Secular changes in cardiovascular risk factors and attack rate of myocardial infarction among men aged 50 in Gothenburg, Sweden. Accurate prediction using risk models

Aims. Coronary risk factor changes were related to attack rate of acute myocardial infarction (AMI). Methods and results. Cross‐sectional population samples of 50‐year‐old men were examined every 10th year from 1963 to 2003. Attack rates of AMI were recorded from 1975 to 2004. Prevalence of smoking decreased from 56% in 1963 to 22% in 2003. Leisure time physical activity decreased (n.s.), while psychological stress remained the same. Diabetes prevalence increased from 3.6% to 6.6%. Body mass index (BMI) increased from 24.8 to 26.4 kg m^?2. Blood pressures decreased from 138.2/90.6 to 134.7/84.9 mmHg (P = 0.00001). Serum total cholesterol decreased from 6.42 to 5.50 mmol L^?1 (P = 0.0001), but serum triglycerides increased from 1.26 to 1.71 mmol L^?1 (P = 0.0001). The multivariable risk according to total cholesterol, blood pressure and smoking for AMI decreased from the set value 1.0 in 1963 to 0.418. From 1975–1979 to 2000–2004 attack rates for AMI for the age groups 35–44, 45–54 and 55–64 declined to 45%, 46% and 45%, respectively. The 28‐day case fatality declined from 30%, 38% and 46% to 12%, 16% and 20%. Conclusion. The more than 50% decline in attack rate of AMI during 30 years was comparable with the decline in risk factors.     

Intensive lipid lowering may reduce progression of carotid atherosclerosis within 12 months of treatment: the METEOR study

Background. In several statin trials, vascular event rates for treatment groups begin to separate 1 year after commencement of treatment. For atherosclerosis progression, the temporal sequence of the effect has not been defined. We used data from the Measuring Effects on intima media Thickness: an Evaluation Of Rosuvastatin (METEOR) trial to determine the earliest time point at which significant differences in atherosclerosis progression rates could be detected after initiation of statin therapy. Methods. The METEOR trial was a double‐blind, randomized placebo‐controlled trial that studied the effect of LDL‐C lowering with 40 mg rosuvastatin on the rate of change of carotid intima media thickness (CIMT) measured by B‐mode ultrasound amongst 984 low risk subjects. Ultrasound assessments were made at baseline and every 6 months up to 2 years. Results. Rosuvastatin treatment was associated with a 49% reduction in LDL‐C‐C, a 34% reduction in total cholesterol, an 8.0% increase in HDL‐C and a 16% reduction in triglycerides (all P < 0.0001 compared with placebo). The difference in rate of mean maximum CIMT progression between the rosuvastatin and placebo groups (based on near and far wall measurements from both left and right common carotid and internal carotid segments and carotid bifurcation) was not statistically significant after 6 months (0.0023 mm year^?1 and 0.0106 mm year^?1, respectively P = 0.34). After 12 months, CIMT progression rates were significantly different between the groups: 0.0032 mm year^?1 and 0.0133 mm year^?1 in the rosuvastatin‐treated and placebo‐treated groups, respectively (P = 0.049). This divergence grew with further follow‐up: ?0.0009 mm year^?1 and 0.0131 mm year^?1 after 18 months (P < 0.001) and ?0.0014 mm year^?1 and 0.0131 mm year^?1 after 24 months of treatment (P < 0.001). Results were stronger for the mean common CIMT progression (based on near and far wall measurements from both left and right common carotid segments). Conclusion. Aggressive LDL‐C lowering seems to exert its beneficial effect on atherosclerosis progression during the first 12 months of treatment. This parallels the timing of event reduction seen in clinical trials and suggests that the efficacy of lipid lowering treatment on CIMT progression can be evaluated in trials with a duration of 1 year, given sufficient sample size, high precision of measurements and a treatment effect comparable to that seen in METEOR. Trial Registration: Clinicaltrials.gov identifier: NCT00225589.     

