Predictors of death during 10 years after coronary artery bypass grafting with particular emphasis on age

OBJECTIVES: To describe predictors of death during 10 years of follow-up after coronary artery bypass grafting (CABG); to evaluate whether age interacts with the influence of various predictors on outcome; and to compare the mortality during 10 years after CABG with the mortality in an age- and sex-matched control population. DESIGN: Prospective, observational study. SETTING: Department of Thoracic and Cardiovascular Surgery at Sahlgrenska University Hospital and Scandinavian Heart Centre in G?teborg, Sweden. PARTICIPANTS: All patients from western Sweden who underwent CABG between 1 June 1988 and 1 June 1991 without simultaneous valve surgery and with no previous CABG. MAIN OUTCOME MEASUREMENTS: All-cause mortality during 10 years but more than 30 days after CABG. RESULTS: In all, 2000 patients participated in the survey. The following factors appeared as independent predictors of death: preoperative factors-age, history of congestive heart failure, cerebrovascular disease, history of intermittent claudication, current smoking, degree of left ventricular impairment, valvular disease and duration of angina pectoris; peroperative factors-ventilator time and neurological complications; postoperative factors-arrhythmia, requirement of digitalis and requirement of antidiabetics. There was an interaction between age and history of cerebrovascular disease with a stronger impact on outcome in younger patients. The late (>30 days after CABG) 10-year mortality in the study cohort was 29.6% compared with 25.9% in the control population (P=0.02). CONCLUSION: Among patients who underwent CABG, 13 independent predictors for mortality were found, mainly among preoperative factors but also among peroperative factors, postoperative complications and medication requirement after CABG.     

Effect of a media campaign to reduce delay times for acute myocardial infarction on the burden of chest pain patients in the emergency department

We evaluated the effect of a media campaign aimed at reducing delay times in suspected acute myocardial infarction (AMI) on the volume of chest pain patients seen in the emergency department. During the 1st week of the campaign, the mean number of chest pain patients increased from 10.5 per day prior to the start to 25.4. However, the number declined rapidly in subsequent months. The greatest increase was observed in patients with chest pain in whom AMI was not suspected on examination. During the campaign, 4,805 patients with chest pain appeared in the emergency department as compared with 4,407 patients during the same time period prior to its start, an increase of 9%. The number of patients with confirmed AMI increased from 595 to 629 (6%).     

Influence of gender on survival,mode of death,reinfarction, use of medication,and aspects of well being during a period of five years after onset of acute myocardial infarction

Background and hypothesis: This study was undertaken to describe prognosis during a period of 5 years after an acute myocardial infarction (AMI) in relation to gender. Methods: All patients studied were hospitalized in a single hospital during a period of 21 months due to AMI, regardless of age and whether they were admitted to the coronary care unit or another ward. A total of 862 AMI patients [581 (67%) men and 281 (33%) women] were prospectively evaluated. Males were younger and less frequently had a history of congestive heart failure and hypertension. Results: The overall 5-year mortality rate was 48% among men compared with 61 % among women (p < 0.001). However, in a multivariate analysis considering age, gender, and a previous history of cardiovascular diseases, female gender was not independently associated with death. Revascularization in terms of coronary artery bypass grafting and percutaneous transluminal angioplasty did not differ significantly between men and women. The rate of reinfarction was 34% among men and 38% among women (p > 0.2). Conclusion: During 5 years of follow-up in a consecutive series of 862 AMI patients, women had a worse prognosis than men, with a mortality of 61 % compared with 48% (p < 0.001). However, after controlling for a number of potentially confounding prognostic factors, female gender was not independently associated with mortality.     

