The National Heart Attack Alert Program: Progress at 5 Years in Educating Providers,Patients, and the Public and Future Directions

The National Heart Attack Alert Program (NHAAP) was launched by the National Heart, Lung, and Blood Institute in 1991 with the goal of reducing morbidity and mortality from acute myocardial infarction (AMI) through the rapid identification and treatment of individuals with symptoms and signs of an AMI. To achieve this goal, the NHAAP established objectives for each of three phases of action where treatment delays can occur: in the hospital, the prehospital setting, and the patient/bystander arena. The NHAAP initially directed its educational efforts toward emergency department professionals. Recommendations for reducing delays in emergency department identification of patients presenting with heart attack symptoms were developed by a working group convened in late 1991. These recommendations were published in February 1994 in a peer-reviewed journal reaching more than 17,000 emergency physicians. The NHAAP worked in a partnership with its coordinating committee, representing 40 health professional, voluntary, and government organizations, to extend the reach of the report's recommendations to their members. Strategies for promoting the emergency department recommendations included publication of excerpts in newsletters and journals of the medical, nursing, and prehospital provider organizations represented on the NHAAP Coordinating Committee, and through symposia at annual meetings. Industry assisted with dissemination efforts and with implementing a continuous quality improvement program based on the paper's recommendations. The NHAAP also developed, with the Joint Committee on Accreditation of Health Care Organizations, a time-to-treatment indicator for thrombolytic therapy to be incorporated into their Indicator Measurement System (IMSystem). To track achievement of the objectives related to the Hospital Action Phase, national data sources for emergency department management of patients with AMI were evaluated at the 5-year point of the NHAAP. Data from a national registry showed that the median time from presentation at the emergency department to receiving thrombolytic therapy declined by about one third between 1992 and the last half of 1995. The percentage of all Medicare patients receiving thrombolytic therapy within the recommended 30 minutes after emergency department arrival nearly doubled between 1992 and 1995. Based on these and other results presented at the 5-year juncture of the program, the NHAAP Coordinating Committee assessed progress and identified new areas of focus for the next 5 years. Improvements in emergency departments' ability to identify and treat AMI patients progressed during the first 5 years of the NHAAP, when the program was highlighting this as a priority. This model is continuing to be used to address delays in the Prehospital Action Phase. Further research from a National Heart, Lung, and Blood Institute (NHLBI) community intervention trial will guide the program in its plans for full-scale public education to address the Patient/Bystander Recognition and Action Phase.     

Time-dependent predictors of primary cardiac arrest in patients with acute myocardial infarction

To understand predictors of cardiac arrest early in acute myocardial infarction (AMI), for the Thrombolytic Predictive Instrument, we developed a multivariable regression model predicting primary cardiac arrest using time-dependent variables based on a case-control study of emergency department (ED) patients with AMI: 65 cases with sudden cardiac arrest and 258 without cardiac arrest. Within the first hour of AMI symptom onset, adjusting for age, systolic blood pressure, serum potassium, and infarct size, increased risk of cardiac arrest was associated with electrocardiographic prolonged QTc interval and a greater sum of ST-segment elevation. After 1 hour, the effect of ST-segment elevation was much reduced and the effect of the QTc interval was reversed, so prolonged QTc appeared protective. Accordingly, for patients presenting 30 minutes after chest pain onset, compared with a QTc of 0.44, the risk for cardiac arrest for patients with QTc of 0.50 was more than doubled (odds ratio [OR] 2.20, 95% confidence intervals [CI] 1.17 to 4.13), whereas for those presenting after an hour, it was much lower (e.g., at 1.5 hours, OR 0.21, 95% CI 0.06 to 0.73). Patients presenting 30 minutes after chest pain onset with a sum of ST elevation of 20 mm had a threefold higher risk than patients with a sum of ST elevation of 5 mm (OR 3.37, 95% CI 1.83 to 6.20). However, if presenting 1.5 hours after chest pain onset, the risk was barely elevated (OR 1.18; 95% CI 1.09 to 1.29). Thrombolytic therapy was protective, halving the odds of cardiac arrest (OR 0.51, 95% CI 0.27 to 0.93). Thus, the relation of prolonged QTc interval and substantial ST segment elevation to cardiac arrest in AMI may be obscured because patients with these risks are more likely to die soon after AMI onset, before ED presentation, and are thereby unavailable for study. Those with prolonged QTc or substantial ST elevation who survive the initial 1.5-hour period are those less susceptible to these risks.     