Prognostic role of the glucometabolic status assessed in a metabolically stable phase after a first acute myocardial infarction: the SHEEP study

Objectives. Our objective was to examine fasting glucose and insulin levels in patients surviving 3 months after a first AMI in relation to long‐term prognosis. Design. A total of 1167 consecutive patients between 45 and 70 years with a first nonfatal AMI underwent a standardized clinical examination and were followed for a mean of 8 years for total and cardiac mortality and hospitalization for nonfatal cardiovascular disease. Impaired fasting glucose (IFG) was defined as fasting glucose between 5.6 and 7 mmol L^?1 and a level ≥7 mmol L^?1 as newly detected diabetes. Patients with a fasting glucose level <5.6 mmol L^?1 and without a history of diabetes were classified as normoglycemic (NG). An estimate of insulin resistance was calculated using the homeostasis model assessment (HOMA). Results. We recorded 219 deaths, 121 deaths from cardiac causes, during the follow‐up period. After adjustment for several potential confounders, hazard ratios for total mortality were 1.36 (95% confidence interval 0.93–1.99, P = 0.11), 2.27 (1.26–4.09, P = 0.006) and 2.15 (1.43–3.21, P < 0.001) for patients with IFG, newly detected diabetes and history of diabetes when compared to the NG group. Cardiac mortality, risk of hospitalization for recurrent nonfatal AMI, stroke or heart failure generally showed a similar pattern to that of total mortality. Insulin level and HOMA values were also associated with increased risk for recurrent events. Conclusions. We confirmed that both known and newly detected diabetes is a strong prognostic factor in AMI. In addition, our findings suggest that glucose levels below the diabetes cut off value might also predict poor long‐term prognosis when assessed in a metabolically stable phase.     

Glomerular filtration rate and parathyroid hormone are associated with 1,25-dihydroxyvitamin D in men without chronic kidney disease

Abstract. Karhapää P, Pihlajamäki J, Pörsti I, Kastarinen M, Mustonen J, Niemelä O, Tuomi H, Kuusisto J (University of Eastern Finland, Kuopio; University of Tampere, Tampere; Finnish Medical Agency, Kuopio; and University of Tampere, Tampere, Finland). Glomerular filtration rate and parathyroid hormone are associated with 1,25‐dihydroxyvitamin D in men without chronic kidney disease. J Intern Med 2012; 271 : 573–580. Background and aim. Vitamin D, estimated glomerular filtration rate (eGFR) and parathyroid hormone (PTH) are related to cardiovascular disease risk. We examined the associations between the levels of 25‐hydroxyvitamin D (25‐D) and 1,25‐dihydroxyvitamin D (1,25‐D) and both eGFR and PTH. Design and setting. Cross‐sectional population‐based study in Kuopio, Eastern Finland. Subjects. A total of 909 men without known chronic kidney disease (CKD) and not receiving antidiabetic medication, aged from 45 to 73 years, were included in the study. Main outcome measures. Fasting levels of 25‐D, 1,25‐D, creatinine and PTH were measured, and an oral glucose tolerance test (OGTT) was performed. Results. High levels of 25‐D were associated with low levels of eGFR and PTH (β = ?0.17, P = 9 × 10^?7 and β = ?0.28, P = 6 × 10^?17, respectively, adjusted for age, body mass index and levels of calcium, phosphorus and glucose in a 2‐h OGTT, and also for either eGFR or PTH). By contrast, high 1,25‐D levels were associated with high levels of eGFR and PTH (β = 0.17, P = 2 × 10^?6 and β = 0.19, P = 5 × 10^?8, respectively, adjusted as mentioned earlier and additionally for 25‐D). Eighteen per cent of men in the highest 25‐D quartile were in the lowest 1,25‐D quartile and also had a lower eGFR than men with high levels of both 25‐D and 1,25‐D (P = 4 × 10^?5). Finally, 15% of men in the lowest 25‐D quartile were in the highest 1,25‐D quartile and also had higher PTH levels than men with low levels of both 25‐D and 1,25‐D (P = 2 × 10^?3). Conclusion. Our findings suggest that both eGFR and PTH are significantly associated with vitamin D metabolism in men without known CKD.     

The clinical course of renal function in NIDDM patients with normo- and microalbuminuria

