Mortality, mode of death and risk indicators for death during 5 years after coronary artery bypass grafting among patients with and without a history of diabetes mellitus

OBJECTIVE: To describe mortality, mode of death, risk indicators for death and symptoms of angina pectoris among survivors during 5 years after coronary artery bypass grafting (CABG) among patients with and without a history of diabetes mellitus. METHODS: All patients in western Sweden who underwent CABG without concomitant valve surgery and who had no previous CABG between June 1988 and June 1991 were entered prospectively in this study. After 5 years, information on deaths that had occurred was obtained for the analysis. RESULTS: In all, 1998 patients were included in the analysis; 242 (12%) had a history of diabetes. Among the non-diabetic patients, 5-year mortality was 12.5%; the corresponding relative risk for diabetic patients was 2.1 (95% confidence interval 1.6 to 2.9). A history of diabetes was an independent risk indicator of death; there was no significant interaction between any other risk indicator and diabetes. Independent risk indicators for death among diabetic patients were: current smoking, renal dysfunction and left ventricular ejection fraction < 0.40. Compared with non-diabetic patients, those with diabetes more frequently died in hospital, died a cardiac death, or had death associated with the development of acute myocardial infarction and with symptoms of congestive heart failure. Among survivors, diabetic patients tended to have more angina pectoris 5 years after CABG than did those without diabetes. CONCLUSION: During a period of 5 years after CABG, diabetic patients had a mortality twice that of non-diabetic patients. The increased risk included death in hospital, cardiac death and death associated with development of acute myocardial infarction and with symptoms of congestive heart failure.     

Impact of congestive heart failure and left ventricular systolic function on the prognostic significance of atrial fibrillation and atrial flutter following acute myocardial infarction

BACKGROUND: Reports on the prognostic importance of atrial fibrillation following myocardial infarction have provided considerable variation in results. Thus, this study examined the impact of left ventricular systolic function and congestive heart failure on the prognostic importance of atrial fibrillation in acute myocardial infarction patients that might explain previous discrepancies. METHODS: The study population was 6676 patients consecutively admitted to hospital with acute myocardial infarction. Information on the presence of atrial fibrillation/flutter, left ventricular systolic function and congestive heart failure were prospectively collected. Mortality was followed for 5 years. RESULTS: In patients with left ventricular ejection fraction<0.25, atrial fibrillation/atrial flutter was associated with an increased in-hospital mortality (OR=1.8 (1.1-3.2); p<0.05) but not an increased 30-day mortality. In patients with 0.250.35. In patients with congestive heart failure, atrial fibrillation/atrial flutter was associated with an increased in-hospital mortality (OR=1.5 (1.2-1.9); p<0.001) and increased 30-day mortality (OR=1.4 (1.1-1.7); p<0.001) but not in patients without congestive heart failure. In hospital survivors, atrial fibrillation/atrial flutter was associated with an increased long-term mortality in all subgroups except those with left ventricular ejection fraction<0.25. CONCLUSIONS: Atrial fibrillation/atrial flutter is primarily associated with increased in-hospital mortality in heart failure patients. Long-term mortality is increased in all subgroups except those with left ventricular ejection fraction<25%.     

Prognosis of congestive heart failure after prior myocardial infarction in older persons with atrial fibrillation versus sinus rhythm

In a prospective study of 651 older persons with congestive heart failure after prior myocardial infarction, persons with atrial fibrillation had a significantly higher mortality than those with sinus rhythm if they had an abnormal (p = 0.005) or normal (p = 0.0001) left ventricular ejection fraction. The Cox regression model showed that significant independent risk factors for total mortality were age (risk ratio 1.03 for an increment of 1 year of age), hypertension (risk ratio 1.2), diabetes mellitus (risk ratio 1.4), abnormal left ventricular ejection fraction (risk ratio 2.1), and atrial fibrillation (risk ratio 1.5).     

Heart Failure with Preserved Left Ventricular Ejection Fraction in Patients with Acute Myocardial Infarction

Background

The prevalence and clinical outcomes of heart failure with preserved left ventricular ejection fraction after acute myocardial infarction have not been well elucidated.