Time of onset of symptoms of acute myocardial infarction

Several studies have observed an increased occurrence of acute myocardial infarction (AMI) in the morning based on subjective self-reports and objective confirmation. Evidence has also been collected to suggest a circadian variation in the onset of sudden cardiac death and silent myocardial ischemia. No published reports have examined the time of onset of AMI in relation to time after awakening. The present study examines the times of onset of AMI in relation to awakening in 137 patients with confirmed AMI. Information concerning time of awakening on the day of AMI revealed a marked increase in the onset of initial AMI symptoms within the first hour after awakening. Of the patients studied, approximately 23% reported onset of the initial symptoms of AMI within 1 hour after awakening. An increased onset of symptoms of AMI soon after awakening was also observed when patients in whom the acute cardiac symptoms were known to or may have caused awakening were excluded from consideration. This was also noted in subgroups of AMI patients classified according to age, order and location of AMI. These results extend previous observations of the circadian morning increase of AMI onset and assist in narrowing the search for potential triggers of the circadian variation of onset of AMI to physiologic changes that may occur soon after awakening.     

Symptom presentation of acute myocardial infarction: influence of sex,age, and risk factors

Objectives The purpose of this study was to examine the symptomatology of onset of acute myocardial infarction (AMI) in patients according to sex, age, and existence of conventional risk factors. Background Some studies have suggested that sex and other patient characteristics may influence symptoms in AMI, but data were limited and conflicting. Methods This was a prospective, observational study of a large number of symptoms in 1996 patients admitted to Clinical Hospital Split between January 1990 and July 1995 as the result of a first AMI. For each patient, the structured data form covering experience of pain at 10 body locations and 11 other symptoms, baseline characteristics, risk factors, and peak cardiac enzyme levels was completed a median of 3 days after AMI. Results Any pain, and specifically chest pain, was more often reported by male patients, smokers, hypertensive patients, nondiabetic patients, and hypercholesterolemic patients. Women were more likely to report nonchest pain other than epigastric and right shoulder pain, as well as various nonpain symptoms. The independent predictors of atypical AMI presentation (ie, absence of pain) in both men and women were lower levels of creatine kinase-MB fraction (P < .0001 and P = .0003, respectively), diabetes mellitus (P = .0002 and P = .002, respectively), older age (P = .001 and P = .01, respectively), and absence of smoking in men (P = .005). The independent predictors of presence of nonpain symptoms in both men and women were higher levels of creatine kinase-MB fraction (P = .01 and P = .049, respectively) and diabetes mellitus (P = .048 and P = .005, respectively); in men, it was hypercholesterolemia (P = .01). Conclusions Our results suggest that sex, age, smoking, hypertension, diabetes, and hypercholesterolemia may affect the symptoms in AMI. Women with diabetes represent a high-risk subgroup for painless onset followed by various other symptoms. (Am Heart J 2002;144:1012-7.)     

National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia

The National Heart Attack Alert Program (NHAAP), which is coordinated by the National Heart, Lung, and Blood Institute (NHLBI), promotes the early detection and optimal treatment of patients with acute myocardial infarction and other acute coronary ischemic syndromes. The NHAAP, having observed the development and growth of chest pain centers in emergency departments with special interest, created a task force to evaluate such centers and make recommendations pertaining to the management of patients with acute cardiac ischemia. This position paper offers recommendations to assist emergency physicians in EDs, including those with chest pain centers, in providing comprehensive care for patients with acute cardiac ischemia.     

Efficiency of a physician-operated mobile intensive care unit for prehospital thrombolysis in acute myocardial infarction.

