One year mortality outcomes of all coronary and intensive care unit patients with acute myocardial infarction, unstable angina or other chest pain in Hamilton, Ontario, a city of 375,000 people

Over a one year period (1979 to 1980) all cardiac admissions to the coronary care units (CCU) and all intensive care unit (ICU) overflow admissions in Hamilton, Ontario, a city of approximately 375,000 people, were documented. Mortality status was determined one year following admission. There were 2004 individuals with either acute myocardial infarction (810), unstable angina (811) or other chest pain (783) as their first CCU/ICU admitting diagnosis that year. Mortalities in-hospital and by one year were: acute myocardial infarction 17 and 27%, respectively; unstable angina 1.5 and 9.2%, respectively; and other chest pain 1.4 and 3.1%, respectively. Of one year mortality following acute myocardial infarction, 63% occurred during the initial hospitalization, whereas this figure was 16% for unstable angina. For acute myocardial infarction, female mortality was greater than male mortality overall and in all but one age category. Mortality following acute myocardial infarction and unstable angina was strongly related to age. Repeat CCU/ICU admission occurred in 24% of acute myocardial infarction, 28% of unstable angina and 15% of other chest pain, while a total of death or nonfatal CCU/ICU readmission occurred in 31% of acute myocardial infarction, 32% of unstable angina and 17% of other chest pain.     

Acute Myocardial Infarction Following Hospitalization for Gastrointestinal Bleeding: Incidence,Predictors, Management,and Outcomes

BackgroundClinical characteristics of patients with acute myocardial infarction after gastrointestinal bleeding are poorly characterized. We sought to evaluate the incidence, management and outcomes of myocardial infarction following hospitalization for gastrointestinal bleeding.MethodsPatients admitted with a diagnosis of gastrointestinal bleeding with and without subsequent hospital readmissions for acute myocardial infarction within 90 days were identified in the 2014 U.S. Nationwide Readmission Database. Patients with myocardial infarction with and without a recent prior gastrointestinal bleed were compared to determine differences in management and in-hospital outcomes. Logistic regression models were used to estimate odds of invasive management and all-cause in-hospital mortality after covariate adjustment.ResultsA total of 644,622 patients with gastrointestinal bleeding were identified, of which 7523 (1.2%) were readmitted for myocardial infarction within 90 days. Compared to patients with myocardial infarction without recent gastrointestinal bleeding, patients with myocardial infarction within 90 days after gastrointestinal bleeding were older, more likely to be women, have kidney disease, presented with non-ST segment elevation myocarsdial infarction, and were less likely to undergo invasive management of acute myocardial infarction (28% vs 63%, P < .01). Prior gastrointestinal bleeding was associated with higher all-cause in-hospital myocardial infarction mortality (22% vs 9%, P < .01).ConclusionIn the first 3 months after hospitalization for gastrointestinal bleeding, 1 of every 83 patients was readmitted with acute myocardial infarction. Patients with myocardial infarction after gastrointestinal bleeding were less likely to undergo invasive management and coronary revascularization and had higher mortality than those without recent bleeding.     

The definitions of acute coronary syndrome, myocardial infarction, and unstable angina

The acute coronary syndrome encompasses a spectrum of conditions that include acute myocardial infarction, unstable angina pectoris, and, to some extent, sudden cardiac death. Recently, the diagnosis of myocardial infarction has been redefined by The Joint European Society of Cardiology/American College of Cardiology Committee. However, the conceptual meaning of the term myocardial infarction has not been changed. Thus, the current diagnoses of myocardial infarction as well as of unstable angina are clinical syndromes based on symptoms, electrocardiogram, and sensitive biochemical markers.     