Objectives. To assess the clinical course of renal function in relation to risk factors in NIDDM patients with normo- and microalbuminuria. Design. Prospective clinical study. Setting. Outpatient diabetic clinic. Subjects. Thirty-two NIDDM patients with normo- or microalbuminuria followed for (mean (range)) 5.5 (3.3–7.5) years. Main outcome measures. Glomerular filtration rate, urinary albumin excretion rate, blood pressure, lipids, glycaemic control. Results. The mean rate of decline of glomerular filtration rate was ?1.2±2.3 (mean±SD) (95% confidence intervals: ?2.0–?0.3) mL min^?1 1.73 m^?2 year^?1 (p=0.009). A considerable interindividual variation was observed (range ?6.7 to +3.4 mL  min^?1 1.73 m^?2 year^?1). No difference was found between normo- and microalbuminuric patients (?1.2±0.5 vs. ?1.0±0.7 mL min^?1 1.73 m^?2 year^?1) or between patients with and without antihypertensive treatment (?1.7±0.7 vs. ?0.7±0.4  mL min^?1 1.73 m^?2 year^?1). By multiple linear regression analysis the fall rate of glomerular filtration was determined by the mean glomerular filtration rate level (p=0.036). Analysis of patients without antihypertensive treatment revealed that urinary albumin excretion rate and HbA_1c levels significantly determined the fall rate of glomerular filtration (P<0.001 and=0.014). Conclusions. The average decline in renal function of these normo- and microalbuminuric NIDDM patients was not increased as compared to the age related fall rate of healthy subjects but varied markedly. Low glomerular filtration rate is associated with a higher fall rate. In patients without antihypertensive treatment higher urinary albumin excretion rate, and poorer glycaemic control are factors associated with an increased fall rate of glomerular filtration.     

Cardiovascular screening with electrocardiography and echocardiography in collegiate athletes

Background

Current guidelines for preparticipation screening of competitive athletes in the US include a comprehensive history and physical examination. The objective of this study was to determine the incremental value of electrocardiography and echocardiography added to a screening program consisting of history and physical examination in college athletes.

Methods

Competitive collegiate athletes at a single university underwent prospective collection of medical history, physical examination, 12-lead electrocardiography, and 2-dimensional echocardiography. Electrocardiograms (ECGs) were classified as normal, mildly abnormal, or distinctly abnormal according to previously published criteria. Eligibility for competition was determined using criteria from the 36^th Bethesda Conference on Eligibility Recommendations for Competitive Athletes with Cardiovascular Abnormalities.

Results

In 964 consecutive athletes, ECGs were classified as abnormal in 334 (35%), of which 95 (10%) were distinctly abnormal. Distinct ECG abnormalities were more common in men than women (15% vs 6%, P < .001) as well as black compared with white athletes (18% vs 8%, P < .001). Echocardiographic and electrocardiographic findings initially resulted in exclusion of 9 athletes from competition, including 1 for long QT syndrome and 1 for aortic root dilatation; 7 athletes with Wolff-Parkinson-White patterns were ultimately cleared for participation. (Four received further evaluation and treatment, and 3 were determined to not need treatment.) After multivariable adjustment, black race was a statistically significant predictor of distinctly abnormal ECGs (relative risk 1.82, 95% confidence interval, 1.22-2.73; P = .01).

Conclusions

Distinctly abnormal ECGs were found in 10% of athletes and were most common in black men. Noninvasive screening using both electrocardiography and echocardiography resulted in identification of 9 athletes with important cardiovascular conditions, 2 of whom were excluded from competition. These findings offer a framework for performing preparticipation screening for competitive collegiate athletes.     

Prevalence and prognostic significance of ECG abnormalities in HIV-infected patients: results from the Strategies for Management of Antiretroviral Therapy study

Background

It remains debated whether to include resting electrocardiogram (ECG) in the routine care of human immunodeficiency virus (HIV)–infected patients.

Methods

This analysis included 4518 HIV-infected patients (28% women and 29% blacks) from the Strategies for Management of Antiretroviral Therapy study, a clinical trial aimed to compare 2 HIV treatment strategies. ECG abnormalities were classified using the Minnesota Code. Cox proportional hazards analysis was used to examine the association between baseline ECG abnormalities and incident cardiovascular disease (CVD).

Results

More than half of the participants (n = 2325, or 51.5%) had either minor or major ECG abnormalities. Minor ECG abnormalities (48.6%) were more common than major ECG abnormalities (7.7%). During a median follow-up of 28.7 months, 155 participants (3.4%) developed incident CVD. After adjusting for the study-treatment arms, the presence of major, minor, and either minor or major ECG abnormalities was significantly predictive of incident CVD (hazard ratio [95% confidence interval]: 2.76 [1.74-4.39], P < .001; 1.58 [1.14-2.20], P = .006; 1.57 [1.14-2.18], P = .006, respectively). However, after adjusting for demographics, CVD risk factors, and HIV characteristics (full model), presence of major ECG abnormalities were still significantly predictive of CVD (1.83 [1.12-2.97], P = .015) but not minor or major abnormalities taken together (1.26 [0.89-1.79], P = .18; 1.25 [0.89-1.76], P = .20, respectively). Individual ECG abnormalities that significantly predicted CVD in the fully adjusted model included major isolated ST-T abnormalities, major prolongation of QT interval, minor isolated ST-T, and minor isolated Q-QS abnormalities.

