Observations on blood viscosity changes after acute myocardial infarction.

Serial blood rheologic measurements were made in 25 patients with acute myocardial infarction; measurements included blood and plasma viscosities, hematological data and plasma protein concentrations. The blood viscosity was elevated on admission and for more than 21 days after acute myocardial infarction. However, the cause of the elevated viscosity was changed as a function of time after acute myocardial infarction. During the first three days after admission, the high blood viscosity was mainly attributable to high hematocrit values. Thereafter, the hematocrit fell, but blood viscosity remained high. High blood viscosity after the first three days of acute myocardial infarction can be correlated with increases in plasma viscosity and red cell aggregation, which in turn are explained by elevations of alpha 2 globulin and fibrinogen concentrations. Patients with higher blood viscosity on admission had a significantly higher incidence of complications, i.e., shock, thromboembolism and left ventricular failure.     

Pericardial effusion in acute myocardial infarction: clinical feature and significance]

To determine the incidence and clinical significance of pericardial effusion after acute myocardial infarction, two-dimensional echocardiography was serially performed in 137 consecutive patients. Pericardial effusion was observed in 45 patients (33%), of whom 22 were followed until they recovered and were discharged. Pericardial effusion was more frequent in patients with anterior acute infarction than those with inferior acute infarction, and so it was in non-recanalized patients than in recanalized ones. Patients with pericardial effusion had higher peak levels of creatine kinase, higher wall motion score indices, and higher defect scores of thallium imagings. The improvement of regional wall motion at an infarct zone in patients with pericardial effusion was less regardless of the successful early recanalization. These results show that pericardial effusion is a common event in patients with acute myocardial infarction and observation of transition of pericardial effusion is important for predicting prognosis.     

The whole blood and plasma viscosity changes in course of acute myocardial infarction

The whole blood and plasma viscosity changes in course of acute myocardial infarction were examined. The examination were performed at the beginning of acute phase of myocardial infarction (period 1), at second to third day (period 2) and after about 10 days of infarction episode (period 3). 77 patients (mean age 56.8 +/- 9.8 years) suffered from myocardial infarction were examined. The whole blood viscosity at following shear rates [s-1]: 0.116; 1.0; 4.59; 150 and plasma viscosity were performed. Besides the viscometric examinations the total cholesterol, LDL-cholesterol, HDL-cholesterol, triglycerides, glucose and fibrinogen as well as blood morphology and ESR were determined. All rheological measurements were carried out at the temperature of 37 degrees C immediately after blood drawing. The control group consisted of 110 healthy persons (aged 56.6 +/- 10 years). Some persons of control group have got risk factors of atherosclerosis as: obesity, artery hypertension and cigarette smoking. The following additional parameters were investigated: hematocrit, the artery pressure, the body mass index, total cholesterol concentration, serum LDL-cholesterol, HDL-cholesterol, fibrinogen and blood morphology. The corrected whole blood viscosity was adjusted to 45% of hematocrit. It was stated that the native whole blood viscosity was disturbed at all periods of disease. The corrected whole-blood viscosity in all periods of acute myocardial infarction comparing with controls increased. The greatest rise of corrected whole blood viscosity was especially observed in second period of acute myocardial infarction. Plasma viscosity in patients with acute myocardial infarction is increased in all periods. The greatest rise of plasma viscosity was in second period of disease. The rheological blood and plasma disturbances were connected with increase of total cholesterol, LDL-cholesterol, triglycerides and fibrinogen. These disturbances of blood and plasma viscosity may play a role in promoting myocardial infarction factors.     

Prognosis significance of blood homocysteine after myocardial infarction]

INTRODUCTION AND AIMS: Homocysteinemia is an independent risk factor of coronary artery disease and of myocardial infarction. In the present study we intend to relate fasting homocystein levels to prognosis after a myocardial infarction. METHODS: From 1990 to 1992, we studied fasting homocysteinemia levels on a group of 112 patients aged under 56 years that had suffered a myocardial infarction between 3 and 12 months before. We obtained, the patients names, addresses, phone numbers and physicians' name. Seven years later (on average) we collected data regarding the patients evolution, consulting medical records, their physicians or by personal contact. We evaluated complications, namely mortality, vascular morbidity, such as unstable angina, re-infarction, stroke, and the need for invasive procedures (catheterism, PTCA, CABG). According to previous studies of the group, we used a cut-point of 10.10 mumol/L to define patients with normal or pathological levels of homocysteinemia. We excluded all patients that took vitamin B supplements, co-factors of HC metabolism, during this follow-up. RESULTS: We were able to obtain data on 110 patients. Patients with normal HC levels (n = 62) presented less global complications (26 versus 72%, p < 0.0001), non significant tendency to have lower mortality (1.6 versus 6%), had lower morbidity (14 versus 36%, p < 0.01) and lower invasive procedure need (18 versus 48%, p < 0.001). In the group with pathological homocystein levels (n = 48), those with higher homocystein levels presented a higher degree of complications. CONCLUSIONS: In this population with myocardial infarction under 56 years of age, a high homocysteinemia level is an important prognostic factor. This study suggests that we can improve the prognosis and decrease the complications after myocardial infarction by lowering elevated homocystein levels.     