Objective

To analyze the prevalence of heart failure with preserved left ventricular ejection fraction in acute myocardial infarction and its association with mortality.

Methods

Patients with acute myocardial infarction (n = 1,474) were prospectively included. Patients without heart failure (Killip score = 1), with heart failure with preserved left ventricular ejection fraction (Killip score > 1 and left ventricle ejection fraction ≥ 50%), and with systolic dysfunction (Killip score > 1 and left ventricle ejection fraction < 50%) on admission were compared. The association between systolic dysfunction with preserved left ventricular ejection fraction and in-hospital mortality was tested in adjusted models.

Results

Among the patients included, 1,256 (85.2%) were admitted without heart failure (72% men, 67 ± 15 years), 78 (5.3%) with heart failure with preserved left ventricular ejection fraction (59% men, 76 ± 14 years), and 140 (9.5%) with systolic dysfunction (69% men, 76 ± 14 years), with mortality rates of 4.3%, 17.9%, and 27.1%, respectively (p < 0.001). Logistic regression (adjusted for sex, age, troponin, diabetes, and body mass index) demonstrated that heart failure with preserved left ventricular ejection fraction (OR 2.91; 95% CI 1.35–6.27; p = 0.006) and systolic dysfunction (OR 5.38; 95% CI 3.10 to 9.32; p < 0.001) were associated with in-hospital mortality.

Conclusion

One-third of patients with acute myocardial infarction admitted with heart failure had preserved left ventricular ejection fraction. Although this subgroup exhibited more favorable outcomes than those with systolic dysfunction, this condition presented a three-fold higher risk of death than the group without heart failure. Patients with acute myocardial infarction and heart failure with preserved left ventricular ejection fraction encounter elevated short-term risk and require special attention and monitoring during hospitalization.     

Myocardial infarct size and mortality in patients with non-insulin-dependent diabetes mellitus

Abstract. Objectives. To study the infarct size and mortality in patients with non-insulin-dependent diabetes mellitus (NIDDM) and in non-diabetic subjects with their first acute myocardial infarction. Design. Seven year follow-up study of large representative cohorts of patients with non-insulin-dependent diabetes mellitus and non-diabetic subjects (study 1) and the FINMONICA acute myocardial infarction register study in 1988-89 (study 2). Setting. Populations of the districts of the Kuopio University Hospital and Turku University Central Hospital (study 1). Populations of Kuopio and North Karelia provinces and Turku/Loimaa area (study 2). Subjects. Study 1: 1059 patients with non-insulin dependent diabetes mellitus and 1373 non-diabetic subjects aged 45–64 years at baseline; during the follow-up 166 patients with non-insulin-dependent diabetes mellitus (91 men and 75 women) and 30 non-diabetic subjects (25 men and five women) were hospitalized for their first acute myocardial infarction. Study 2: 1622 patients aged 25–64 years hospitalized for their first acute myocardial infarction; 144 patients (90 men and 54 women) had non-insulin-dependent diabetes mellitus and 1153 (890 men and 263 women) were non-diabetic. Main outcome measures. The infarct size was assessed on the basis of maximum levels of serum cardiac enzymes (studies 1 and 2) and QRS-score (study 1). Results. No differences were found in maximum levels of serum cardiac enzymes between diabetic and non-diabetic patients. Similarly QRS-score gave no suggestion of a difference in infarct size between diabetic and non-diabetic patients. In both studies mortality before hospital admission was similar in diabetic and non-diabetic patients, but mortality within 28 days from hospital admission was twice as high in diabetic patients as in non-diabetic patients. Cardiac failure was the main cause of death significantly more often in diabetic patients than in non-diabetic patients (study 2). Conclusions. Poorer prognosis of acute myocardial infarction in diabetic patients appears not to be explained by a larger infarct size but probably by adverse effects of the diabetic state itself on myocardial function.     

