Two-year survival after myocardial infarction

We have studied 773 consecutive cases (706 individuals) with definite myocardial infarction treated in the Coronary Care Unit at Danderyd Hospital in Stockholm during the period 1984-85. Hospital mortality was 12.9% in all patients and 8.9% in patients under 70 years of age. Six hundred and six patients were discharged from the hospital and followed up for 2 years. The 2-year mortality in ischaemic heart disease was 14.4% in all patients and 9.5% in patients under 70 years of age and, including all causes of death, 20.3% and 14.6%, respectively. Our policy for medical treatment included frequent use of beta-adrenergic blocking agents, even in heart failure, and restricted use of antiarrhythmic drugs and digitalis. A short delay of admission may have been beneficial for the result of different kinds of anti-ischaemic intervention. Furthermore, a routinely performed exercise ECG before discharge and after 6 weeks, as part of a structured follow-up, has improved our ability to detect complications at an early stage and to optimize medical treatment.     

Five-year risk of developing clinical diabetes after first myocardial infarction; the FINAMI study.

AIM: To investigate the incidence of clinical diabetes as determined by the incidence of diabetes drug reimbursements within a 5-year period after the first myocardial infarction (MI) in patients who were non-diabetic at the time of their first MI. RESEARCH DESIGN AND METHODS: A population-based MI register, FINMONICA/FINAMI, recorded all coronary events in persons of 35-64 years of age between 1988 and 2002 in four study areas in Finland. These records were used to identify subjects sustaining their first MI (n = 2632). Participants of the population-based risk factor survey FINRISK (surveys 1987, 1992, 1997 and 2002), who did not have diabetes or a history of MI, served as the control group (n = 7774). The FINMONICA/FINAMI study records were linked with the National Social Security Institute's drug reimbursement records, which include diabetes medications, using personal identification codes. The records were used to identify subjects who developed diabetes during the 5-year follow-up period (n = 98 in the MI group and n = 79 in the control group). RESULTS: Sixteen per cent of men and 20% of women sustaining their first MI were known to have diabetes and thus were excluded from this analysis. Non-diabetic men having a first MI were at more than twofold {hazard ratio (HR) 2.3 [95% confidence interval (CI) 1.6-3.4]}, and women fourfold [HR 4.3 (95% CI 2.4-7.5)], risk of developing diabetes mellitus during the next 5 years compared with the control population without MI. CONCLUSIONS: Many patients who do not have diabetes at the time of their first MI develop diabetes in the following 5 years.     

Emotional support and survival after myocardial infarction. A prospective, population-based study of the elderly.

OBJECTIVE: To compare the survival of elderly patients hospitalized for acute myocardial infarction who have emotional support with that of patients who lack such support, while controlling for severity of disease, comorbidity, and functional status. DESIGN: A prospective, community-based cohort study. SETTING: Two hospitals in New Haven, Connecticut. PATIENTS: Men (n = 100) and women (n = 94) 65 years of age or more hospitalized for acute myocardial infarction between 1982 and 1988. MEASUREMENTS: Social support, age, gender, race, education, marital status, living arrangements, presence of depression, smoking history, weight, and physical function were assessed prospectively using questionnaires. The presence of congestive heart failure, pulmonary edema, and cardiogenic shock; the position of infarction; in-hospital complications; and history of myocardial infarction were assessed using medical records. Comorbidity was defined using an index based on the presence of eight conditions. RESULTS: Of 194 patients, 76 (39%) died in the first 6 months after myocardial infarction. In multiple logistic regression analyses, lack of emotional support was significantly associated with 6-month mortality (odds ratio, 2.9; 95% CI, 1.2 to 6.9) after controlling for severity of myocardial infarction, comorbidity, risk factors such as smoking and hypertension, and sociodemographic factors. CONCLUSIONS: When emotional support was assessed before myocardial infarction, it was independently related to risk for death in the subsequent 6 months.     