Very early diagnosis and risk stratification of patients admitted with suspected acute myocardial infarction by the combined evaluation of a single serum value of cardiac troponin-T, myoglobin, and creatine kinase MB(mass)

AIMS: The diagnostic and prognostic capacity of biochemical markers of acute myocardial infarction in the emergency department were evaluated in consecutive patients (n=155) with suspected acute myocardial infarction. METHODS AND RESULTS: Serum myoglobin >/=110 microg. l(-1)and creatine kinase MB(mass)>/=5 microg. l(-1)had a high accuracy (0.77-0.85) (ns) for acute myocardial infarction diagnosis in patients presenting >2 h after symptom onset. Troponin-T (>/=0.10 microg. l(-1)) had a lower accuracy (0.53-0.70) for acute myocardial infarction diagnosis, but was the most important 1-year prognostic marker (cardiac death or non-fatal acute myocardial infarction). In patients without ST elevation, combined analysis of two biochemical tests would accurately identify an additional 20% of acute myocardial infarction patients (predictive value of a positive test=0.82) and also identify those without acute myocardial infarction (predictive value of a negative test=0.80). One-year event-free survival was excellent (96%) for patients with two negative biochemical tests, intermediate (74%) for those with discordant tests, and only 53% for patients with two positive biochemical tests. CONCLUSIONS: Analysis of biochemical tests in the emergency department prior to hospital admission could accurately identify approximately 20% additional acute myocardial infarction patients. The prognosis of these patients is poor, and they may be a target for primary PTCA or new early initiated aggressive medical therapies.     

The determination of serum estradiol, testosterone and progesterone in acute myocardial infarction

The levels of serum estradiol, testosterone and progesterone were determined in 13 cases of acute myocardial infarction. Thirteen intensive care patients without coronary, hepatic or renal disease, 13 cases of unstable angina and 15 normal subjects. The patients were males ranging from 24 to 56 years of age, the average being 40.4 years. The levels of serum estradiol in the acute myocardial infarction and unstable angina groups were significantly higher than in the normal group, and no difference was found between the normal and intensive care patient. The testosterone levels were significantly lower in the acute myocardial infarction and unstable angina groups than in the normal group. Progesterone levels increased in acute myocardial infarction patients. The estradiol: testosterone ratio was considerably elevated in the acute phase of myocardial infarction, and in unstable angina patients. No difference was found between the intensive care patient and normal groups.     

Acute myocardial infarction during l-thyroxine therapy in a patient with intermittent changing axis deviation, permanent atrial fibrillation and without significant coronary stenoses

It has been rarely reported intermittent changing axis deviation also occurs during atrial fibrillation. Intermittent changing axis deviation during acute myocardial infarction and changing axis deviation associated with atrial fibrillation and acute myocardial infarction too have been also rarely reported. It has also been reported acute myocardial infarction during l-thyroxine substitution therapy in a patient with elevated levels of free triiodothyronine and without significant coronary artery stenoses. An acute myocardial infarction due to coronary spasm associated with l-thyroxine therapy has also been reported too. We present a case of changing axis deviation during acute myocardial infarction in a 56-year-old Italian woman with permanent atrial fibrillation and l-thyroxine therapy and without significant coronary stenoses. Also this case focuses attention on changing axis deviation in the presence of atrial fibrillation during acute myocardial infarction and on the possible development of acute myocardial infarction without significant coronary stenoses associated with l-thyroxine therapy.     

Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI

Background

Despite the widespread use of electrocardiographic changes to characterize patients presenting with acute myocardial infarction, little is known about recent trends in the incidence rates, treatment, and outcomes of patients admitted for acute myocardial infarction further classified according to the presence of ST-segment elevation. The objectives of this population-based study were to examine recent trends in the incidence and death rates associated with the 2 major types of acute myocardial infarction in residents of a large central Massachusetts metropolitan area.

Methods

We reviewed the medical records of 5383 residents of the Worcester (MA) metropolitan area hospitalized for either ST-segment elevation acute myocardial infarction (STEMI) or non-ST-segment acute myocardial infarction (NSTEMI) between 1997 and 2005 at 11 greater Worcester medical centers.