Relation between beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure. The Multicenter Diltiazem Post-Infarction Research Group

This study examined the relations among beta-adrenergic blocker use, various correlates of left ventricular function and the chance of developing congestive heart failure in patients after myocardial infarction. The study was performed with the placebo group of the Multicenter Diltiazem Post-Infarction Trial. Ejection fraction data were available in 1,084 patients; of these, 557 were receiving a beta-blocker and 527 were not. In addition to ejection fraction, other correlates of left ventricular function included the presence or absence of pulmonary rales, chest X-ray film evidence of pulmonary congestion and the presence of an S3 gallop. Beta-blocker use was less frequent in patients with an ejection fraction less than 30%, rales, an S3 gallop and pulmonary congestion on chest X-ray film. Twenty-one percent of patients with an ejection fraction less than 30%, 42% of patients with rales, 28% of patients with an S3 gallop and 28% of patients with pulmonary congestion were receiving beta-blocker therapy. For every correlate of left ventricular function, the chance of developing congestive heart failure was greater in patients with diminished left ventricular function than in those without. For each level of left ventricular function, the chance of developing congestive heart failure requiring treatment was greater in patients not taking a beta-blocker.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of the angiotensin-converting enzyme inhibitor trandolapril on mortality and morbidity in diabetic patients with left ventricular dysfunction after acute myocardial infarction. Trace Study Group.

OBJECTIVES: This study evaluated the efficacy of long-term treatment with the angiotensin-converting enzyme (ACE) inhibitor trandolapril in diabetic patients with left ventricular dysfunction after acute myocardial infarction (AMI). BACKGROUND: Patients with diabetes mellitus have a high mortality following AMI, probably due to a high risk of congestive heart failure and reinfarction. Because ACE inhibition effectively reduces progression of heart failure, it could be particularly beneficial in diabetic patients after AMI. METHODS: The study is a retrospective analysis using data from the Trandolapril Cardiac Evaluation (TRACE) study, which was a randomized, double-blind, placebo-controlled trial of trandolapril in 1,749 patients with AMI and ejection fraction < or =35%. The mean follow-up time was 26 months. RESULTS: A history of diabetes was found in 237 (14%) of the 1,749 patients. Treatment with trandolapril resulted in a relative risk (RR) of death from any cause for the diabetic group of 0.64 (95% confidence interval 0.45 to 0.91) versus 0.82 (0.69 to 0.97) for the nondiabetic group. In the diabetic group, trandolapril reduced the risk of progression to severe heart failure markedly (RR, 0.38 [0.21 to 0.67]), and no significant reduction of this end point was found in the nondiabetic group. CONCLUSIONS: The ACE inhibition after myocardial infarction complicated by left ventricular dysfunction appears to be of considerable importance in patients with diabetes mellitus by saving lives and substantially reducing the risk of progression to severe heart failure.     

Echocardiographic predictors of prognosis after first acute myocardial infarction

We prospectively studied 490 patients who had a first myocardial infarction and performed a complete 2-dimensional echocardiographic study 相似文献   

Beta-blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists in treatment of elderly patients with acute myocardial infarction

Administration of beta-blockers reduces mortality among old persons during and after acute myocardial infarction. The American College of Cardiology/American Heart Association guidelines recommend that persons without contraindications to use of beta-blockers should be administered beta-blockers within a few days of myocardial infarction (if administration is not initiated acutely) and that their administration should be continued indefinitely. These guidelines also recommend the use of angiotensin converting enzyme inhibitors in treating persons within the first 24 h of suspected onset of acute myocardial infarction with ST-segment elevation in two or more anterior precordial leads or with congestive heart failure in the absence of significant hypotension or other contraindications to use of ACE inhibitors; and persons during and after convalescence from acute myocardial infarction with congestive heart failure associated with an abnormal left ventricular ejection fraction (LVEF) or with asymptomatic left ventricular systolic dysfunction with a LVEF < 40%. These guidelines state that there are no class I indications for using calcium antagonists after myocardial infarction. If patients have persistent angina pectoris after myocardial infarction despite treatment with beta-blockers and nitrates or hypertension inadequately controlled by other drugs, administration of a nondihydropyridine calcium antagonist such as verapamil or diltiazem should be added to the therapeutic regimen if the LVEF is normal. If the LVEF is abnormal, administration of amlodipine or felodipine should be added to the therapeutic regimen.     