Contrast echocardiographic assessments of myocardial blood flow in acute myocardial infarction]

Clinical information on the regional myocardial blood flow in the post-ischemic myocardium has been limited. In the present study, we assessed the influence of early coronary reperfusion and coronary obstruction that remained after reperfusion on regional myocardial perfusion by myocardial contrast echocardiography. The study population consisted of 17 patients with acute myocardial infarction who underwent either successful PTCR or emergent PTCA within 6 hours after the onset of the symptom. Myocardial blood flow was visualized by selective injections of hand-agitated poly-gelin colloid solutions into the right and left coronary arteries before and after coronary reperfusion. Before coronary reperfusion, the area at risk for necrosis was defined as the area of contrast defects by the intracoronary injection of contrast medium. The size (severity) of this defect correlated with the anatomic distribution of the obstructed coronary artery. Immediately after emergent PTCA (mean residual stenosis = 25%), 2 of 10 patients still showed injected contrast medium, however, in the remaining 8 patients (80%), the contrast washout time in the risk area was 1.5 times (mean value) longer than that in the normal region. This indicated impairment of the microcirculation in the post-ischemic myocardium. Immediately after PTCR (mean residual stenosis = 89%, p < 0.01 vs PTCA), contrast enhancement was observed only in the peripheral region of the risk area; contrast defects at the center of this region were observed on contrast echocardiography after reperfusion for all patients. This showed that there was impairment of myocardial blood flow in the risk area, even after successful recanalization in patients undergoing PTCR.(ABSTRACT TRUNCATED AT 250 WORDS)     

急性心肌梗死患者血清瘦素水平的变化及其临床意义

目的 探讨瘦素在急性心肌梗死（AMI）发生、发展过程中的变化及其临床意义.方法 动态检测40例AMI病人不同病程中的外周血清瘦素水平,并检测20例同期住院的不稳定型心绞痛（UA）病人和20名健康志愿者（对照组）外周血清瘦素.对AMI组病人溶栓24小时后的心电图ST段回落进行检测.依据结果分为ST回落≥50%和ST回落＜50%两组.比较溶栓前后的血清瘦素和溶栓后血清瘦素下降百分比.结果 （1）AMI组的血清瘦素（15.83±3.51）g/L和UA组的血清瘦素（9.83±3.55）g/L显著高于对照组的血清瘦素（3.68±1.32）g/L,P值均＜0.01;AMI组血清瘦素明显高于UA组（P＜0.05）.（2）AMI组病人经溶栓治疗后血清瘦素下降.（3）AMI组病人溶栓前血清瘦素水平高低与溶栓后24小时ST段回落相关,ST回落≥50%组的溶栓前血清瘦素显著低于回落＜50%组,P＜0.01.（4）溶栓24小时后血清瘦素下降程度与24小时ST段回落相关：ST回落≥50%组的瘦素下降率（48.3%±6.2%） 明显大于ST回落＜50%组的瘦素下降率（10.5%±2.3%）,P＜0.01;（5）AMI病人血清瘦素与肿瘤坏死因子-α（ TNF-α）水平呈正相关.结论 瘦素可能参与了AMI心肌损伤过程,动态检测血清瘦素水平有助于判断AMI疾病的进程与疗效.     