The efficiency of an emergency medical system for routinely performed prehospital thrombolysis is evaluated for 1 of the 7 physician-staffed mobile intensive care units (MICU) in former West Berlin. During 19 consecutive months the MICU had 4,920 missions, and 1,226 patients had chest pain of presumed cardiac origin. The diagnosis at hospital discharge was acute myocardial infarction (AMI) in 406 patients and "interrupted" infarction in 11 patients (total 417). Correct on-scene electrocardiographic diagnosis of acute injury was made in 268 patients (64%) and was false-positive in 4 patients (1%). In 8%, present ST elevations were not recognized. In 27%, the electrocardiogram on scene was nondiagnostic (16% with no ST elevation, 11% with bundle branch block). Of all 417 patients with later hospital evidence of AMI, 317 (76%) were seen by the MICU physician within 4 hours, and 173 (41%) within the first hour from symptom onset. Two hundred three patients seen within 4 hours had diagnostic ST elevation on the scene, of whom 124 (61%) received prehospital thrombolysis (74 patients [36%] within the first hour). There was no prehospital death; hospital mortality was 6.3%. Because greater than 50% of all patients in the community, hospitalized because of AMI, made use of the MICU and 3/4 of them had called within 4 hours from symptom onset, a large proportion of all patients with AMI were candidates for the actually received prehospital thrombolysis.     

Point-of-care tests in suspected acute myocardial infarction: A systematic review

Background

A review of cardiac point-of-care (POC) tests used to detect or exclude acute myocardial infarction (AMI) with a focus on test performance within 6 hours after the start of symptoms.

Methods

A systematic review of articles on the diagnostic accuracy of point of care (POC) tests in patients suspected of AMI from the PubMed database from January 1st 1990 to December 1st 2012.

Results

Our search yielded 42 studies evaluating POC tests. Troponin (Tn) was investigated in 29 studies, and creatine kinase-myocardial band isoenzyme (CK-MB), myoglobin, and heart-type fatty acid-binding protein (H-FABP) each in 13 studies. Eight studies used a multimarker approach. In 14 studies results were presented or could be recalculated for test results within 6 hours of symptom onset or with a median time from symptoms onset to testing of 3 hours. In this time frame the negative predictive value (NPV) ranged from 31 to 97% with single testing, and from 59 to 100% with a multi-marker approach. Just one study satisfied to all items used for methods appraisal.

Conclusions

The ideal POC test for the diagnosis of AMI within 6 hours after the onset of symptoms does not yet exist. Evaluated POC tests were in general of poor methodological quality and reported too many false negatives to be considered as save for the assessment of patients suspected of AMI. A POC test of high-sensitive troponin could possibly fill the gap in the early hours after symptom onset, especially in those with non-definitive electrocardiography.     

Knowledge of heart disease and stroke among cardiology inpatients and outpatients in a Canadian inner-city urban hospital

BACKGROUND:

Heart disease and stroke are leading causes of death in North America. Nevertheless, in 2003, the Heart and Stroke Foundation of Canada reported that nearly two-thirds of Canadians have misconceptions regarding heart disease and stroke, echoing the results of similar American studies. Good knowledge of these conditions is imperative for cardiac patients who are at greater risk than the general population and should, therefore, be better educated. The present study evaluated the awareness of heart disease and stroke among cardiac patients to assess the efficacy of current education efforts.

METHODS:

Two hundred fifty-one cardiac inpatients and outpatients at St Michael’s Hospital (Toronto, Ontario) were surveyed in July and August 2004. An unaided questionnaire assessed respondents’ knowledge of cardiovascular risk factors, symptoms of heart attack and stroke, and actions in the event of cardiovascular emergency. Demographic data and relevant medical history were also obtained.

RESULTS:

Cardiac patients demonstrated relatively adequate knowledge of heart attack warning symptoms. These patients also demonstrated adequate awareness of proper actions during cardiovascular emergencies. However, respondents were not aware of the most important risk factors for cardiovascular disease. Knowledge of stroke symptoms was also extremely poor. Socioeconomic status, and personal history of heart attack and stroke were positively correlated with good knowledge.

CONCLUSIONS:

Future patient education efforts should address the awareness of the important cardiovascular risk factors and knowledge of cardiovascular warning symptoms (especially for stroke), as well as inform patients of appropriate actions during a cardiovascular emergency. Emphasis should be placed on primary and secondary prevention, and interventions should be directed toward low-income cardiac patients.     

Use of neutrophil count in early diagnosis and risk stratification of AMI

Background

Neutrophils are rapidly released into the circulation upon acute stress such as trauma or acute myocardial infarction (AMI). We hypothesized that neutrophil count might provide incremental value in the early diagnosis and risk stratification of AMI.