Conclusion

Nearly 1 in 2 of the HIV-infected patients in our study had ECG abnormalities; 1 in 13 had major ECG abnormalities. Presence of ECG abnormalities, especially major ECG abnormalities, was independently predictive of incident CVD. These results suggest that the ECG could provide a convenient risk-screening tool in HIV-infected patients.     

Common candidate gene variants are associated with QT interval duration in the general population

Objectives. QT interval prolongation is associated with increased risk of sudden cardiac death at the population level. As 30–40% of the QT‐interval variability is heritable, we tested the association of common LQTS and NOS1AP gene variants with QT interval in a Finnish population‐based sample. Methods. We genotyped 12 common LQTS and NOS1AP genetic variants in Health 2000, an epidemiological sample of 5043 Finnish individuals, using Sequenom MALDI‐TOF mass spectrometry. ECG parameters were measured from digital 12‐lead ECGs and QT intervals were adjusted for age, gender and heart rate with a nomogram (Nc) method derived from the present study population. Results. The KCNE1 D85N minor allele (frequency 1.4%) was associated with a 10.5 ms (SE 1.6) or 0.57 SD prolongation of the adjusted QT_Nc interval (P = 3.6 × 10^?11) in gender‐pooled analysis. In agreement with previous studies, we replicated the association with QT_Nc interval with minor alleles of KCNH2 intronic SNP rs3807375 [1.6 ms (SE 0.4) or 0.08 SD, P = 4.7 × 10^?5], KCNH2 K897T [?2.6 ms (SE 0.5) or ?0.14 SD, P = 2.1 × 10^?7] and NOSA1P variants including rs2880058 [4.0 ms (SE 0.4) or 0.22 SD, P = 3.2 × 10^?24] under additive models. Conclusions. We demonstrate that each additional copy of the KCNE1 D85N minor allele is associated with a considerable 10.5 ms prolongation of the age‐, gender‐ and heart rate‐adjusted QT interval and could thus modulate repolarization‐related arrhythmia susceptibility at the population level. In addition, we robustly confirm the previous findings that three independent KCNH2 and NOSA1P variants are associated with adjusted QT interval.     

Review of Emergency Department thrombolytic therapy and changes in inpatient mortality of acute myocardial infarction on the NSW Central Coast 1986 to 1994–96

Aims: To examine changes in inpatient mortality of acute myocardial infarction (AMI) from 1986 to 1994–96 and to review the Emergency Department (ED) use of thrombolytic therapy (TT) for AMI on the NSW Central Coast. Method: A retrospective review of medical records of patients presenting to the EDs of Gosford and Wyong Hospitals with a discharge diagnosis of AMI (ICD9 code 410.x) from 1 January 1986 to 31 December 1986 and 1 January 1994 to 31 December 1996. Data were collected on patients' age, sex, duration of symptoms on arrival at the ED, ECG changes and presence of positive ECG criteria for thrombolysis, agent used, contraindications to TT, and inpatient mortality. The main measure of outcome was inpatient mortality. Results: There were 423 admissions for AMI in 1986 and 1220 admissions in 1994–96. The overall inpatient mortality has declined from 18.9% in 1986 to 9% in 1994–96 (p<0.0001). The mean age of patients has increased from 67.5 years to 68.1 years (p=0.35). The proportion of patients over age 75 years has increased significantly from 24.6% to 30.3% (p<0.0001). Presentation times from onset of symptoms have not changed significantly from a median time of two hours in 1986 to 2.5 hours in 1994 to 1996 (p=0.52). The overall proportion of patients with ECG criteria for TT was 53.2% in 1994–96. TT was administered to 42.9% of patients with a mean door to needle time of 67 minutes (median 45 minutes). The Australasian College for Emergency Medicine benchmark door to needle time of 60 minutes was achieved in 71.3% of patients. Streptokinase was the predominant agent given in 78%, while recombinant tissue plasminogen activator accounted for 15.7% of patients. Patients not receiving TT due to negative ECG criteria showed a decline in mortality from 18.6% to 6.7% (p<0.0001). Patients who underwent mechanical revascularisation (by bypass graft or angioplasty) increased from 8.7% to 17.4% (p<0.0001). Inpatient mortality has declined for all age groups, for both sexes, and for all sites of AMI. Conclusion: There have been significant declines in inpatient mortality of patients with AMI on the Central Coast. TT has had a significant impact on this decline but has an eligibility rate of less than half. Significant declines in mortality have also been seen in patients ineligible for thrombolysis. These patients have benefited from other therapies introduced or more widely used in the last decade. The results achieved on the Central Coast compare favourably with published reviews in Australia and overseas despite the lack of facilities for coronary angiography, coronary angioplasty and cardiothoracic surgery.     