Early mobilization after myocardial infarction. A controlled study

The effects of early mobilization after uncomplicated myocardial infarction were investigated in a strictly randomized controlled study conducted during a period of transition in the therapeutic practice of the Cantonal Hospital in Geneva, Switzerland. One hundred fifty-four patients under age 70 who were hospitalized for acute myocardial infarction and who had no complications on day 1 or day 2 were randomly assigned to two treatment groups. In the early mobilization group, patients were treated by a physical therapist with a progressive activity program beginning on day 2 or 3 after infarction. In the control group, patients underwent the traditional hospital regimen of strict bed rest for 3 or more weeks. The mean duration of hospitalization was 21.3 days for treated patients and 32.8 days for the control group. The follow-up period ranged from 6 to 20 (average 11.2) months. There were no statistically significant differences between the two groups with regard to hospital or follow-up mortality, rate of reinfarction, arrhythmias, heart failure, angina pectoris or ventricular aneurysm, or results of an exercise test. There was significantly greater disability in the control than in the treated group on follow-up examination. This controlled trial, based on a rigid experimental design, provides important confirmation of the benefits of early mobilization observed in uncontrolled programs in recent years.     

Cardiac rehabilitation after myocardial infarction in the community.

OBJECTIVES: The aim of this study was to examine participation in cardiac rehabilitation after myocardial infarction (MI) by age and gender and the association of participation with survival. BACKGROUND: Lesser participation in cardiac rehabilitation has been reported for women and the elderly. METHODS: All incident MIs in Olmsted County were validated. Baseline characteristics and outcomes were ascertained from the medical record. Logistic regression examined the association between participation, age, and gender. Propensity scores were used to examine the association between participation and outcome. RESULTS: Among 1,821 persons with incident MI (58% men, 46% age >70 years), 55% participated in cardiac rehabilitation. Participants were more likely to be men, younger, and have fewer comorbidities (p < 0.01 for all comparisons). After adjustment, women were 55% less likely to participate than men (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.34 to 0.60), and persons 70 years or older were 77% less likely to participate than persons younger than 60 (OR 0.23, 95% CI 0.16 to 0.33). Participants had a lower risk of death and recurrent MI at three years (p < 0.001 and p = 0.049, respectively). The survival benefit associated with participation was stronger in more recent years (relative risk [RR] for 1998 vs. 1982 0.28, 95% CI 0.18 to 0.43; RR for 1990 vs. 1982 0.41, 95% CI 0.33 to 0.52). CONCLUSIONS: Approximately half of the patients participated in cardiac rehabilitation after MI. Participation did not increase over time. Women and elderly persons were less likely to participate, independently of other characteristics. Participation in rehabilitation was independently associated with decreased mortality and recurrent MI, and its protective effect was stronger in more recent years.     

Blood pressure and survival after myocardial infarction: The Framingham study

Blood pressures were routinely obtained biennially from 2,336 men in the Framingham cohort over a 20 year period of follow-up study. During that time 193 men had their first myocardial infarction. Blood pressure after myocardial infarction was unrelated to survival over the next 5 years, but the blood pressure status preceding the infarction was distinctly related to survival, with hypertensive patients having almost three times the mortality of normotensive patients. These results are explained by the two-fold greater risk of death incurred by hypertensive patients who had a substantial decrease in pressure after myocardial infarction compared with that of men who remained hypertensive. The greater the decrease in pressure after myocardial infarction the greater was the mortality. With exclusion of men who experienced a reduction of more than 10 mm Hg in pressure, men with hypertension after myocardial infarction had a five-fold greater risk of mortality than that of normotensive patients.A decrease in pressure with interim myocardial infarction occurs frequently, even when the influence of age, treatment and regression toward the mean are taken into account. Men who experienced such reductions in pressure had a reduction in vital capacity (not statistically significant) and an increase in heart rate, thus suggesting that poorer myocardial function accounts for the greater mortality.     

Prognostic stratification of patients after myocardial infarction.