Early preventive treatment of left ventricular dysfunction following myocardial infarction: optimal timing and patient selection.

Treatment for clinical congestive heart failure is effective, but because severe ventricular dysfunction is often present at the time of clinical presentation, it may only be palliative. Recent clinical studies indicate that treatment of symptomless left ventricular dysfunction from 1 week following myocardial infarction or later may prevent further ventricular dilation and possibly reduce the occurrence of heart failure. Considering the potential for progressive ventricular dilation that exists from the time of myocardial infarction, early intervention following myocardial infarction may provide greater benefit. In a double-blind study, 100 patients with Q-wave myocardial infarction, but without clinical heart failure, were randomized to treatment with captopril 50 mg twice daily or placebo, 24-48 hours following onset of symptoms. During 3 months of treatment, the placebo group showed significant increases in left ventricular end-diastolic and end-systolic volume indices with ejection fraction unchanged. In contrast, the captopril group showed a slight but insignificant increase in left ventricular end-diastolic volume index and a significant reduction in end-systolic volume index with ejection fraction increased. Thus, early treatment of patients following Q-wave myocardial infarction with converting enzyme inhibition is effective in preventing ventricular dilation and provides an advantage over later treatment. Selection of patients with Q-wave infarction at 24 hours, after thrombolysis, provides therapy for those most likely to benefit, which is well tolerated without risk of hypotension.     

Congestive heart failure symptoms in patients with preserved left ventricular systolic function: analysis of the CASS registry

The clinical characteristics and long-term survival of 284 patients from the Coronary Artery Surgery Study (CASS) registry data base who had moderate to severe congestive heart failure symptoms and a left ventricular ejection fraction greater than or equal to 0.45 were studied. A control group consisting of registry patients with an ejection fraction greater than or equal to 0.45 who did not have heart failure was used for comparison. Patients who had heart failure were older and more likely to be female and to have a higher incidence of hypertension, diabetes and chronic lung disease than registry patients who did not have heart failure. As a group, patients with heart failure had more severe angina and were more likely to have had a prior myocardial infarction than were registry patients without heart failure. At 6 year follow-up, 82% of patients in the heart failure group survived compared with 91% of patients in the control group (p less than 0.0001). Multivariate analysis using the Cox proportional hazards model identified the following independent predictors of mortality: regional ventricular systolic dysfunction, number of diseased coronary arteries, advanced age, hypertension, lung disease, diabetes, increased left ventricular end-diastolic pressure and heart failure symptoms. Among patients with heart failure, the 6-year survival rate of those who had three-vessel coronary artery disease was 68% compared with 92% for the group without coronary artery disease. However, the 6-year survival rate for patients with heart failure who underwent surgical revascularization of diseased coronary arteries was not significantly improved compared with that of patients treated medically.(ABSTRACT TRUNCATED AT 250 WORDS)     

Congestive heart failure with preserved left ventricular systolic function after acute myocardial infarction: clinical and prognostic implications

AIMS: To characterise the prevalence, in-hospital complications, management, and long-term outcome of patients with congestive heart failure but preserved left ventricular systolic function after acute myocardial infarction. METHODS: 3166 consecutive patients screened for entry in the Bucindolol Evaluation in Acute Myocardial Infarction Trial with definite acute myocardial infarction and echocardiographic assessment of left ventricular systolic function were included between 1998 and 1999 in this prospective observational study. Main outcome measures were occurrences of in-hospital complications and all cause mortality. RESULTS: Congestive heart failure was seen during hospitalisation in 1464 patients (46%), 717 patients had preserved left ventricular systolic function (wall motion index > or =1.3 corresponding to ejection fraction > or =0.40), and 732 patients had systolic dysfunction (wall motion index <1.3). One year mortality in patients with no heart failure, heart failure with preserved systolic function, and heart failure with systolic dysfunction were 6, 22 and 35%, P<0.0001. Unadjusted risk of death from all causes associated with heart failure and preserved systolic function was 3.3 (95% CI 2.8-4.0), and after adjustment for baseline characteristics and left ventricular systolic function in multivariate Cox proportional hazards analysis the risk was 2.1 (95% CI 1.7-2.6), P<0.0001. CONCLUSIONS: Congestive heart failure is frequently present in patients with preserved left ventricular systolic function, and is associated with increased risk of in-hospital complications and death following acute myocardial infarction.     