Results

The incidence rates (per 100,000) of STEMI decreased appreciably (121 to 77), whereas the incidence rates of NSTEMI increased slightly (126 to 132) between 1997 and 2005. Although in-hospital and 30-day case-fatality rates remained stable in both groups, 1-year postdischarge death rates decreased between 1997 and 2005 for patients with STEMI and NSTEMI.

Conclusions

The results of this study demonstrate recent decreases in the magnitude of STEMI, slight increases in the incidence rates of NSTEMI, and decreases in long-term mortality in patients with STEMI and NSTEMI. Our findings suggest that acute myocardial infarction prevention and treatment efforts have resulted in favorable decreases in the frequency of STEMI and death rates from the major types of acute myocardial infarction.     

Association of Thrombocytopenia,Revascularization, and In-Hospital Outcomes in Patients with Acute Myocardial Infarction

BackgroundThe impact of thrombocytopenia on revascularization and outcomes in patients presenting with acute myocardial infarction remains poorly understood. We sought to evaluate associations between thrombocytopenia, in-hospital management, bleeding, and cardiovascular outcomes in patients hospitalized for acute myocardial infarction in the United States.MethodsPatients hospitalized from 2004 to 2014 with a primary diagnosis of acute myocardial infarction were identified from the National Inpatient Sample. Management of acute myocardial infarction was compared between patients with and without thrombocytopenia. Multivariable logistic regression models were used to estimate odds of in-hospital adverse events stratified by thrombocytopenia and adjusted for demographics, cardiovascular risk factors, comorbidities, and treatment.ResultsA total of 6,717,769 patients were hospitalized with a primary diagnosis of acute myocardial infarction, and thrombocytopenia was reported in 219,351 (3.3%). Patients with thrombocytopenia were older, more likely to have other medical comorbidities, were more likely to undergo coronary artery bypass grafting (28.8% vs 8.2%, P < .001), and were less likely to receive a drug-eluting stent (15.5% vs 29.5%, P < .001). After multivariable adjustment, thrombocytopenia was independently associated with nearly twofold increased odds of in-hospital mortality (adjusted odds ratio 1.91; 95% confidence interval, 1.86-1.97). Thrombocytopenia was also independently associated with ischemic stroke, cardiogenic shock, cardiac arrest, and bleeding complications.ConclusionsPatients with thrombocytopenia in the setting of acute myocardial infarction had increased odds of bleeding, cardiovascular outcomes, and mortality compared with patients without thrombocytopenia. Future investigations to mitigate the poor prognosis of patients with acute myocardial infarction and thrombocytopenia are warranted.     

Echoventriculographic detection, localization, and quantification of left ventricular asynergy in acute myocardial infarction. A correlative echo- and electrocardiographic study.

"Echoventriculography", an echocardiographic method specially developed to scan the regional function of the left ventricle, is introduced for studying left ventricular wall motion alteration in patients with acute myocardial infarction. Purposeful probe directions, a 2:1 magnification, and careful adjustment of the gain and reject levels allowed a direct echocardiographic scanning of practically the entire left ventricle. Technically acceptable echoventriculograms were obtained from the upper and lower halves of the septal, anterior, lateral, and postero-inferior left ventricle segments in all observations on 30 consecutive patients with acute myocardial infarction. Various degrees of regional left ventricular asynergy were present in 100 per cent of the patients with acute myocardial infarction. In contrast, synergic ventricular segmental wall motion was observed in 40 healthy subjects. Pronounced asynergy was already detectable within 12 hours from onset of the symptoms of acute myocardial infarction. Echoventriculography detected acute left ventricular asynergy as well in the anteroseptal or lateral as in the posteroinferior locations. The anterior and/or septal infarction (13 of the 30 patientsy always showed a paradoxical systolic motion of the, generally large, infarcted areas. The amplitude of abnormal outward motion was up to 5 mm. In the posteroinferior infarctions (17 patients) akinetic or hypokinetic modes prevailed. The contractile function of the uninvolved segments could be measured at the same time. Hypercontractile left ventricular wall motion was common in these healthy areas in acute myocardial infarction. These findings provide useful insight into the various components of the overall left ventricular pump function in acute myocardial infarction. The validity of the echoventriculographic evaluations of the segmental left ventricular function subsets was further confirmed in 2 patients undergoing left ventricular cineangiographic studies and in 2 by necropsy. The site of the asynergic left ventricular wall motion abnormalities correlated excellently with electrocardiographic prediction of the site of acute myocardial infarction. The echoventriculographic analysis proved to be more accurate in detecting asynergy than was the electrocardiogram. This new echoventriculographic method may become a useful tool for serial noninvasive alalysis of left ventricular performance, in detecting both the asynergic areas and the reserve function of the normal regions in acute myocardial infarction.     