An attempt was made to stratify risk of subsequent cardiac events in post-infarct patients according to a combination of the results of clinical assessment, routine diagnostic investigations, and pre-discharge exercise testing in 350 consecutive patients who were followed up for one year. Patients were classified prospectively on the basis of the extent of myocardial damage as assessed by peak enzyme release, reciprocal change on the electrocardiogram at the time of myocardial infarction, Norris prognostic index, ability to perform a pre-discharge exercise test (and test result), and ability to tolerate beta adrenergic blockade on discharge. Of the 50 patients with contraindications to pre-discharge exercise testing, 26% died or had reinfarctions compared with 9% of the 300 exercised patients; the 24 non-exercised patients with evidence of extensive myocardial damage or reciprocal changes on the electrocardiogram were particularly at risk. Similarly, among the 300 exercised patients, extensive myocardial damage, reciprocal change on the electrocardiogram, and ST depression on exercise testing were the major risk markers in that each identified at least 75% of the patients who had subsequent cardiac events. The 63 exercised patients who had all three of these major risk markers constituted a high risk group: 18 (29%) died or had reinfarction. Of the remaining 237 patients, only 9 (4%) had cardiac events. The 35 high risk patients with exercise induced angina pectoris or clinical contraindications to beta blockade were particularly at risk; 15 (43%) died or had reinfarction. This approach to risk stratification identified a small cohort of high risk patients in a large population of myocardial infarction survivors; it also identified a large group with a very low risk of subsequent cardiac events.     

Improved survival after acute myocardial infarction in patients with advanced Killip class

BACKGROUND: The continuing applicability of the Killip classification system to the effective stratification of long-term and short-term outcome in patients with acute myocardial infarction (MI) and its influence on treatment strategy calls for reanalysis in the setting of today's primary reperfusion treatments. HYPOTHESIS: Our study sought to test the hypothesis that Killip classification, established on admission in patients with acute MI, is an effective tool for early prediction of in-hospital mortality and long-term survival. METHODS: A series of 909 consecutive Olmsted County patients admitted with acute MI to St. Marys Hospital, Mayo Clinic, between January 1988 and March 1998 was analyzed. Killip classification was the primary variable. Endpoints were in-hospital death, major in-hospital complications, and post-hospital death. RESULTS: Patients analyzed included 714 classified as Killip I, 170 classified as Killip II/III, and 25 classified as Killip IV. Increases in in-hospital mortality and prevalence of in-hospital complications correspond significantly with advanced Killip class (p < 0.01), with in-hospital mortality 7% in class I, 17.6% in classes II/III, and 36% in class IV patients (p < 0.001). Killip classification was strongly associated with mode of therapy administered within 24 h of admission (p < 0.01). Killip IV patients underwent primary angioplasty most commonly and were less likely to receive medical therapy. CONCLUSIONS: Killip classification remains a strong independent predictor of in-hospital mortality and complications, and of long-term survival. Early primary angioplasty has contributed to a decrease in mortality in Killip IV patients, but effective adjunctive medical therapy is underutilized.     

Diabetic patients after myocardial infarction

Diabetes mellitus is not just another risk factor for cardiovascular events; it per se defines maximal risk for target organ damage including the cardiovascular system. Diabetes is one of the main drivers in the race towards a higher incidence in cardiovascular disease worldwide. In addition, it is also one of the often unrecognized predecessors of myocardial infarction and sudden cardiac death. About three quarters of patients post-MI show impaired glucose tolerance or full blown diabetes. The MONICA/KORA data have shown that the higher risk for mortality and morbidity in diabetics is maintained past the first event. However, the STENO-2 trial has shown that consequently managing diabetes and concomitant cardiovascular risk factors can significantly reduce the risk for cardiovascular events in this high-risk group.     

Short-term survival after acute myocardial infarction predicted by hemodynamic parameters.