Effect of new versus known versus no atrial fibrillation on 30-day and 10-year mortality in patients with acute coronary syndrome

Coronary artery disease promotes the development of atrial fibrillation (AF). The aim of this study was to determine short- and long-term mortality in patients with acute coronary syndromes (ACS) and AF, depending on the AF presentation. A total of 2,335 consecutive patients with ACS were included. AF was classified as known persistent or permanent AF, known paroxysmal AF, new AF at admission, and new AF during hospitalization for ACS. Four hundred forty-two patients had any AF: 54 with known persistent or permanent AF, 150 with known paroxysmal AF, 54 with new AF at admission, and 184 with new AF during hospitalization. Statistically significant differences among subgroups related to previous heart failure (p <0.0001), stroke (p = 0.04), myocardial infarction (p <0.0001), angina pectoris (p <0.0001), hypercholesterolemia (p = 0.007), coronary artery bypass grafting (p <0.0001), and percutaneous coronary intervention (p = 0.03) were observed. Thirty-day mortality differed among the subgroups (p = 0.02) and was lowest in patients with known paroxysmal AF (7.3%). Ten-year mortality ranged from 53% to 78% among the subgroups. There were 5 predictors of long-term mortality across the subgroups: age (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.04 to 1.09, p <0.0001), previous myocardial infarction (HR 1.4, 95% CI 1.0 to 1.8, p = 0.04), heart failure (HR 1.8, 95% CI 1.3 to 2.4, p = 0.0002), diabetes (HR 1.7, 95% CI 1.2 to 2.2, p = 0.0005), and smoking (HR 1.7, 95% CI 1.2 to 2.3, p = 0.001). In conclusion, patient characteristics and 30-day mortality differed significantly among the subgroups, but long-term mortality did not. Any AF associated with ACS almost doubled the long-term mortality risk. AF in patients with ACS should therefore be regarded as an important risk factor irrespective of its presentation.     

Serum homocysteine concentration as an indicator of survival in patients with acute coronary syndromes

BACKGROUND: Circulating homocysteine levels are predictive of survival in patients with stable coronary artery disease. The prognostic value of serum homocysteine levels, obtained in the acute phase in patients with myocardial infarction or unstable angina, is unknown. OBJECTIVES: To test the hypothesis that circulating homocysteine levels, obtained during the first 24 hours following hospital admission in patients with acute coronary syndromes, are predictive of long-term mortality. METHODS: To test this hypothesis we performed a prospective inception cohort study at a teaching hospital in Gothenburg, Sweden. A total of 579 patients (179 women and 400 men; median age, 67 years) were included (Q-wave myocardial infarction in 163 patients, non-Q-wave myocardial infarction in 210 patients, unstable angina pectoris in 206 patients). Main Outcome Measure: All-cause mortality. RESULTS: During a median follow-up of 628 days, 65 patients died. The serum homocysteine level (mean [SD]) was significantly lower in long-term survivors (n = 514) than in nonsurvivors (n=65) (12.3 [7.0] vs 14.3 [5.9] pmol/L; P=.003). The relative risk (all-cause mortality) for patients with homocysteine levels in the upper quartile was 2.4 (95% confidence interval, 1.5-4.0) compared with that of patients in the 3 lower quartiles. After adjustment for relevant confounders, the relative risk estimate remained significant (relative risk= 1.69; 95% confidence interval, 1.02-2.80). In a stepwise model the homocysteine level provided prognostic information additional to that of patient age, diabetes mellitus, and diuretic usage prior to hospital admission (P=.03). CONCLUSION: The serum homocysteine level on hospital admission is an independent predictor of long-term survival in patients with acute coronary syndromes.     

Determinants for an impaired quality of life 10 years after coronary artery bypass surgery

OBJECTIVE: To identify determinants of an inferior quality of life (QoL) 10 years after coronary artery bypass grafting (CABG). SETTING: Sahlgrenska University Hospital, G?teborg, Sweden. PARTICIPANTS: All patients from Western Sweden who underwent CABG between 1988 and 1991 without simultaneous valve surgery and no previous CABG. MAIN OUTCOME MEASURES: Questionnaires for evaluating QoL 10 years after the operation. Three different instruments were used: The Nottingham health profile (NHP), the psychological general wellbeing index (PGWI), and the Physical Activity Score (PAS). RESULTS: 2000 patients underwent CABG, of whom 633 died during 10 years of follow-up. Information on QoL at 10 years was available in 976 patients (71% of survivors). A history of diabetes and chronic obstructive pulmonary disease were the two independent predictors for an inferior QoL with all three instruments. Furthermore, there were three predictors of an inferior QoL with two of the instruments: high age, female sex and a history of hypertension. A number of factors predicted an inferior QoL with one of the instruments. These were the duration of angina pectoris and functional class prior to CABG, renal dysfunction, a history of cerebrovascular disease, obesity, height, duration of respirator treatment and requirement of inotropic drugs postoperatively. In addition, when introducing preoperative QoL into the model a low QoL before surgery was a strong independent predictor also of an inferior QoL 10 years after CABG. CONCLUSION: Variables independently predictive of an impaired QoL 10 years after CABG, irrespective of the instrument used, were an impaired QoL prior to surgery, chronic obstructive pulmonary disease and a history of diabetes. However, other factors reflecting gender, the previous history as well as postoperative complications were also associated with the QoL 10 years later in at least one of these instruments.     

