Postpartum acute myocardial infarction

We report a postpartum acute myocardial infarction that occurred during the first week after cesarean section delivery. We also calculated the rate of postpartum myocardial infarction as related to all women with myocardial infarctions seen in our hospital.(Am J Obstet Gynecol 1997;177:1553-5.)     

Menstrual and reproductive factors and risk of non-fatal acute myocardial infarction in Italy

OBJECTIVE: We analyzed the relation between factors related to endogenous female hormones and the risk of acute myocardial infarction (AMI). STUDY DESIGN: We used a combined dataset from three Italian case-control studies, including 609 women with non-fatal AMI and 1106 controls hospitalized for acute conditions. RESULTS: The odds ratios (OR) of AMI were 1.36 (95% confidence intervals, CI 0.95-1.96) in women with an irregular menstrual pattern compared to a regular one, and 1.45 (95% CI 1.07-1.97) in parae compared to nulliparae, without linear trend in risk with number of children. No relation was found with menopausal status, age at menarche and menopause, abortion, and age at first and last birth. Compared to women without abortions the OR was 0.84 (95% CI 0.60-1.18) for >1 abortion; compared to women without spontaneous or induced abortion, the ORs were 0.92 (95% CI 0.62-1.38) for >1 spontaneous and 0.63 (95% CI 0.36-1.08) for >1 induced abortion. The association of parity and irregular menstrual cycles was stronger in pre-/peri-menopausal women and in current smokers. Compared to nonsmokers with regular menstrual cycle, the OR was 5.98 (95% CI 3.38-10.56) for smokers with irregular one, and compared to nonsmokers nulliparae the OR for smokers parae was 4.77 (95% CI 3.12-7.29). CONCLUSIONS: Irregular menstrual cycles and parity were related to increased AMI risk, mainly among pre-/peri-menopausal women and among smokers.     

The hospital course of acute myocardial infarction in the Tainan area.

The hospital records of 204 patients with acute myocardial infarction (AMI) admitted from August 1988 through July 1990 were reviewed. Of these, 138 patients who were admitted within 24 hours after onset of symptoms were enrolled in this retrospective study. In 138 patients (110 men, 28 women; aged 62.6 +/- 11.3 years), the mean prehospital time was 4.8 +/- 4.5 hours (median 3.0, range 0.5 to 24.0). Ninety-nine of these 138 patients were classified as an early presentation group (less than 6 hours); their mean prehospital time was 2.5 +/- 1.3 hours. Of these, 60 patients received thrombolytic therapy with intravenous streptokinase (SK), and their prehospital time was 2.3 +/- 1.2 hours, with mean time to SK therapy of 3.7 +/- 1.5 hours. The in-hospital mortality of these 60 patients was 16.7%. The remaining 39 patients, without SK therapy, had a higher in-hospital mortality (28.2%); their mean prehospital time was 2.7 +/- 1.3 hours. For the late presentation group (greater than or equal to 6 hours), the mean prehospital time was 10.6 +/- 4.3 hours and the in-hospital mortality was 7.7%. The frequency of severe congestive heart failure (Killip class III or IV) at admission was significantly higher in patients with early presentation, than with late presentation (30.7% vs 7.6%, p less than 0.05). The overall causes of death included congestive heart failure (79%), ventricular arrhythmia (8%) and underlying medical illness (13%). In conclusion, 43.4% of the AMI patients in this study received SK therapy, within a mean time of 3.7 +/- 1.5 hours after onset.(ABSTRACT TRUNCATED AT 250 WORDS)     

The use of hormone replacement therapy in women with acute myocardial infarction: an audit of current practice

We undertook criterion-based audit of the current practice of prescribing hormone replacement therapy for women with acute myocardial infarction; the audit included 181 consecutive women admitted to one hospital with this diagnosis in one calendar year. The set standard was that, barring any contraindication, all postmenopausal women with acute myocardial infarction should be prescribed hormone replacement therapy before discharge from hospital. The evidence base of this standard derives from more than 30 epidemiological and clinical studies and a large body of biological data. Only 4.7% of the women were current users of hormone replacement therapy and the set standard was met in only 3% of eligible nonusers. Professionals caring for women who have had a myocardial infarction need to consider hormone replacement therapy as a secondary prophylaxis of myocardial infarction. Gynaecologists should liaise with colleagues in other specialties and general practice to ensure that information on the nongynaecological benefits of hormone replacement therapy is widely disseminated.     