Serum cyclic 3',5'-nucleotide phosphodiesterase activity in myocardial infarction

The activities of cyclic 3',5'-nucleotide phosphodiesterases which hydrolyze cyclic 3',5'-nucleotides were measured in sera from patients with an acute myocardial infarction, angina pectoris and other heart diseases. Cyclic AMP and cyclic GMP phosphodiesterase activities were significantly elevated in acute myocardial infarction, but not in angina pectoris and other cardiovascular diseases. The peak activity appeared approximately within 24 hours following the acute attack of chest pain, and then gradually decreased as the patient recovered. The observed changes of cyclic 3',5'-nucleotide phosphodiesterase activity were similar to that of the other enzyme activities such as GOT, CPK and LDH in sera of acute myocardial infarction. These data reflect damage of myocardial cells during myocardial infarction.     

Continuous ST‐segment Monitoring of Patients with Right Bundle Branch Block and Suspicion of Acute Myocardial Infarction

Background: Patients with right bundle branch block comprise 5–9% of all patients with acute myocardial infarction. In spite of this, limited data exist on early diagnosis or the usefulness of continuous electrocardiographic monitoring in these patients. Methods: A prospective multicenter study with 14 Swedish coronary care units. Patients with right bundle branch block and suspicion of acute myocardial infarction with less than 6 hours symptom duration were included. All patients were monitored with continuous vectorcardiography for 12–24 hours. Results: Seventy‐nine patients were included, 43% had acute myocardial infarction. Patients with acute myocardial infarction had significantly higher initial ST‐vector magnitude values (P = 0.0014) compared to patients without acute myocardial infarction. Patients with acute myocardial infarction also showed gradual regression of ST‐vector magnitude over time that was not seen for patients without acute myocardial infarction (P = 0.005). ST‐vector magnitude measured at the J‐point differentiated best between patients with and without acute myocardial infarction. A cutoff value of 125 μV for initial ST‐vector magnitude resulted in 55% sensitivity and 87% specificity for the diagnosis of acute myocardial infarction. Over time, patients with acute myocardial infarction showed greater changes in QRS‐vector difference compared to patients without acute myocardial infarction (P = 0.052). Conclusion: Vectorcardiographic monitoring shows good diagnostic abilities for patients with right bundle branch block and clinical suspicion of acute myocardial infarction and could be useful for continuous monitoring of these patients.     

Coronary care unit utilization in Hamilton, Ontario, a city of 375,000 people

All cardiac admissions to coronary care unit (CCU) beds and all intensive care unit (ICU) overflow admissions in Hamilton, Ontario, a city of 375,000 people, were documented over a one-year period, 1979-80. There were 4180 such admissions, 89% of them to CCUs. In the CCUs, 22% of patients had acute myocardial infarction, 24% unstable angina and 21% other chest pain. For myocardial infarction, hospitalization rate was 224 per 100,000, hospital mortality 42 per 100,000 and 48% of all myocardial infarction deaths in the community occurred in hospital. Of all myocardial infarction patients admitted to the CCU, 69% were correctly diagnosed on admission (sensitivity) and of all the admission diagnoses of myocardial infarction, 72% were eventually found to be correct (positive predictive value). Mean values for CCU patients overall were age 62.5 years, CCU stay 2.88 days and hospital stay 9.7 days; and for acute myocardial infarction patients in CCUs, age 63.4 years, CCU stay 3.98 days and hospital stay 13.28 days. For myocardial infarction, CCU mortality was 10.9%, hospital mortality 15.2% and, with the inclusion of ICU overflow patients, hospital mortality was 17.6%. Age-specific mortality for myocardial infarction was 9.7% age 45 to 64 years, and 32.8% over 70 years.     

