies. RESULTS OF DATA SYNTHESIS: To date, relatively few patients with myocardial infarction have been considered eligible for fibrinolytic therapy. In this group, both early and late mortality have been significantly reduced. Patients excluded from thrombolysis, however, continue to have a high early mortality. The data suggest that the potential benefits of this treatment might be extended to selected high-risk subgroups. In particular, the risk-benefit ratio may favor the inclusion of otherwise healthy elderly patients; certain patients presenting more than 6 hours after the onset of symptoms; and patients with a history of controlled systolic hypertension or brief, nontraumatic cardiopulmonary resuscitation. The data do not support the use of fibrinolytic therapy as primary treatment in patients with unstable angina or suspected myocardial infarction in the absence of confirmatory electrocardiographic changes. CONCLUSIONS: The full potential of thrombolytic therapy to alter the natural history of acute myocardial infarction can only be realized through the continued evaluation of selection criteria and the identification and treatment of the greatest possible number of eligible patients.     

Relation of soluble and platelet P-selectin to early outcome in patients with acute myocardial infarction after thrombolytic therapy

Pre- and post-treatment platelet and soluble P-selectin were measured in a group of patients enrolled in the GUSTO-III study and were correlated with clinical outcomes. A peak in soluble P-selectin levels at 3 hours after thrombolytic therapy and lower baseline platelet P-selectin were associated with successful thrombolysis.