糖尿病合并非ST段抬高急性冠状动脉综合征患者的临床特点、治疗及远期预后

目的 了解糖尿病合并非ST段抬高急性冠状动脉综合征(ACS)患者的临床特点、治疗及远期预后.方法 在我国北方38个中心连续入选因非ST段抬高ACS住院的患者,记录既往病史、入院情况、住院期间主要治疗和心血管事件,并在发病6、12和24个月对所有患者进行随访.采用Kaplan-Meier牛存分析比较糖尿病和非糖尿病患者2年累计事件发生率,Cox回归多因素分析用于2年累计死亡影响因素的识别.结果 共注册非ST段抬高ACS住院患者2294例,其中已知糖尿病患者420例,占18.3%.平均年龄(64.9±6.7)岁,高于非糖尿病患者的(62.3±8.6)岁(P<0.01),女性患者(占48.1%)、既往有高血压病、心肌梗死、心力衰竭、卒中者均多于非糖尿病患者.合并糖尿病患者住院期间抗血小板约物的应用(92.1%比95.0%,P<0.05)、接受冠状动脉造影(30.0%比36.3%,P<0.05)和冠状动脉介入治疗(12.1%比18.8%,P<0.05)的患者少于非糖尿病者.住院期间以及2年累计的死亡、慢性心力衰竭以及心肌梗死、卒中、心力衰竭和死亡的联合终点事件发生率均明显高于非糖尿病者.多因素回归分析显示,年龄≥70岁、糖尿病、既往心肌梗死、既往心力衰竭、就诊时收缩压<90 mm Hg(1 mm Hg=0.133 kPa)和心率>100次/min是非ST段抬高ACS患者2年死亡的危险因素.结论 合并糖尿病的非ST段抬高ACS患者住院期间和2年死亡、慢性心力衰竭和联合终点事件发牛率明显高于非糖尿病者.糖尿病是非ST段抬高ACS患者2年死亡的独立危险因素.我国非ST段抬高ACS患者住院期间抗血小板治疗和早期介入检杳和治疗有待加强.有必要进行更有针对性的大规模临床研究,以提高糖尿病并发ACS的治疗水平,改善该人群的预后.

Abstract：

Objective To observe the clinical characteristics,treatment options and outcome of diabetic patients with non-ST elevation acute coronary syndromes(NSTEACS).Methods Consecutive patients admitted with NSTEACS from 38 centers in north China were enrolled.Medical histories,clinical characteristics,treatments and outcomes were evaluated and follow-up was made at 6,12,and 24 months 'after their initial hospital admission.Cumulative event rates were compared between diabetic and nondiabetic patients.Results There were 420 diabetic patients out of 2294 NSTEACS patients(18.3%).Diabetic patients were older[(64.9±6.7)years vs.(62.3±8.6)years,P<0.01],more often women (48.1% vs.35.3%,P<0.05)and were associated with higher baseline comorbidities such as previous hypertension,myocardial infarction,congestive heart failure and stroke than non-diabetic patients.The incidence of antiplatelet therapy(92.1% vs.95.O%,P<0.05),coronary angiography(30.0% vs.36.3%,P<0.05)and revascularization(12.1% vs.18.8%,P<0.05)was lower in patients with diabetes than non-diabetic patients.In hospital and 2-year mortality as well as the incidence of congestive heart failure and composite outcomes of myocardial infarction,stroke,congestive heart failure and death were substantially higher in diabetic patients compared with non-diabetic patients.Muhivariative Cox regression analysis revealed that age≥70 years,diabetes,previous myocardial infarction,previous congestive heart failure,systolic blood pressure less than 90 mm Hg(1 mm Hg=0.133 kPa)and heart rate more than 100bpm at admission were risk factors for 2-year death.Conclusion In NSTEACS,diabetes is associated with higher rate of in-hospital and 2-year death,congestive heart failure and composite outcomes of myocardial infarction,stroke,congestive heart failure and death.Diabetes mellitus is a major independent predictor of 2-year mortaliy post NSTEACS.Status of antiplatelet therapy,coronary angiography and revascularization should be improved for diabetic patients with NSTEACS during hospitalization.     