Treatment strategies of acute myocardial infarction: updates on revascularization,pharmacological therapy,and beyond

Owing to recent advances in early reperfusion strategies, pharmacological therapy, standardized care, and the identification of vulnerable patient subsets, the prognosis of acute myocardial infarction has improved. However, there is still considerable room for improvement. This review article summarizes the latest evidence concerning clinical diagnosis and treatment of acute myocardial infarction.     

Lack of association between prodromes nausea and vomiting, and specific electrocardiographic patterns of acute myocardial infarction

We conducted an observational study on 164 patients consecutively admitted to our coronary care unit in order to evaluate the predictive role of cardiac prodromes nausea and vomiting, in distinguishing a particular electrocardiographic pattern (Q wave versus non-Q wave and localisation) of an acute myocardial infarction. Patients with the prodromes made up 47.0% of all Q wave myocardial infarction and 59.4% in those without Q wave myocardial infarction. Furthermore, patients had nausea and vomiting in 25.0% of all Q wave myocardial infarction and in 31.2% of all non-Q wave infarction. No significant differences were found in the patients who experienced nausea and vomiting in the localisation (anterior versus inferior) of myocardial infarction. Our findings indicate that the cardiac prodromes of nausea and vomiting do not play any particular role in predicting a specific electrocardiographic pattern of acute myocardial infarction.     

急性心肌梗死早期血钾浓度与冠状动脉造影相关罪犯血管及室性心律失常的关系

目的 探讨急性心肌梗死患者早期血钾浓度与冠状动脉造影相关罪犯血管及室性心律失常的关系.方法 选择136例符合“急性心肌梗死诊断标准”,且发病时间＜12 h的患者.入院后立即采静脉血3ml,测血钾浓度,做18导联心电图.患者均同意做急诊介入治疗,给予冠状动脉造影,确定急性心肌梗死的罪犯血管.观察急性心肌梗死患者早期血钾浓度与冠状动脉造影确定罪犯血管及室性心律失常的关系,并进行统计学分析.结果 急性心肌梗死罪犯血管为左前降支的血钾浓度最低,左回旋支血钾浓度最高,右冠状动脉的血钾浓度位于左前降支及左回旋支之间.左前降支病变与左回旋支病变血钾浓度对比差异有统计学意义（P＜0.01）.右冠状动脉病变与左回旋支病变血钾浓度对比差异有统计学意义（P＜0.05）.急性心肌梗死低血钾组与正常血钾组室性心律失常发生率对比差异有统计学意义（P＜0.01）.结论 急性心肌梗死患者,罪犯血管是左前降支的发病早期最容易合并低血钾,预后普遍较差.急性心肌梗死早期合并低血钾易发生室性心律失常.     

Changing axis deviation, paroxysmal atrial fibrillation and elevation of prostate-specific antigen during acute myocardial infarction

It has been rarely reported left bundle branch block with changing axis deviation also during acute myocardial infarction. It has also been rarely reported changing axis deviation with changing bundle branch block during acute myocardial infarction. Prostate-specific antigen (PSA) is an established tool in detecting prostate cancer. Immediately after 15 min of exercise on a bicycle ergometer, serum PSA concentrations increased by as much as threefold. Apparently spurious result has been reported in a work about mean serum PSA concentration during acute myocardial infarction with mean serum PSA concentration significantly lower on day 2 than either day 1 or day 3 and it has been reported that these preliminary results could reflect several factors, such as antiinfarctual treatment, reduced physical activity or an acute-phase response. We present a case of changing axis deviation with onset of atrial fibrillation and elevation of serum PSA concentration in an 88-year-old Italian man during acute myocardial infarction. Our report confirms previous findings and extends the evaluation of PSA during acute myocardial infarction.     