Serum cholesterol concentration before and after streptokinase in acute myocardial infarction

Abstract. Objective. To determine if serum cholesterol concentration should be measured before or after streptokinase therapy within the first 24 h of myocardial infarction. Design. Prospective study of patients receiving streptokinase therapy for acute myocardial infarction (AMI). Setting. Coronary care unit of a district general hospital. Subjects. Thirty-one patients (26 men aged 38–74 years, mean 60 years) admitted with a definite diagnosis of myocardial infarction. Intervention. Streptokinase therapy given intravenously at a mean of 5 h (range 1.5–15 h) after the onset of chest pain. Main outcome measures. Serum cholesterol concentration just prior to, and 11.5 h (range 4–20.5 h) after streptokinase administration. Results. There was a significant mean fall of 0.4 mmol l^?1 (P = 0.002, 95% CI = 0.2–0.6) in serum cholesterol concentration from a pre-streptokinase concentration of 7.0 (range 5.3–9.9) to a post-streptokinase concentration of 6.6 (range 4.9–9.9). In the patients who showed a fall in cholesterol concentration, the magnitude of fall correlated with the baseline cholesterol concentration (r = 0.66, P < 0.01) but not with peak cardiac enzyme activities (r = 0.05, P > 0.2 for aspartate aminotransferase; r = 0.10, P > 0.2 for lactate dehydrogenase), time from onset of chest pain to post-streptokinase measurement (r = 0.27, P > 0.2) or time from streptokinase administration to post-streptokinase measurement (r = 0.01, P > 0.2). Conclusion. Serum cholesterol concentration may be underestimated when measured after streptokinase therapy, particularly when the true basal value is high. Further management of this risk factor may be based more accurately on its measurement before than after streptokinase therapy within the first 24 h of AMI.     

Comparative analysis of cardiac troponin i and creatine kinase-MB as markers of acute myocardial infarction

Background: The World Health Organization (WHO) criteria for the diagnosis of acute myocardial infarction (AMI) includes presentation of chest pain over 20 min, evolutionary changes on the electrocardiogram (ECG), and abnormal levels of cardiac enzymes. Hypothesis: A multicenter study was conducted to evaluate the efficacy of cardiac troponin I (cTnI) in detecting and ruling out AMI. Methods: The normal range for cTnI in 149 apparently healthy subjects without known history of cardiac or other diseases was 0 to 0.5 ng/ml. Cutoffs of 2.5 ng/ml for cTnI and 5.0 ng/ml for creatine kinase-MB (CK-MB) were used. Results: The diagnostic sensitivity of blood collected from 291 consecutive patients with suspicion of AMI was 95.0 and 96.4%, respectively, for samples obtained at 4–48 h after AMI onset. CK-MB was more sensitive during the early 4–8 h interval (84 vs. 74%); both had 100% sensitivity from 12–36 h. CTnI remained at 100% for 72 h, while CK-MB declined to 57%. The clinical specificity was 97.4 vs. 85.8%, respectively, on non-AMI patients with cardiac and noncardiac diseases, and those with renal disease. Conclusion: cTnI is an excellent marker for detecting and ruling out AMI, because it has better specificity and a wider diagnostic window than the accepted standard, CK-MB.     

Electrocardiographic features differentiating dilated cardiomyopathy from hypertrophic cardiomyopathy

To determine the usefulness of electrocardiographic (ECG) features in differentiating between hypertrophic cardiomyopathy with features mimicking dilated cardiomyopathy (D-HCM) and true dilated cardiomyopathy (DCM), we compared ECGs of 52 consecutive patients (11 with D-HCM, 41 with DCM). Left atrial dimension, left ventricular internal dimension, and septal and posterior wall thickness were employed as echocardiographic indexes, while QRS duration, amplitude of RV₅ or V₆ + SV₁, number of abnormal Q waves, P-terminal force in V₁, and frontal plane QRS axis were used as ECG parameters. The patients with D-HCM demonstrated a larger number of abnormal Q waves (P < .0001), greater prolongation of QRS duration (P < .0001), and lower amplitude of RV₅ or V₆ + SV₁ (P < .0001). In all cases of D-HCM, atrial overload was observed and abnormal QRS axis in 9 (82%) of the 11 patients. These features were noted in 21 (51%) and 17 (41%), respectively, of the 41 DCM patients (P < .005 and P < .05, respectively). Despite significant differences in the echocardiographic parameters between D-HCM and DCM, excluding left ventricular end-diastolic dimension, ECG abnormalities were more significant between the two groups. The results indicate that ECG features are extremely useful in differentiation between DCM and D-HCM.     