Events in the cardiac arrhythmia suppression trial: baseline predictors of mortality in placebo-treated patients

Patients randomized to placebo in the encainide and flecainide arms of the Cardiac Arrhythmia Suppression Trial (CAST) have been found to have a relatively low 1-year mortality rate of 3.9% in comparison with previous studies of patients in the postmyocardial infarction period. To determine the comparability of CAST with previous studies, baseline variables were examined in the 743 patients randomized to placebo in the flecainide and encainide arms of CAST. Twenty-three baseline characteristics were correlated with major outcome events: arrhythmic death (16 events), total mortality (26 events) and congestive heart failure (51 events). On multivariate analysis the risk of new or worsening congestive heart failure was significantly associated with diuretic use, diabetes, high New York Heart Association functional class, age, prolonged QRS duration and low ejection fraction. The risk of arrhythmic death or resuscitated cardiac arrest was significantly associated with an index Q wave myocardial infarction, history of heart failure, use of digitalis, diabetes and prolonged QRS duration. Total mortality or resuscitated cardiac arrest was significantly associated with an index Q wave myocardial infarction, diabetes, ST segment depression, high functional class, prolonged QRS duration and low ejection fraction. The variables at baseline associated with mortality from all causes or arrhythmic death or resuscitated cardiac arrest and heart failure in the CAST placebo-treated patients are similar to those identified in previous postmyocardial infarction studies. Thus, the observation of increased mortality in CAST associated with the administration of encainide and flecainide for suppression of ventricular premature depolarizations is probably applicable to any comparably defined group of patients in the postmyocardial infarction period.     

Glucose and insulin abnormalities relate to functional capacity in patients with congestive heart failure.

AIMS: In addition to diabetes mellitus, less severe abnormalities of glucose and insulin metabolism may be related to functional status in patients with heart failure. We examined the relationship of hyperglycaemia (> or =6.1 mmol. l(-1)) and hyperinsulinaemia (> or =11.2 mU. l(-1)) to functional status and cardiac function in patients with heart failure. METHODS AND RESULTS: Fasting plasma glucose and insulin levels were obtained in 663 heart failure patients. The average left ventricular ejection fraction was 0.28+/-0.07, 63% were in New York Heart Association Functional Class (NYHA-FC) I/II and 37% were in NYHA-FC III/IV. Twenty seven percent had diabetes mellitus, but an additional 8% had undiagnosed diabetes mellitus (glucose > or =7 mmol. l(-1)) and 9% had glucose levels between 6.1 and 7 mmol. l(-1), so that a total of 43% (287) of patients had elevated glucose levels (> or =6.1 mmol. l(-1)). In general, more diabetic patients had NYHA-FC III/IV symptoms, shorter 6 min walk distances, but similar left ventricular ejection fractions compared to non-diabetic patients. The non-diabetic patients in NYHA-FC III/IV had higher glucose and insulin levels than patients in NYHA-FC I/II (6.3+/-0.2 vs 5.6+/-0.1 mmol. l(-1), P<0.001 and 19.6+/-2.3 vs 10. 2+/-0.6 mU. l(-1), P<0.001). Non-diabetic patients with elevated glucose levels had shorter 6 min walk distances compared to those with normal glucose levels (368.2+/-8 m vs 389.+/-4 m, P=0.02), however, left ventricular ejection fraction was similar. CONCLUSION: Glucose abnormalities are extremely common in heart failure patients (43% of patients). Diabetes mellitus and hyperglycaemia or hyperlinsulinaemia in non-diabetic patients were related to worse symptomatic status but not worsening left ventricular ejection fraction compared to patients with normal glucose and insulin levels.     