Beta-blockers, angiotensin-converting enzyme inhibitors, and calcium antagonists in treatment of elderly patients with acute myocardial infarction

Administration of beta-blockers reduces mortality among old persons during and after acute myocardial infarction. The American College of Cardiology/American Heart Association guidelines recommend that persons without contraindications to use of beta-blockers should be administered beta-blockers within a few days of myocardial infarction (if administration is not initiated acutely) and that their administration should be continued indefinitely. These guidelines also recommend the use of angiotensin converting enzyme inhibitors in treating persons within the first 24 h of suspected onset of acute myocardial infarction with ST-segment elevation in two or more anterior precordial leads or with congestive heart failure in the absence of significant hypotension or other contraindications to use of ACE inhibitors; and persons during and after convalescence from acute myocardial infarction with congestive heart failure associated with an abnormal left ventricular ejection fraction (LVEF) or with asymptomatic left ventricular systolic dysfunction with a LVEF < 40%. These guidelines state that there are no class I indications for using calcium antagonists after myocardial infarction. If patients have persistent angina pectoris after myocardial infarction despite treatment with beta-blockers and nitrates or hypertension inadequately controlled by other drugs, administration of a nondihydropyridine calcium antagonist such as verapamil or diltiazem should be added to the therapeutic regimen if the LVEF is normal. If the LVEF is abnormal, administration of amlodipine or felodipine should be added to the therapeutic regimen.     

血清瘦素、脂联素与冠心病病变程度的相关性研究

目的探讨血清瘦素、脂联素(APN)水平与冠心病(CHD)病变程度的相关性。方法应用ELISA法对稳定型心绞痛(SA)组(21例)、不稳定型心绞痛(UA)组(23例)、急性心肌梗死(AMI)组(24例)和正常对照(CO)组(20例)进行血清瘦素、脂联素水平检测,并进行统计学分析。结果血清瘦素水平冠心病各组明显高于正常对照组(P<0.05),UA组及AMI组高于SA组(P<0.05),AMI组高于UA组(P<0.05),血清瘦素水平与冠心病病变程度呈正相关(r=0.60,P<0.05);血清APN水平UA组及AMI组明显低于SAP组和对照组(P<0.05),冠心病各组与正常对照组比较有统计学意义(P<0.05),AMI组与UA组比较有统计学意义(P<0.05),脂联素与冠心病病变程度呈负相关(r=-0.59,P<0.05)。结论血清瘦素、脂联素与冠心病发病密切相关,冠心病患者血清瘦素水平升高,血清瘦素水平与冠心病病变程度呈正相关。冠心病患者血清APN水平下降,血清脂联素与冠心病病变程度呈负相关。     

Bilateral coronary thrombosis in the absence of inducible coronary spasm, thrombocytosis, coagulation abnormalities, or angiographic evidence of coronary artery disease: previously undescribed method of myocardial infarction

A 32-year-old man presented with symptoms and electrocardiographic changes consistent with acute anterolateral myocardial infarction. Selective coronary angiography revealed thromboses in the infarct related artery as well as in the right coronary artery. This case is unique because bilateral in-situ coronary thrombosis producing acute myocardial infarction was documented in the absence of previously proposed mechanisms.     

Probable triggers of onset of acute myocardial infarction

Three cases of acute myocardial infarction are presented in which a probable triggering mechanism can be identified. The presence of triggering physical and mental stresses is consistent with recent documentation of a morning increase in frequency of acute myocardial infarction. This documentation suggests that the onset of acute myocardial infarction is not a random event. Recent advances in knowledge of the pathophysiology of acute myocardial infarction provide a background to the understanding of the probable triggering mechanism in these three cases. Further prospective study of patients with acute myocardial infarction in whom detailed information is collected sufficient to identify triggering activities may provide important insight into the pathophysiology of myocardial infarction and improved strategies for prevention.