ST-segment depression in lead aVR: a useful predictor of impaired myocardial reperfusion in patients with inferior acute myocardial infarction

STUDY OBJECTIVE: During inferior acute myocardial infarction (AMI), the ECG lead aVR is frequently ignored, and therefore its clinical significance remains unclear. We examined the relation between ST-segment deviation seen in lead aVR on ECGs obtained at hospital admission and myocardial reperfusion in patients who have experienced recanalized inferior AMIs. DESIGN AND SETTING: Retrospective study. PATIENTS: A total of 225 patients with inferior AMIs in whom Thrombolysis in Myocardial Infarction grade 3 flow was achieved within 6 h after symptom onset. MEASUREMENTS AND RESULTS: Patients were classified as follows according to ST-segment deviation in lead aVR on an ECG obtained at hospital admission: group A, 103 patients with no ST-segment depression; group B, 80 patients with ST-segment depression of < or = 1.0 mm; and group C, 42 patients with ST-segment depression of > 1.0 mm. There were no differences in time from symptom onset to hospital admission or in the culprit lesion among the three groups. The degree of ST-segment elevation in leads II, III, aVF, V5, or V6, the degree of ST-segment depression in leads V1 to V4, and the sum of ST-segment deviation in these leads were lowest in group A and highest in group C. In groups A, B, and C, the incidence of impaired myocardial reperfusion, defined as myocardial blush grade 0/1, was 2%, 23%, and 67%, respectively (p < 0.001). The sensitivity and negative predictive values of ST-segment depression in lead aVR for impaired myocardial reperfusion were higher than those based on other ECG variables. Multivariate analysis showed that the degree of ST-segment depression in lead aVR was an independent predictor of impaired myocardial reperfusion (odds ratio 8.41; 95% confidence interval, 2.96 to 23.9; p < 0.001). CONCLUSIONS: We conclude that the degree of ST-segment depression in lead aVR is a useful predictor of impaired myocardial reperfusion in patients who have experienced inferior AMIs.     

Intracoronary ST segment evolution during primary coronary stenting predicts infarct zone recovery

In patients with acute myocardial infarction (AMI), early ST segment elevation resolution on ECG predicts myocardial reperfusion and LV recovery. Intracoronary ECG is more sensitive than surface ECG to detect regional ischemia. In patients undergoing primary percutaneous coronary intervention (PCI), we investigated if failed myocardial reperfusion, despite successful infarct vessel recanalization, could be rapidly and easily identified by intracoronary ST segment monitoring from guidewire recording. We recorded intracoronary and standard ECG during primary coronary stenting (PCI) in 50 patients with AMI (59 ± 11 years; anterior AMI in 66%). All patients had a successful PCI and underwent 2D echocardiography soon after PCI and 6 months later. Following PCI, intracoronary ST resolution ≥ 50% from baseline was documented in 39 patients (78%; group A; from 11 ± 8 to 1 ± 2 mm) but not in 11 (22%; group B; from 11 ± 8 to 8 ± 5 mm). Group A had slightly shorter ischemic time (202 ± 94 vs. 238 ± 112 min in B; P = 0.2) and smaller peak CK values (2,752 ± 2,038 vs. 4,802 ± 3,671 U/L in B; P = 0.02). After PCI, ST resolution was found on standard ECG in 34 (87%) group A and in 3 (27%) group B patients. At 6‐month follow‐up, left ventricular ejection fraction was greater in group A (47% ± 8% vs. 39% ± 8% in B; P < 0.001) with improved wall motion score index (from 2.2 ± 0.3 to 1.7 ± 0.3 in A; from 2.3 ± 0.4 to 2.1 ± 0.4 in B; P < 0.001). There were no significant differences between intracoronary and standard ECG for sensitivity (92% vs. 86%) and specificity (62% vs. 57%) to predict improved infarct zone recovery after 6 months. ST elevation resolution on intracoronary recording during PCI predicts infarct zone recovery. Monitoring ST segment evolution by intracoronary ECG allows prompt and inexpensive identification in the catheterization laboratory of those patients without myocardial reperfusion, who may require adjunctive therapeutic interventions after successful infarct vessel recanalization. Catheter Cardiovasc Interv 2005;64:53–60. © 2004 Wiley‐Liss, Inc.     