Methods

We conducted a prospective observational multicenter study to examine the diagnostic accuracy of the combination of neutrophil count and cardiac troponin T from 1125 consecutive patients who presented to the Emergency Department with symptoms suggestive of acute myocardial infarction. The final diagnosis was adjudicated by 2 independent cardiologists.

Results

Neutrophil count was higher in patients with acute myocardial infarction compared with other diagnoses (median 6.7 vs. 5.0 × 10⁹/L, respectively, P <.001). The accuracy of the neutrophil count for diagnosing acute myocardial infarction, quantified by the area under the receiver operating characteristic curve (AUC) was 0.69, which was significantly lower than that of cardiac troponin T (AUC 0.89, P <.001). The combination of the neutrophil count and cardiac troponin T did not improve the early diagnosis of acute myocardial infarction versus cardiac troponin T alone (P = .79). The prognostic accuracy of neutrophil count for death and AMI was significantly lower than that of cardiac troponin T. However, patients in the highest tertile of neutrophil count had a significantly increased risk of death and AMI at 90 and 360 days compared with patients in the lowest tertile (hazard ratios 2.47 [95% confidence interval, 1.63–3.72] and 2.28 [95% confidence interval, 1.55–3.36], respectively).

Conclusion

The neutrophil count does not improve the early diagnosis of AMI in patients presenting with chest pain but identifies patients at increased risk of death.     

Analysis of cardiac symptoms preceding cardiac arrest

Prodromal symptoms and cardiac history were examined in 227 patients with coronary artery disease who were successfully resuscitated after out-of-hospital cardiac arrest. Cardiac arrest was sudden—with either no symptoms or symptoms for less than 1 hour—in 71% of the patients. Nonsudden death—death occurring after more than 1 hour of symptoms—occurred in 29% of the patients. A history of cardiovascular disease was present in 85% of patients with sudden cardiac arrest and in 83% with nonsudden arrest. Cardiac arrest occurred without symptoms in 38% of the patients with sudden cardiac arrest and was the first expression of coronary artery disease in 4% of the entire study group. This study indicates that cardiac arrest usually occurs with symptoms and almost always in the setting of a history of cardiovascular disease.     

Is pre-hospital thrombolysis in acute myocardial infarct valuable as a routine measure?]

In 4920 consecutive missions of the mobile intensive care unit Klinikum Steglitz, 1226 patients (25%) had chest pain of presumed cardiac origin. In 272 patients (22%) an acute myocardial infarction (AMI) was diagnosed in the field. In four patients the diagnosis was wrong; 11 patients with proven coronary artery disease had significant ST-segment elevation, but did not develop AMI. In hospital, a total of 406 patients had evidence of AMI; 173 of these (41%) were seen by an emergency physician in the field already within the first hour after onset of symptoms. In 6%, diagnostic ST-elevation was not recognized by the emergency physician; 27% had non-diagnostic ECG changes (11% bundle-branch block). Prehospital thrombolysis within 4 h after symptom onset was performed in 126 of 205 patients (61%); 74 of these patients were seen by the emergency physician within the first hour. The main reason for exclusion was advanced age. Inclusion of older patients and also those with bundle-branch block could further increase the prehospital thrombolysis rate. Conclusion: With an effective emergency medical system a large proportion of all patients with AMI can correctly be identified and properly treated with a thrombolytic drug in the field. The time gain is considerable.     

Clinical outcomes according to symptom presentation in patients with acute myocardial infarction: Results from the FAST‐MI 2010 registry

Background

Atypical clinical presentation in acute myocardial infarction (AMI) patients is not uncommon; most studies suggest that it is associated with unfavorable prognosis.

Hypothesis

Long‐term clinical impact differs according to predominant symptom presentation (typical chest pain, atypical chest pain, syncope, cardiac arrest, or dyspnea) in AMI patients.

Methods

FAST‐MI 2010, a nationwide French registry, included 4169 patients with AMI in 213 centers at the end of 2010 (76% of active centers). Demographics, medical history, hospital management, and outcomes were compared according to predominant symptom presentation.