Pericarditis in the acute phase of myocardial infarction: incidence and clinical significance]

STUDY OBJECTIVE: To evaluate the incidence and the clinical significance of pericarditis in the acute myocardial infarction. DESIGN: Retrospective study. SETTING: The Coronary Care Unit of a University Hospital. PATIENTS AND METHODS: We have studied 668 consecutive patients with their first acute myocardial infarction admitted at the Coronary Care Unit, Hospital General de Galicia, Santiago de Compostela, Spain, in the years 1983 to 1988. Pericarditis was defined as the presence of a pericardial friction rub on auscultation during the hospital course. Pericarditis was noted in 86 patients (12.8%), who were considered as group A. The remain 582 patients were considered as group B. Statistical analysis was carried out using the BMDP statistical package. MAIN RESULTS: Pericarditis occurred in 12.8% of the patients. Patients with, compared to those without, pericarditis had a lower age (59.0 +/- 12.4 years; p = .0005), and a higher percentage of males (86.1% versus 75.6%; p = .038), an a higher percentage of smokers (63.9% versus 48.6%; p = .01). The delay to the hospital admission was greater in group A (12.6 +/- 18.5 hours versus 8.0 +/- 11.7 hours; p = .0024). Pericarditis more often occurred in the setting of anterior wall myocardial infarction and in Q-wave infarct. The group A had a higher CPK peak (1877.5 +/- 1548.9 UI/L versus 1240.2 +/- 961.5 UI/I; p = .001) and a higher peak of CK-MB (213.7 +/- 134.7 UI/L versus 160.8 +/- 112.9 UI/L; p = .001). In-hospital mortality was significantly lower in group A (6.9% versus 17.2%; p = .016). The multivariate analysis by stepwise logistic regression identified the Q- wave myocardial infarct, the age, the delay to the hospital admission, the peak of MB creatine kinase and location of infarct as the only independent predictive variables for the pericarditis occurrence. CONCLUSIONS: We conclude that the pericarditis in the setting of Q-wave myocardial infarction, with anterior wall location, and is related to transmural extension of the myocardial necrosis.     

Whole blood folate, homocysteine in serum, and risk of first acute myocardial infarction

High level of total homocysteine (tHcy) is a risk factor for coronary artery disease (CAD), but the mechanism is not known. The serum concentration of tHcy, total cholesterol, high density lipoprotein cholesterol (HDL-C), and apolipoprotein A-I (apo A-I) and the concentration of folate in whole blood were measured in 107 patients with first acute myocardial infarction (MI) and 103 controls. The level of whole blood folate was lower and that of tHcy higher in cases than in controls. An increase of 50 nmol/l whole blood folate was associated with an OR for MI of 0.75, and an increase of 5 micromol/l tHcy with an OR for MI of 1.57. Correlations were observed between the levels of whole blood folate and tHcy and between whole blood folate and alcohol intake, and in MI cases, between tHcy, HDL-C, and apo A-I as well as between HDL-C and alcohol intake. The number of cigarette smokers was higher among cases than controls. In smokers, the level of tHcy was higher and that of whole blood folate lower than in non-smokers. After adjustment for smoking, the whole blood folate and tHcy-associated risks of MI became non-significant. We conclude that smoking may affect folate status and tHcy level adversely. The risk of MI in smokers may at least partly be attributed to hyperhomocysteinemia or low folate.     

The feasibility of urokinase therapy in acute myocardial infarction

Seventeen patients with early acute myocardial infarction were treated with urokinase to determine the feasibility of administration of this drug to acutely ill patients. Before the institution of urokinase therapy, 15 patients had complications of myocardial infarction, including arrhythmia, congestive heart failure, intractable pain, shock and cardiac arrest. Hemorrhage was the only significant complication of urokinase therapy; it occurred in 3 patients but necessitated the discontinuation of urokinase administration in only 1. It was feasible to administer urokinase to acutely ill patients with myocardial infarction without compromising the usual care given these patients.     

Pericarditis in acute myocardial infarction: characterization and clinical significance

To determine the significance of pericarditis following acute myocardial infarction, the hospital course and 12-month follow-up were analyzed in 703 patients enrolled in the Multicenter Investigation of the Limitation of Infarct Size (MILIS). Pericarditis, defined by the detection of a pericardial rub, occurred in 20% of the patients (n = 141) and was more likely to follow Q wave than non-Q wave infarction (25% vs 9%, p less than 0.001). Patients with pericarditis experienced more serious myocardial damage compared to those without pericarditis, as evidenced by a larger infarct size (25 +/- 1 vs 17 +/- 1 MB-CK gm-Eq/m2, p less than 0.001), a lower admission left ventricular ejection fraction (42 +/- 1% vs 48 +/- 1%, p less than 0.001), and a higher incidence of congestive heart failure (47% vs 26%, p less than 0.001) and atrial tachyarrhythmias (16% vs 10%, p less than 0.05). When patients were classified by the presence of Q or non-Q wave infarction, these differences persisted although statistical significance was not always achieved due to smaller sample size. Mortality at 12-month follow-up for patients with pericarditis was 18% compared with 12% for patients without pericarditis (p = 0.055). This mortality difference could be accounted for in part by the lower ventricular ejection fraction in patients with pericarditis (p = 0.20 after adjustment).     