Transient repolarization alterations dominate the initial phase of an acute anterior infarction — a vectorcardiography study

Objective

To study effects of ischemia-reperfusion on ventricular electrophysiology in humans by three-dimensional electrocardiography.

Methods

Fifty-seven patients with first-time acute anterior ST elevation myocardial infarction were monitored from admission and > 24 h after symptom onset with continuous vectorcardiography (VCG; modified Frank orthogonal leads). Global ventricular depolarization and repolarization (VR) measures were compared at maximum vs. minimum ST vector magnitude (STVM) (median 208; 111–303 vs. 362; 165–1359 min after symptom onset).

Results

At maximum vs. minimum STVM the Tarea (overall VR dispersion) almost tripled (118 vs. 41 μVs; p < 0.0001), the T-loop bulginess was 90% greater (Tavplan 0.91 vs 0.48 μV; p < 0.0001), and Tpeak-end/QT was 39% larger (0.32 vs 0.23; p < 0.0001). QRSarea (overall dispersion of depolarization) was 12% larger at maximum STVM, while QRS duration was 10% longer at minimum STVM.

Conclusions

Ischemia-reperfusion was accompanied by profound and transient alterations of VR dispersion, while changes in depolarization were modest and delayed.     

Protein A is the von Willebrand factor binding protein on Staphylococcus aureus

Endovascular infection is a highly critical complication of invasive Staphylococcus aureus disease. For colonization, staphylococci must first adhere to adhesive endovascular foci. Von Willebrand factor (vWF) is a large, multimeric glycoprotein mediating platelet adhesion at sites of endothelial damage. Earlier it was demonstrated that vWF binds to and promotes the surface adhesion of S. aureus, prompting this effort to identify the vWF adhesin. In Western ligand assays of S. aureus lysates, staphylococcal protein A (SPA) was recognized by purified vWF. Surface plasmon resonance demonstrated the binding of soluble vWF to immobilized recombinant protein A with a K(d) of 1.49 x 10(-8) mol/L. Using flow cytometry, the binding of fluorescein isothiocyanate-labeled vWF to S. aureus was found to be saturable and inhibitable by unlabeled vWF, antiprotein-A antibodies, or IgG. Isogenic Deltaspa::Tc(r) mutants were constructed by the insertion of a tetracycline resistance cassette into spa using allelic replacement, and it exhibited decreased binding of soluble vWF and decreased adhesion to vWF-adsorbed surfaces. The interaction was restored on complementation of the mutants with spa-containing plasmid pSPA7235. In conclusion, protein A confers interaction of S. aureus with soluble and immobilized vWF in a newly discovered function characterizing protein A as a novel member of the staphylococcal surface protein adhesin superfamily and suggesting its potential role in the pathogenesis of endovascular staphylococcal disease.     

International Collaborative Effort (ICE) on birthweight; plurality; and perinatal and infant mortality. I: Methods of data collection and analysis

This paper describes the collection and analysis of data by a group of international collaborators (International Collaborative Effort on Perinatal and Infant Mortality) interested in comparative studies on birthweight distributions and reproductive outcome. This is the first of a series of reports on the results of these studies. It gives an account of the countries or states involved, and the collection and characteristics of the data. The countries and states included sixteen of the United States, plus England and Wales, Denmark, Bavaria and North Rhine-Westphalia from the Federal Republic of Germany, Israel, Japan, Norway, Scotland, and Sweden. The data comprised birthweight distributions in 500-gram groups for all births and for singletons separately, for livebirths, stillbirths, first week deaths and, where available, late neonatal and infant deaths, from 1970 up to 1985.