The prognostic value of predischarge quantitative two-dimensional echocardiographic measurements and the effects of early lisinopril treatment on left ventricular structure and function after acute myocardial infarction in the GISSI-3 Trial

BACKGROUND: Left ventricular dilatation and a low ejection fraction afteracute myocardial infarction are independent indicators of apoor prognosis. ACE inhibitors have been shown to decrease leftventricular dilatation after myocardial infarction. In the GISSI-3trial, patients were randomlyassigned, within 24 h of onsetof myocardial infarction symptoms, to 6 weeks of treatment withlisinopril, nitroglycerin, both or neither, in an open, 2 x2 factorial design. The study showed that early treatment inrelatively unselected patients with lisinopril decreases mortalityat 6 weeks and severe left ventricular dysfunction. We assessed(1) the prognostic value of pre-discharge 2-D echocardiographicvariables, and (2) the effects of lisinopril on the progressionof left ventricular dilatation. METHODS AND RESULTS: 2-D echocardiograms were available pre-discharge in 8619 GISSI-3trial patients discharged alive. In 6405 of these patients,a 2-D echocardiographic study was also available at 6 weeks,and at 6 months. Pre-discharge end-diastolic and end-systolicvolumes, and ejection fraction predicted 6-month mortality andnon-fatal clinical congestive heart failure (P<0.01). Theincrease in left ventricular volumes over time was significantlyreduced by 6 weeks' lisinopril treatment in patients with wallmotion asynergy pre-discharge of 27%. Patients with wall motionasynergy <27% showed no dilatation and lisinopril did notaffect volumes at 6 months. Patients randomized to lisinoprilalso had smaller volumes after withdrawal of treatment at 6weeks. Lisinopril did not affect left ventricular ejection fraction. CONCLUSIONS: 2-D echocardiography independently contributes to pre-dischargerisk stratification in terms of 6-month mortality and clinicalheart failure after myocardial infarction, and early, short-termtreatment with lisinopril in unselected myocardial infarctionpatients attenuates left ventricular dilatation; an effect evidentin patients with larger infarcts. These results probably onlypartly explain the effect of lisinopril on total mortality concentratedin the first week after infarction.     

The incidence, clinical characteristics and prognostic significance of a left bundle-branch block associated with an acute myocardial infarct

To assess the current incidence and meaning of left bundle-branch block associated with acute myocardial infarction we studied 1,239 patients consecutively admitted in three hospitals. Left bundle branch block was present in 42 cases (3.3%). Compared to the patients without left bundle-branch block, those with left bundle-branch block were older (70 +/- 8.8 versus 63.9 +/- 11.4 years; p < 0.001), and had a more prevalent history of diabetes, angina, myocardial infarction and heart failure. Left bundle-branch block was associated more frequently with female gender and poor left ventricular ejection fraction. Patients with left bundle branch block were admitted with a longer interval from the onset of the symptoms (7.8 +/- 6.3 versus 5.4 +/- 6.7 hours; p < 0.01) and received in a lesser rate thrombolytics agents (21% versus 56%; p < 0.001), than those without left bundle-branch block. Complications significatively associated with left bundle-branch block were: complete AV block; heart failure and one-year mortality (40.4% versus 19.5%, p < 0.01). Female gender, age and heart failure were independent predictors of mortality whereas left bundle-branch block was not. In conclusion, current incidence of left bundle-branch block in acute myocardial infarction is lower than that referred in the pre-thrombolytic era. Left bundle-branch block is accompanied by a low rate of thrombolysis, whereas a higher mortality rate of these patients seems to depend on their clinical characteristics.     