Results

Typical chest pain with no other symptom was reported in 3020 patients (68% in STEMI patients, 76% in NSTEMI patients). Atypical chest pain, dyspnea, syncope, and cardiac arrest were reported in 11%, 11%, 5%, and 1%, respectively. Patients with atypical clinical presentation had a higher cardiovascular risk profile and received fewer medications and a less invasive strategy. Using Cox multivariate analysis, atypical chest pain was not associated with higher death rate at 3 years (HR: 0.96, 95% CI: 0.69‐1.33, P = 0.78), whereas cardiac arrest (HR: 2.44, 95% CI: 1.00‐5.97, P = 0.05), syncope (HR: 1.70, 95% CI: 1.18‐2.46, P = 0.005), and dyspnea (HR: 1.66, 95% CI: 1.31‐2.10, P < 0.001) were associated with higher long‐term mortality compared with patients with typical isolated chest pain. Similar trends were observed in STEMI and NSTEMI populations.

Conclusions

Atypical clinical presentation is observed in about 20% of AMI patients. Cardiac arrest, dyspnea, and syncope represent independent predictors of long‐term mortality in STEMI and NSTEMI populations.

     

Long-term outcome of primary percutaneous transluminal coronary angioplasty for low-risk acute myocardial infarction in patients older than 80 years: a single-center, open, randomized trial

Background Although coronary reperfusion therapy with thrombolytic agents or percutaneous transluminal coronary angioplasty (PTCA) immediately after acute myocardial infarction (AMI) has survival benefits for younger patients, the effect of coronary reperfusion therapy for very elderly (aged 80 years and older) patients with AMI remains controversial. Methods and Results We studied 120 patients aged 80 years and older at relatively low risk with AMI. The patients were randomized into a primary PTCA group (n = 61) or a “conservative” no-PTCA group (n = 59). Long-term follow-up examination was conducted with regard to endpoints, which included all causes of death, cardiac death, nonfatal re-MI, the development of congestive heart failure, and cerebral vascular accident. End-diastolic volume index and end-systolic volume index were significantly increased in both groups at follow-up examination 6 months after AMI. However, left ventricular ejection fraction, end-diastolic volume index, and end-systolic volume index were similar between both groups. With endpoints of all causes of death, cardiac death, reinfarction, congestive heart failure, and cerebral vascular accident, a 3-year Kaplan-Meier event-free survival rate analysis revealed no significant benefits in the PTCA group. Anteroseptal MI, multivessel disease, and left ventricular ejection fraction were significantly associated with the combined events with multivariate Cox proportional hazards analysis results. Conclusion First, primary PTCA for very elderly patients with AMI appears to have few beneficial effects on combined events during a 3-year period. Second, early PTCA did not prevent left ventricle remodeling after AMI in patients with AMI at relatively low risk. (Am Heart J 2002;143:497-505.)     

Workshop: Patient Self-Management: Update of Ongoing Studies in Sweden

Identification of patients with acute cardiac ischemia (ACI) remains challenging. The object of this study was to examine the role of clinical findings in the diagnosis/triage of emergency department (ED) patients with symptoms suggestive of ACI. The study was designed as a secondary data analysis of a multicenter prospective controlled clinical trial. It was set in 10 midwest, southeast, and northeast U.S. hospitals, and 10,689 patients with chest pain or other symptoms suggesting ACI presenting from May 1993 to December 1993, participated. The results indicated that ACI patients were more likely to have chest pain as a chief complaint or presenting symptom (P = 0.001). The presenting symptom of nausea was more commonly associated with a final diagnosis of ACI (P = 0.003). Shortness of breath as the chief complaint and presenting symptoms of abdominal pain, nausea, dizziness, and fainting were less frequent among patients with a final diagnosis of ACI (P = 0.001). A past history of diabetes mellitus, myocardial infarction, or angina pectoris was more frequently associated with a final diagnosis of ACI (P = 0.001). A lower pulse rate in patients with a final diagnosis of ACI (P = 0.001) was not considered clinically significant. Median first and highest systolic blood pressures (SBPs) were higher, median lowest SBPs were lower, median diastolic blood pressure of the lowest SBPs were lower, and initial and highest pulse pressures were wider in patients with a final diagnosis of ACl (P = 0.001). On arrival, these blood pressure variables in AMI patients, subsequently classified as Killip class 4, were above the threshold for this classification. Rales were more commonly present in patients with a final diagnosis of ACI (P= 0.001). All primary ST-segment abnormalities, Q waves, and T-wave abnormalities, except T-wave flattening, were seen more frequently in patients with a final diagnosis ACI (P= 0.001). Normal ECGs were more frequently associated with a non-ACI final diagnosis, yet 20% of AMI patients and 37% of Unstable Angina Pectoris (UAP) patients had normal ECGs. It can be concluded that certain clinical features can help to identify ED patients with ACI. Initially normal ECGs can be seen in 20% of patients with AMI and 37% of patients with UAP. Patients with ACI can present with normal blood pressures and develop cardiogenic shock. Clinical outcome data for ACI patients are presented.     