Survival after early surgical revascularization in patients with both acute myocardial infarction and cardiogenic shock.

BACKGROUND AND PURPOSE: Previous studies have reported encouraging results with percutaneous transluminal coronary angioplasty (PTCA) in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock. However, PTCA is often unsuccessful and the mortality rate is more than 80%. The success rate of early surgical revascularization in patients with cardiogenic shock and failed PTCA is not clear. This study assessed the effect of early surgical revascularization on survival chances in patients with cardiogenic shock and failed PTCA. PATIENTS AND METHODS: Nineteen patients referred to our hospital by cardiologists due to cardiogenic shock and failed PTCA were included in this study. During the period from February 1995 through August 1997, seven patients were treated using mechanical circulatory support with extracorporeal membrane oxygenation (ECMO) and no surgical revascularization, and from August 1997 through June 1999, 12 patients underwent emergency surgical revascularization. The patient characteristics and in-hospital mortality were compared between groups. RESULTS: Ten patients were treated after acute infarction and nine were treated after cardiac intervention. No significant differences were found between the two groups in age, sex, hypertension, diabetes, smoking, and previous infarction. The in-hospital mortality rates were 100% in patients receiving mechanical circulatory support with ECMO and 25% in patients who underwent emergency surgical revascularization (p = 0.003). In the emergency revascularization group, four of 12 patients had surgical revascularization more than 18 hours after AMI and the in-hospital mortality rate was 25%. CONCLUSION: Surgical revascularization improved survival in patients with cardiogenic shock and failed PTCA.     

Time domain heart rate variability as a predictor of long-term prognosis after acute myocardial infarction.

BACKGROUND AND PURPOSE: Decreased heart rate variability (HRV) has been shown to be a predictor of both sudden cardiac death and cardiovascular death among patients surviving acute myocardial infarction (MI). However, the prognostic significance of time domain HRV in patients with MI is still controversial. In addition to the mean of all normal-to-normal (NN) intervals, we analyzed the prognostic significance of the 5 most widely used time domain parameters of HRV during long-term follow-up in patients surviving their first MI. METHODS: Five time domain measures of HRV from 24-hour ECG were obtained after discharge in 260 consecutive patients (207 males; mean age, 60 years) surviving their first MI. These parameters included: standard deviation of all NN intervals, mean of standard deviations of all NN intervals in all 5-minute segments (SDNNi), standard deviation of the average of all NN intervals in all 5-minute segments, the square root of the mean of the sum of the squares of differences between adjacent NN intervals, and percentage of differences between adjacent NN intervals > 50 ms. RESULTS: The study endpoint was cardiovascular death. After follow-up for 67 months (range, 1 to 114 months), there were 55 cardiovascular deaths (21%) including 39 sudden deaths (15%). Multivariate Cox regression analysis showed that SDNNi < 30 ms was a significant predictor of cardiovascular death (hazard ratio, 4.98; 95% confidence interval [CI], 2.03 to 12.21; p < 0.001) as was number of ventricular premature complexes >/= 10 beats/hour (hazard ratio, 5.34; 95% CI, 2.26 to 12.62; p < 0.001), age >/= 70 years (hazard ratio, 3.65; 95% CI, 1.44 to 9.23; p = 0.006), and left ventricular ejection fraction < 45% (hazard ratio, 3.29; 95% CI, 1.13 to 9.57; p = 0.03). SDNNi < 30 ms was also an important predictor of sudden cardiac death (hazard ratio, 5.02; 95% CI, 1.49 to 16.85; p = 0.009). CONCLUSIONS: These data suggest that SDNNi is a significant time domain parameter of HRV for long-term prognosis in post-MI patients.     