Plasma viscosity and haematocrit in the course of acute myocardial infarction

Plasma viscosity and haematocrit were determined in 44 patientswith acute myocardial infarction on the 1st, 2nd, 3rd and 10thday of hospitalization. The highest haematocrit value for theentire group was found on the 1st day of acute myocardial infarction—43.3SD±4.6% declining progressively to 38.8 SD±3.5%on the 10th day (P<0.001). Plasma viscosity for the entiregroup was normal on the first day of acute myocardial infarction(1.44 SD±0.10cp) and started to increase on the secondday (1.51 SD±016 cp, P<0.001). A relationship wasfound between reinfarction or death (17 patients) occurringduring hospitalization and changes in haematocrit and plasmaviscosity. In this group plasma viscosity rose to 1.63 SD±0.19cp on the second day of acute myocardial infarction (P<0.001vs plasma viscosity value on the first day). This elevationpersisted on the third day. Haematocrit values in this groupwere 47.9 SD±3.6% on the first day of acute myocardialinfarction declining progressively and significantly afterwards.In the remaining patients both plasma viscosity and haematocritwere normal and did not change. No correlation of plasma viscosityand haematocrit were found when tested for other clinical complications,sex, age, maximal creatine phosphokinase values and coronaryrisk factors. We suggest that variations in haematocrit andplasma viscosity during acute myocardial infarction exist ina group of patients in whom reinfarction or death occurs. Thechanges in haematocrit and plasma viscosity precede the complicationsby 4–8 days. It is possible that the early elevation ofhaematocrit and plasma viscosity during acute myocardial infarctionmay initially aggravate coronary microcirculatory blood flowand thus contribute to the later occurrence of reinfarctionor death.     

Plasma viscosity and haematocrit in the course of acute myocardial infarction

Plasma viscosity and haematocrit were determined in 44 patientswith acute myocardial infarction on the 1st, 2nd, 3rd and 10thday of hospitalization. The highest haematocrit value for theentire group was found on the 1st day of acute myocardial infarction—43.3SD±4.6% declining progressively to 38.8 SD±3.5%on the 10th day (P<0.001). Plasma viscosity for the entiregroup was normal on the first day of acute myocardial infarction(1.44 SD±0.10cp) and started to increase on the secondday (1.51 SD±016 cp, P<0.001). A relationship wasfound between reinfarction or death (17 patients) occurringduring hospitalization and changes in haematocrit and plasmaviscosity. In this group plasma viscosity rose to 1.63 SD±0.19cp on the second day of acute myocardial infarction (P<0.001vs plasma viscosity value on the first day). This elevationpersisted on the third day. Haematocrit values in this groupwere 47.9 SD±3.6% on the first day of acute myocardialinfarction declining progressively and significantly afterwards.In the remaining patients both plasma viscosity and haematocritwere normal and did not change. No correlation of plasma viscosityand haematocrit were found when tested for other clinical complications,sex, age, maximal creatine phosphokinase values and coronaryrisk factors. We suggest that variations in haematocrit andplasma viscosity during acute myocardial infarction exist ina group of patients in whom reinfarction or death occurs. Thechanges in haematocrit and plasma viscosity precede the complicationsby 4–8 days. It is possible that the early elevation ofhaematocrit and plasma viscosity during acute myocardial infarctionmay initially aggravate coronary microcirculatory blood flowand thus contribute to the later occurrence of reinfarctionor death.     

Silent myocardial ischemia in myocardial infarction patients: its prognostic significance]

To evaluate the prognostic and clinical significance of silent myocardial ischemia (SMI), we examined cardiac events in 160 patients with old myocardial infarction who underwent ambulatory Holter monitoring, treadmill exercise testing and coronary angiography. Using the Cox's proportional hazard regression model and the survival curves with the Kaplan-Meier method, we identified the predictors of cardiac events. The incidence of cardiac events for all the patients during the 44-month follow-up period was 18%. The significant predictors of unfavorable outcomes were severe coronary lesions and SMI. The incidence of SMI was 38%. The cardiac event rate in patients with SMI was higher than in those without SMI (32 vs 9%, p < 0.05). The most frequent cardiac event in patients with SMI was reinfarction, and the significant predictors of cardiac events for these SMI patients were lower ejection fraction and maximum ST depression on Holter monitoring. In conclusion, SMI proved to be a significant predictor of unfavorable outcome in patients with old myocardial infarction. It was, therefore, suggested that revascularization (PTCA/CABG) should be used as early as possible in patients with SMI whether anginal symptoms are present or not.     