急性心肌梗死心率变异与预后及临床的关系

目的　为探索急性心肌梗死 (AMI)时心率变异性 (HRV)变化规律及对AMI预后的临床意义。方法　检测 10 3例AMI患者症状发生 2 4小时内及 3周时的HRV时域及频域指标 ,并与 90例正常人进行对比。结果　AMI患者HRV明显低于对照组 (P <0 0 5 ) ;合并糖尿病、高血压病等 ,年龄大、梗死面积大、Killip分级差 ,HRV较小。发生心脏事件者HRV明显低于不发生心脏事件者。 结论　提示AMI时自主神经系统功能失衡 ,诱发心脏电生理紊乱 ,影响预后。     

Cardiovascular risk factor awareness in a disadvantaged inner-city population--implications for preventive strategies

BACKGROUND:

Disadvantaged inner-city populations have significantly higher cardiovascular disease (CVD) mortality rates than the general population. Whether a deficiency in the level of awareness, a prerequisite for change, exists that contributes to this socioeconomic divide has not been well established.

OBJECTIVES:

To address CVD risk by assessing the knowledge of CVD risk factors of an inner-city population and comparing it with that of the general population by establishing determinants of CVD knowledge and identifying potential barriers to CVD risk factor reduction in the inner city.

METHODS:

Cross-sectional survey of 136 consecutive patients 40 years of age and older attending an inner-city community health centre. The comparison group consisted of 807 age-matched respondents from the Canadian Heart Health Study, a random sample survey of the general adult Canadian population. Outcome measures included CVD risk factor knowledge, CVD risk factor prevalence and barriers to reducing CVD risk.

RESULTS:

There was no significant difference between inner-city respondent ability to name five of the seven CVD risk factors compared with the general population. Two CVD risk factors were more readily recalled by the inner-city group (lack of exercise, P<0.001; heredity, P=0.003). The average number of risk factors named by an individual from the inner city was significantly higher than the general population (3.1 versus 2.6; P<0.001). Among the inner-city respondents, socioeconomic factors, including higher education level (OR 5.224; P<0.001) and being married (OR 3.651; P=0.008), were independently related to good CVD knowledge; high CVD risk was not related. Lack of motivation (57%), lack of time (34%) and lack of money (30%) were commonly reported as barriers to addressing CVD risk.

CONCLUSIONS:

Elevated CVD risk in the inner city may not be attributable to a deficiency in the level of awareness. However, the relationship between socioeconomic status and knowledge is maintained within the lowest social class tier. The identification of barriers linked to inner-city life has implications for prevention of CVD in the inner city; results suggest that interventions that combine health education with motivational approaches, while necessary, may not be sufficient.     

Patient delay and receipt of thrombolytic therapy among patients with acute myocardial infarction from a community-wide perspective.

The duration of patient delay from the time of onset of symptoms of acute myocardial infarction (AMI) to hospital presentation, and the relation of delay time and various patient characteristics to receipt of thrombolytic therapy were examined as part of a community-based study of patients hospitalized with AMI in the Worcester, Massachusetts, metropolitan area. In all, 800 patients with validated AMI hospitalized at 16 hospitals in the Worcester metropolitan area in 1986 and 1988 constituted the study sample. Patients delayed on average 4 hours between noting symptoms suggestive of AMI and presenting to area-wide emergency departments with no significant change observed between 1986 and 1988. The shorter the time interval of delay, the greater the likelihood of receiving thrombolytic therapy; patients arriving at the emergency department within 1 hour of the onset of acute symptoms were approximately 2.5 and 6.5 times more likely to receive thrombolytic agents than were those presenting to the hospital between 4 and 6, and greater than 6 hours, respectively, after the onset of symptoms. Results of a multivariate analysis showed increasing length of delay, older age, history of hypertension or AMI and non-Q-wave AMI to be significantly associated with failure to receive thrombolytic therapy.     