Low-dose oral contraceptive-induced acute myocardial infarction

Objectives: Since their introduction, oral contraceptives (OCs) have been associated with risk to both the venous and the arterial systems. Studies have shown that OC use is associated with a risk of venous thromboembolism, ischaemic stroke and acute myocardial infarction (MI). MI is rarely seen in patients using OCs, particularly in the absence of clinical risk factors or smoking.

Case: We report a case of acute inferior MI in a 20-year-old non-smoker who had used a low-dose OC (3?mg drospirenone and 30?μg ethinyl estradiol) for 1 month. As far as we know, this is the youngest case of acute MI associated with a low-dose OC.

Conclusion: Low-dose OCs may also be responsible for acute MI even in a very young female without any cardiovascular risk factors. Therefore, the clinicians should be aware of this mortal events during follow-up of the patient using OCs.     

Endometrial carcinoma after cyclical oestrogen-progestogen therapy for Turner's syndrome.

A case of endometrial adenocarcinoma in a patient with Turner's syndrome who had received long term combined oestrogen-progestogen therapy is described.     

Elective inguinal herniorrhaphy after myocardial infarction

A history of myocardial infarction should not be a deterrent to the performance of an elective inguinal herniorrhaphy. This operation has been proved to be safe for this patient population and is attended by a low and quite acceptable complication rate. Thorough preoperative evaluation ensures optimal management in both the perioperative and postoperative period. In stark contrast with elective inguinal herniorrhaphies, emergency procedures are associated with an alarming morbidity and mortality, often the result of cardiovascular complications. In the postinfarction patient with an inguinal hernia, the dual goals of complete cardiac rehabilitation and improved quality of life can be facilitated in a safe and sure manner by elective inguinal herniorrhaphy under local anesthesia.     

Takotsubo cardiomyopathy--transient left ventricular apical ballooning mimicking acute myocardial infarction.

Takotsubo cardiomyopathy is characterized by transient left ventricular dysfunction with clinical symptoms of chest pain, electrocardiographic changes of ST-segment elevation or T wave inversion, which mimics acute myocardial infarction in patients without angiographically significant coronary artery stenosis. We report a 75-year-old woman with a history of chest tightness who presented with typical pictures of takotsubo cardiomyopathy. Acute myocardial infarction was initially diagnosed based on the electrocardiographic changes and elevated troponin. Apical akinesis and ballooning with basal hyperkinesis were noted during left ventriculography. Coronary angiography, however, did not show significant coronary artery stenosis. Electrocardiography was normal 3 months later. Follow-up echocardiography did not show any wall motion abnormality. This patient remained well without chest pain or dyspnea over 24 months of follow-up. Optimal medical management of takotsubo cardiomyopathy remains unclear. This patient received diltiazem to prevent possible coronary artery spasm. The prognosis of this syndrome seems to be favorable except for occasional mortality due to left ventricular rupture or ventricular arrhythmia. Recurrence of this syndrome is rare.     

The effect of ovariectomy and oestrogen replacement on small artery biomechanics in the rat.

OBJECTIVE: To determine the effects of oestrogen deficiency and hormone replacement therapy on the biomechanical properties of a small artery. SAMPLE: Thirty non-pregnant female Sprague-Dawley rats. METHODS: Twenty animals were pharmacologically ovariectomised by triptorelin and received either oestradiol propionate or its vehicle. Ten other animals received only the vehicle for the same period of time (control group). After 12 weeks of treatment, cylindrical segments of the saphenous artery were isolated and cannulated at both ends. Pressure-diameter curves were recorded from segments in normal Krebs-Ringer, using norepinephrine, and then with papaverine. The vessel segment close to the examined one was histologically evaluated. Serum levels of oestradiol and cortisol were determined. MAIN OUTCOME MEASURES: Biomechanical parameters based on the pressure-diameter curves. RESULTS: Pharmacological ovariectomy decreased the passive diameter of the arteries and oestrogen replacement therapy prevented this. Decreased reactivity to norepinephrine was also restored by oestrogen treatment. Pressure induced myogenic tone was decreased significantly by oophorectomy and increased after oestradiol treatment. No significant changes were found in wall thickness, distensibility, elastic modulus or tangential stress. No significant histological alterations were seen in the vessel wall. Oestradiol levels were significantly decreased in the castrated animals compared with the other two groups. CONCLUSIONS: These results suggest that oestrogen deficiency decreases and oestrogen replacement increases the passive diameter of small peripheral arteries, and that oestrogen enhances the reactivity of vascular smooth muscle. These responses may provide the background mechanisms for the increased incidence of arterial hypertension and hot flushes during the menopause and the ability of oestrogen substitution to prevent them.     