In the acute phase of myocardial infarction, short-term prediction of the likelihood of survival helps the physician choose the appropriate therapy for individual patients. Of 122 patients admitted to the coronary care unit of the Thoraxcenter, University Hospital, Rotterdam, with an acute myocardial infarction, 16 died from pump failure. In these and the 106 survivors, the predictive value of peripheral systolic (SP) and diastolic (DP) blood pressure, pulmonary capillary wedge pressure (PCW), mixed venous oxygen saturation (MVO2sat) in the pulmonary artery and heart rate (HR), both alone and in combination, was evaluated at the time of admission and 24 hours later. When, at admission, (DP X MVO2sat)/PCW exceeded 250%, 97/99 patients survived, whereas values below 250% were associated with death in 14/23. All other papameters, taken alone or in other combinations, showed less discriminatory power. Thb mean value of this index in survivors (549%) was statistically different (P less than 0.001) from the mean value in nonsurvivors (183%). Twenty-four hours later all survivors with admission values lower than 250% had an improved index. Of the 14 nonsurvivors with admission values lower than 250%, seven had already died, and in seven others the index had decreased still further; Linear discriminant analysis showed that (0.024 SP -- 0.217 PCW + 0.234 MVO2sat) was the most powerful prognostic index at the time of admission; its time course did not provide a more effective prediction of ultimate fatality than (DP XMVO2sat)/PCW. Determination of (DP X MVO2sat)/PCW in patients hospitalized for acute myocardial infarction provides a reliable prognosis for short-term patient survival. Its practical value in guiding patient management, more particularly for initiating mechanical circulatory assistance or for emergency surgery, must be further assessed.     

Investigation of symptom free patients after myocardial infarction.

The dicrotic pulse is an abnormal carotid pulse found in conjunction with certain conditions characterised by low cardiac output. It is distinguished by two palpable pulsations, the second of which is diastolic and immediately follows the second heart sound. In the course of open chest canine studies of the second heart sound, micromanometers and an electromagnetic flow meter were used to study proximal aortic haemodynamic function in both strong and weak beats. It was found that the incisural notch of the aortic pressure signal is not strongly dependent on the extent of left ventricular ejection, and is of essentially normal amplitude even in beats having greatly reduced aortic flow. In contrast, the magnitude of the systolic upstroke of the aortic pressure pulse is strongly determined by the magnitude of left ventricular ejection and is considerably reduced in weak beats. With low cardiac output the relative size of the incisural notch becomes exaggerated in comparison with the overall pulsation, thus creating the characteristic M shaped waveform of the dicrotic pulse.     

Effect on survival after myocardial infarction of long-term treatment with phenytoin.

A prospective, randomised, open trial was performed in 150 patients to test for any beneficial effects on 2-year mortality of long-term antiarrhythmic therapy with phenytoin in patients with acute myocardial infarction. Patients were stratified according to age, sex, past history of myocardial infarction, and the presence of absence of electrical or mechanical complications in the course of acute infarction. They were then randomised to treatment or control groups (74 v. 76). The former received phenytoin in doses aimed at maintaining plasma phenytoin levels between 40 and 80 mumol/litre. All patients entered the study before discharge from the coronary care ward. Plasma phenytoin levels were in the therapeutic range in between 51 and 75 per cent of subjects at any follow up visit. There were 19 withdrawals from the treatment group, 10 of which were the result of side effects. There were 5 withdrawals from the control group. According to the original intention to treat, there were 18 deaths at 2 years in the treatment group and 14 deaths in the control group. There was no reduction in the incidence of instantaneous or sudden deaths. Deaths on treatment were not associated with a low phenytoin plasma level. Phenytoin treatment showed no beneficial effects on mortality and was associated with a high incidence of side effects.     

Effect on survival after myocardial infarction of long-term treatment with phenytoin.

A prospective, randomised, open trial was performed in 150 patients to test for any beneficial effects on 2-year mortality of long-term antiarrhythmic therapy with phenytoin in patients with acute myocardial infarction. Patients were stratified according to age, sex, past history of myocardial infarction, and the presence of absence of electrical or mechanical complications in the course of acute infarction. They were then randomised to treatment or control groups (74 v. 76). The former received phenytoin in doses aimed at maintaining plasma phenytoin levels between 40 and 80 mumol/litre. All patients entered the study before discharge from the coronary care ward. Plasma phenytoin levels were in the therapeutic range in between 51 and 75 per cent of subjects at any follow up visit. There were 19 withdrawals from the treatment group, 10 of which were the result of side effects. There were 5 withdrawals from the control group. According to the original intention to treat, there were 18 deaths at 2 years in the treatment group and 14 deaths in the control group. There was no reduction in the incidence of instantaneous or sudden deaths. Deaths on treatment were not associated with a low phenytoin plasma level. Phenytoin treatment showed no beneficial effects on mortality and was associated with a high incidence of side effects.