Heart transplantation in acute myocardial infarction]

Ten patients with cardiogenic shock after acute myocardial infarction were referred to the University Hospital Henri Mondor as candidates for cardiac transplantation. The period before transplantation was bridged by maximal pharmacological support including sympathomimetic and phosphodiesterase inhibitor inotropic agents and, in non-responders, by mechanical ventricular assist devices (1 case) or artificial hearts (2 cases). The 7 patients who improved with optimal pharmacological support alone had a good initial course. However, only two of these patients were finally transplanted, three died suddenly either in the intensive care unit or after withdrawal of intravenous drugs and hospital discharge. One patient remained well and after coronary bypass surgery, enjoys good quality life. One patient was found secondarily to be a poor candidate for transplantation and died shortly after. The outcome of 2 of the 3 patients who did not respond to pharmacological treatment and who required mechanical support was spectacularly good and enabled successful cardiac transplantation. Our experience underlines the numerous difficulties of different natures of cardiac transplantation in this indication, the value and risks of the new inotropic agents, and the real but limited role of heroic procedures such as the artificial heart.     

Reperfusion arrhythmias in acute myocardial infarction]

Twenty-seven patients with acute myocardial infarction (AMI), in whom infarct-related coronary artery was occluded and thrombolytic therapy or PTCA were performed, were studied. Reperfusion confirmed by immediate coronary angiography was achieved in 24 patients. Reperfusion arrhythmias (RA) occurred in 19(79.2%) of the patients, including ventricular arrhythmias in 13 (54.2%). Ventricular fibrillation (VF) and sustained ventricular tachycardia (VT) developed in 2(8.4%), and accelerated idioventricular rhythm in 5(20.8%); the latter showed a reliable indicator of coronary artery recanalization. Transient sinus bradycardia or AV block occurred in 10 (66.7%) of the 15 patients with inferior-posterior MI, which was an indicator of recanalization of coronary artery and salvage of myocardium in inferior-posterior MI. The occurrence of RA was not correlated with the duration of ischemia; ventricular RA was not related to the location of AMI and the occurrence and severity of ischemic arrhythmias before reperfusion. The patients with RA were treated with ordinary antiarrhythmic therapy, VF and sustained VT in 2 patients were converted by electric defibrillation. No death related to RA occurred. RA couldn't be prevented by lidocaine.     

急性心肌梗塞患者应激性血糖变化的临床预后意义

目的　探讨急性心肌梗塞（ＡＭＩ）患者应激性血糖变化特点及其急性期的临床预后意义。方法　回顾性分析住院ＡＭＩ患者２２４ 例,分为单纯ＡＭＩ、合并高血压（ＨＴ）、合并Ⅱ型糖尿病（ＤＭ）以及ＤＭ 合并ＨＴ 组。观察其心功能（Ｋｉｌｌｉｐ）、恶性心律失常及病死率差别。结果　（１）无ＤＭ 的ＡＭＩ患者应激性血糖反应（入院２４ 小时血糖≥７．３ ｍ ｍ ｏｌ／Ｌ）出现率为８３ 例／１７１ 例（４８．５％ ）;（２）ＡＭＩ合并ＤＭ 加ＨＴ 患者的临床预后比单纯ＡＭＩ较差;（３）无ＤＭ 的ＡＭＩ患者中的显著血糖应激反应者的临床预后较轻度或无反应者差,而与ＡＭＩ合并ＤＭ 加ＨＴ 组相近。结论　非ＤＭ 的ＡＭＩ患者中发病后２４ 小时内血糖明显升高,提示急性期预后不良     

The evolution and clinical significance of the ventricular late potential in acute myocardial infarction]

Two hundred cases of acute myocardial infarction (AMI) who had survived for 2 or more weeks were studied consecutively. 96.5% had been followed up for 0.5-27 (average 13) months. Signal averaging with filter corner frequencies of 40-250Hz were used to record ventricular late potentials (VLP). During hospitalization, 26.5% had at least one positive VLP. There were no statistical differences in age, gender, CK-peak value, or LVEF prior to the discharge between positive and negative VLP groups. However, there were more positive cases in inferior wall infarction and Killip's grade II or above (P less than 0.05). More VT/VF cases in VLP positive group, but no statistical correlation between the VLP and ventricular arrhythmias in Holter recording. On follow-up, 2/3 positive cases turned out negative, but greater part in these with continuous positive VLP had obvious cardiac dysfunction and reinfarction.