两周运动康复疗法对急性心肌梗塞的疗效观察

目的：探讨两周康复疗法对急性心肌梗塞的疗效。方法：比较１７例接受康复治疗的急性心肌梗塞患和对照组２０例患的临床疗效。结果：康复组１７例病人顺利完成两周康复治疗。门诊随访１～６个月,１例发生心衰,１例出现心绞痛,无再次心肌梗塞和死亡,生活基本自理．对照组２例发生心衰,２例发生心绞痛,再梗塞１例,心脏性猝死１例。结论：两周康复治疗可以促进急性心肌梗塞的康复,改善病人的预后。     

Titration to High-Intensity Statin Therapy Following Acute Myocardial Infarction in Patients With and Without Diabetes Mellitus

Background

Patients with diabetes mellitus (DM) have a high risk for cardiovascular disease (CVD) events after an acute myocardial infarction (AMI). High-intensity statins reduce CVD risk following AMI among patients with and without DM.

Methods

We determined the proportion of Medicare beneficiaries 66 to 75 years of age taking a low/moderate-intensity statin with (n?=?6718) and without (n?=?6414) DM who titrated to a high-intensity statin dosage (i.e., atorvastatin 40 or 80 mg, or rosuvastatin 20 or 40 mg) following an AMI hospitalization in 2014–2015. All patients had a pharmacy claim for a statin fill within 365 days prior to, and within 30 days after their AMI hospitalization. We excluded beneficiaries without Medicare fee-for-service coverage including pharmacy benefits during the study period and those with a pharmacy claim for a high-intensity statin prior to their AMI.

Results

The first statin fill following hospital discharge was for a high-intensity dosage among 37.7% and 44.4% of patients with and without DM, respectively. After multivariable adjustment, the risk ratio (RR) for titrating to a high-intensity statin comparing patients with versus without DM was 1.01 (95% CI 0.96, 1.06). Among patients whose first statin fill post-AMI was for a low/moderate-intensity dosage, 7.5% of those with DM titrated to a high-intensity statin within 182 days, compared with 9.2% of those without DM (multivariable-adjusted RR 0.90 [95% CI 0.75, 1.08]).

Conclusions

Most patients taking a low/moderate-intensity statin were not titrated to a high-intensity dosage following AMI irrespective of their diabetes status, potentially leaving substantial residual risk for recurrent CVD events.

     

Frequency of hypokalemia after successfully resuscitated out-of-hospital cardiac arrest compared with that in transmural acute myocardial infarction

To evaluate the prevalence of hypokalemia in out-of-hospital cardiac arrest, the initial serum potassium and arterial pH values were reviewed from 138 consecutive patients resuscitated from cardiac arrest. For comparison, the same variables were reviewed for 62 consecutive patients who had transmural acute myocardial infarction (AMI) without cardiac arrest. The mean serum potassium level was lower after resuscitation from cardiac arrest (3.6 +/- 0.6 mEq/liter) than during AMI (3.9 +/- 0.5 mEq/liter) (p less than 0.005). The incidence of hypokalemia (potassium less than 3.5 mEq/liter) was greater in patients sustaining cardiac arrest (41%) than in patients who had AMI without cardiac arrest (11%) (p less than 0.001). Hypokalemia was common after cardiac arrest regardless of the occurrence of AMI at the time of arrest. Hypokalemia after cardiac arrest was independent of arterial pH, epinephrine or bicarbonate therapy during resuscitation, or prior therapy with diuretic drugs, digoxin or propranolol. In 10 patients with marked hypokalemia, the serum potassium level returned to normal rapidly (16 hours) during the hospitalization even though only 29% of the predicted potassium requirement was infused before its normalization. Thus, hypokalemia is prevalent immediately after out-of-hospital cardiac arrest, whereas it is uncommon in AMI in the absence of cardiac arrest. The cause and electrophysiologic consequences of this hypokalemia are unknown; in most cases, it is apparently caused by a shift of potassium from the intravascular compartment rather than a total body depletion of potassium.