Trends in Acute Myocardial Infarction in Young Patients and Differences by Sex and Race, 2001 to 2010

Background

Various national campaigns launched in recent years have focused on young women with acute myocardial infarctions (AMIs). Contemporary longitudinal data about sex differences in clinical characteristics, hospitalization rates, length of stay (LOS), and mortality have not been examined.

Objectives

This study sought to determine sex differences in clinical characteristics, hospitalization rates, LOS, and in-hospital mortality by age group and race among young patients with AMIs using a large national dataset of U.S. hospital discharges.

Methods

Using the National Inpatient Sample, clinical characteristics, AMI hospitalization rates, LOS, and in-hospital mortality were compared for patients with AMI across ages 30 to 54 years, dividing them into 5-year subgroups from 2001 to 2010, using survey data analysis techniques.

Results

A total of 230,684 hospitalizations were identified with principal discharge diagnoses of AMI in 30- to 54-year-old patients from Nationwide Inpatient Sample data, representing an estimated 1,129,949 hospitalizations in the United States from 2001 to 2010. No statistically significant declines in AMI hospitalization rates were observed in the age groups <55 years or stratified by sex. Prevalence of comorbidities was higher in women and increased among both sexes through the study period. Women had longer LOS and higher in-hospital mortality than men across all age groups. However, observed in-hospital mortality declined significantly for women from 2001 to 2010 (from 3.3% to 2.3%, relative change 30.5%; p for trend < 0.0001) but not for men (from 2% to 1.8%, relative change 8.6%; p for trend = 0.60).

Conclusions

AMI hospitalization rates for young people have not declined over the past decade. Young women with AMIs have more comorbidity, longer LOS, and higher in-hospital mortality than young men, although their mortality rates are decreasing.     

The Arctic Oscillation and incidence of acute myocardial infarction

Abstract. Messner T, Lundberg V, Wikström B (Kiruna District Hospital, Kiruna; Umeå University Hospital, Umeå; and Kalix District Hospital, Kalix; Sweden). The Arctic Oscillation and incidence of acute myocardial infarction. J Intern Med 2003; 253: 666–670. Objectives. To describe the relation between the Arctic Oscillation (AO) index and the incidence and mortality in acute myocardial infarction (AMI) in the northern, partly subarctic area of Sweden. Design. Comparison of a time series of daily variations in the AO index and register data on the daily number of fatal and nonfatal AMIs. Setting. The northernmost two Swedish counties, Norrbotten and Västerbotten. Subjects. All inhabitants in the Norrbotten and Västerbotten counties were followed for the occurrence of an AMI between 1985 and 1999 within the framework of the WHO MONICA (multinational MONItoring of trends and determinants of CArdiovascular disease) Project. Main outcome measure. Fatal and nonfatal AMIs. Results. There was a consistent positive relation between increasing AO index and an increase in AMI incidence and mortality. The maximum impact on AMI incidence of the AO came after a lag phase of 3 days. A one unit increase in AO index was associated with an increase in: the daily number of AMIs (+3.8%), the case fatality in AMI within 28 days (+5.1%), the number of nonfatal AMIs (+3.4%), and the number of sudden cardiac deaths (+8.3%). Conclusions. An AO index increase, bringing warmer weather over Scandinavia, was associated with an increase in the incidence and mortality in AMI in northern Sweden.     

Effect of intermediate- and high-purity factor VIII concentrates on immune function in HIV-seropositive haemophiliacs as assessed by quantitative CD 4 counts