Diabetes and impaired fasting glucose as predictors of morbidity and mortality in male coronary artery disease patients with reduced left ventricular function

OBJECTIVES: To evaluate the prognostic value of impaired fasting glucose and diabetes mellitus in male patients with coronary artery disease and poor left ventricular function. METHODS AND RESULTS: From a prospective database on patients referred for gated myocardial perfusion imaging between 1998 and 2002 all male patients with a history of coronary artery disease and poor left ventricular function were selected. Poor function was defined as left ventricular ejection fraction < or = 40%. Subjects were classified as non-diabetics with fasting blood glucose levels < 110 mg/dL, non-diabetics with impaired fasting glucose (fasting blood glucose between 110 and 125 mg/dL) and diabetics. Median follow-up was 2.7years. End points were all-cause mortality, cardiac death and hospitalization for heart failure. One hundred and sixty patients were selected (age 65 +/- 9 years and left ventricular ejection fraction 29 +/- 8%). In univariate analysis atrial fibrillation, NYHA class, glycaemia and diabetes mellitus discriminated between survivors and non-survivors. In Cox multivariate regression analysis for all-cause mortality only NYHA class and diabetes mellitus remained significant. Kaplan Meier analysis showed that diabetics had the worst survival and non-diabetics with glucose < 110 mg/dL had the best survival. Non-diabetics with impaired fasting glucose had intermediate survival. Analysis for cardiac death/hospitalization for heart failure showed similar results. CONCLUSION: In male patients with coronary artery disease and impaired left ventricular function diabetes mellitus and fasting glucose are strongly predictive of poor outcome. Diabetics have the worst prognosis but non-diabetics with impaired fasting glucose also are at higher risk compared to nondiabetics with low fasting blood glucose.     

Diabetes mellitus is a strong negative prognostic factor in patients with myocardial infarction treated with thrombolytic therapy

OBJECTIVES: To assess the long-term prognostic values of baseline demographic data, occurrence of vectorcardiographic signs of reperfusion, left ventricular function and coronary angiographic features. DESIGN: Longitudinal study of morbidity and mortality. SETTING: Coronary care unit at Danderyd Hospital, Stockholm, Sweden. SUBJECTS: A total of 222 patients (mean age 61 years) with a suspected acute myocardial infarction treated with thrombolysis were investigated and followed for 2-5 years (mean 1216 days). MAIN OUTCOME MEASURES: Death or a new myocardial infarction. RESULTS: Age above 55 years (P < 0.05), a previous diagnosis of diabetes mellitus (P < 0.005), hypertension (P < 0.05), heart failure (P < 0.001) and myocardial infarction (P < 0.05), a previous use of beta-blockers (P < 0.05) and an ejection fraction below 60% (P < 0.01) were predictors for death or a new myocardial infarction in univariate analysis. Sex, a previous history of smoking or angina pectoris, vectorcardiographic signs of reperfusion or degree of coronary artery disease had no prognostic values. In multivariate analysis including age above 55 years, a previous diagnosis of diabetes mellitus, hypertension and myocardial infarction, and an ejection fraction below 60%, only age (P < 0.05), diabetes mellitus (P < 0. 01) and ejection fraction (P < 0.05) were predictors for death or a new myocardial infarction. CONCLUSIONS: The results of the present study emphasize the importance of diabetes mellitus as a long-term prognostic risk factor in patients with myocardial infarction treated with thrombolysis. Further studies are needed to determine the mechanisms behind this increased risk.     

Prognostic implications of cardiac scintigraphic parameters obtained in the early phase of acute myocardial infarction

A cohort of 76 patients with acute myocardial infarction was studied with infarct-avid scan, radionuclide ventriculography, and thallium-201 myocardial perfusion scintigraphy. Infarct area, left ventricular ejection fraction, and defect score were calculated as radionuclide indices of the extent of myocardial infarction. The correlation was studied between these indices and cardiac events (death, congestive heart failure, postinfarction angina, and recurrence of myocardial infarction) in the first postinfarction year. High-risk patients (nonsurvivors and patients who developed heart failure) had a larger infarct area, a lower left ventricular ejection fraction, and a larger defect score than the others. Univariate linear discriminant analysis was done to determine the optimal threshold of these parameters for distinguishing high-risk patients from others. Radionuclide parameters obtained in the early phase of acute myocardial infarction were useful for detecting both patients with grave complications and those with poor late prognosis during a mean follow-up period of 2.6 years.