A study on the pre-admission characteristics of patients with acute myocardial infarction.

To clarify an appropriate policy to implement Emergency Medical Services (EMS) in Taiwan based on the profiles of patients with acute myocardial infarction (AMI), and to compare the differences of clinical features accompanied by AMI between Orientals and Westerners, 63 consecutive patients with definite AMI entering the emergency room (ER) from September 1989 through January 1990 were studied. Several interesting facts were found: 1) 9.5% (6/63) of patients took public ambulance to seek medical help; 2) 89% came from out of our jurisdiction, and 62% (39/63) were referred from general practitioners or the ER of community hospitals; 3) There were 5 truly delayed cases (7.9%) owing to a lack of sense of danger in case of chest pain; 4) 50% of our cases occurred during sleeping; 5) The time of onset peaked from 0 AM to 6 AM; 6) While 63.5% of patients visited ER within 6 hours after the onset of acute symptoms, only 12.7% were treated with thrombolytic therapy; and 7) AMI patients stayed in ER for an average of over 4 hours. With limited cases, although trends were evident, firm conclusions were not warranted. The following crucial recommendations are suggested: 1) EMS system in terms of caring of AMI patients still needs a well-designed study to map out an appropriate policy; 2) The strengthening education to physicians working in ER or to all primary care physicians of an early use of thrombolytic agents in indicated cases should be warranted to offer timely therapy when necessary; 3) General public should be educated to call for medical help as soon as possible in case of chest pain.     

Outcome of primary percutaneous coronary intervention in octogenarians with acute myocardial infarction.

BACKGROUND/PURPOSE: Acute myocardial infarction (AMI) results in more complications and increased mortality in octogenarians compared to patients in younger age groups. This study investigated the short- and long-term outcomes in octogenarians after primary percutaneous coronary intervention (PCI). METHODS: During the study period from May 1997 to August 2004, 54 patients > or = 80 years old with ST-elevation myocardial infarction (STEMI) were eligible for primary PCI. Data collected included baseline clinical characteristics and usage of cardiovascular medications. Diagnostic coronary angiography and revascularization procedures were performed using standard practices. During hospitalization, the clinical course including serial changes in cardiac enzymes, adverse events associated with myocardial infarction or treatment, and inhospital or long-term mortality of patients were recorded. RESULTS: The mean age of the 54 patients (35 men, 19 women) was 82.8 +/- 2.5 years (range, 80-89 years). Among them, 27 (50%) had anterior infarction, six (11%) had anterolateral infarction, and 21 (39%) had inferior infarction, inclusive of three patients with accompanying right ventricular infarction. Among them, 20 (37%) patients were in Killip class I, nine (17%) were in class II, two (4%) in class III, and 23 (43%) in class IV. The mean delay from onset of symptoms to arrival in hospital was 220 +/- 167 minutes, and 189 +/- 169 minutes from hospital arrival to reperfusion. Diagnostic coronary angiography revealed that 48 (89%) patients had multivessel disease. Inhospital death occurred in 23 (43%) patients, with the leading causes of death being profound cardiogenic shock (61%), and free wall rupture (26%). CONCLUSION: Octogenarian patients who developed STEMI tended to have multivessel disease. These patients had a high inhospital mortality rate that was most likely to be due to cardiogenic shock.