Intermediate-purity factor VIII (FVIII) concentrates are believed to adversely influence cellular immune function and accelerate HIV progression in haemophiliac patients. There are reports that cellular immunity, as measured by serial CD4 lymphocyte counts, is better preserved in HIV-infected haemophiliacs who receive high-purity concentrates compared with those receiving intermediate- or low-purity products. We retrospectively evaluated the rate of CD4 cell count decrease in 44 asymptomatic HIV-seropositive severe haemophilia A patients whose purity of prescribed FVIII concentrate was primarily determined by State of residence. Prior to January 1989 all study subjects received treatment with intermediate- or low-purity products. In January 1989 the patients from Mississippi (n = 15) began to exclusively receive a high-purity, monoclonal antibody purified, plasma-derived product from their State Department of Health. The Mississippi cohort was subsequently converted to a high-purity, recombinant FVIII product in May 1993. Patients from Tennessee and Arkansas (n = 29) received intermediate-purity factor during the entire analysis period. Patients were monitored for an average of 68 months with an average of 11 CD4 cell count measurements. The rate of CD4 cell count decrease was derived from the calculated slope of a simple regression in order to account for large individual CD4 count fluctuations during the study period. There was no statistically significant difference in starting CD4 cell count between the 2 study groups. The rate of CD4 cell count decrease was 21.8 ± 52.9 cells μL^?1 year^?1 and 17.0 ± 32.6 cells μL^?1 year^?1 in the high-purity FVIII group and inter-mediate-purity FVIII group, respectively (P = 0.83). The difference in rate of CD4:CD8 ratio decrease between the two groups was also not statistically significant (P = 0.41). These data suggest that the use of the more costly, high-purity monoclonal antibody purified and recombinant FVIII concentrates does not influence the rate of decrease in CD4 cell count in HIV-seropositive haemophiliacs compared with concentrates of lower specific activity obtained using standard chromatographic techniques.     

Myocardial infarction in patients with acute cerebrovascular disease

The occurrence of acute myocardial infarction (AMI) was assessedby ECG and serum enzymes in 209 unselected patients with acutecerebrovascular disease (CVD), and in 209 sex and age-matchedcontrol patients during the first three hospital days. Enzymecurves suggestive of AMI were seen in 13 of the CVD patientsand in three of the controls. Requirements for a definite diagnosisof AMI was only met by one of the CVD patients. At autopsy, performed in 34 of the 37 deceased CVD patients,myocardial infarcts of various age were seen in 27 patients(79%). In about one-quarter, the myocardial infarction had occurredat approximately the same time as the stroke. In the controls,four out of five deceased patients were autopsied and two hadsigns of myocardial infarction. It is concluded that AMIs are common in patients with acuteCVD and despite conventional diagnostic procedures they oftenpass undiscovered.     

Electrocardiographic findings in cardiogenic shock, risk prediction, and the effects of emergency revascularization: results from the SHOCK trial

Objectives

To evaluate electrocardiographic (ECG) parameters as predictors of 1-year mortality in patients developing cardiogenic shock after acute myocardial infarction (AMI), and to document associations between these ECG parameters and the survival benefit of emergency revascularization versus initial medical stabilization.

Background

Emergency revascularization reduces the risk of mortality in patients developing cardiogenic shock after AMI. The prognostic value of ECG parameters in such patients is unclear, and it is uncertain whether emergency revascularization reduces the mortality risk denoted by ECG parameters.

Methods

In a prospective substudy of 198 SHOCK (SHould we emergently revascularize Occluded Coronaries for cardiogenic shocK) trial patients, ECGs recorded within 12 hours of shock were interpreted by personnel blinded to the patients' treatment assignment and outcome.

Results

The baseline heart rate was higher in non-survivors than in survivors (106 ± 20 versus 95 ± 24 beats/minute, P = .001). There was a significant association between the QRS duration and 1-year mortality in medically stabilized patients (115 ± 28 ms in non-survivors versus 99 ± 23 ms in survivors, P = .012), but not in emergently revascularized patients (110 ± 31 versus 116 ± 27 ms respectively, P = .343). The interaction between the QRS duration, mortality and treatment assignment was significant (P = .009). Among patients with inferior AMI, a greater sum of ST depression was associated with higher 1-year mortality in medically stabilized patients (P = .029), but not in emergently revascularized patients (P = .613, treatment interaction P = .025). On multivariate analysis, the independent mortality predictors were increasing age, elevated pulmonary capillary wedge pressure, heart rate, sum of ST depression in medically stabilized patients, and interaction (P = .016) between a prolonged QRS duration and treatment assignment. The adjusted hazard ratio for 1-year mortality per 20 ms increase in the QRS duration was 1.19 (95% CI 0.98-1.46) in medically stabilized patients and 0.81 (95% CI 0.63-1.03) in emergently revascularized patients.

Conclusion

ECG parameters identified patients with cardiogenic shock who were at high risk. Emergency revascularization eliminated the incremental mortality risk associated with cardiogenic shock in patients with a prolonged QRS duration, or inferior AMI accompanied by precordial ST depression. Prospective assessments of the magnitude of the treatment effect based on ECG parameters are required.