A comparison of heparin strategies after thrombolytic therapy.
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Heparin↗
Biomedical subjects
J M Gore
Publications and source records attributed to J M Gore.
The influence of sex and diabetes mellitus on survival following acute myocardial infarction: a community-wide perspective.
The objective of this report was to examine the effects of sex and diabetic status on in-hospital mortality and 12 year survival following hospital discharge among 4109 patients hospitalized between 1974 and 1986 with acute myocardial infarction. Sixteen general hospitals in the Worcester, MA, standard metropolitan statistical area were included. The age-adjusted in-hospital case-fatality rate was significantly higher in diabetic women (23.3%) than in non-diabetic women (18.9%) (p < 0.05) while no significant difference was noted among men. Over a 12 year follow-up period, the relative risk of dying among diabetic men was 1.56 times that for non-diabetic men (95% CI, 1.43, 1.68). Diabetic women were 1.57 times as likely to die as non-diabetic women (95% CI, 1.45, 1.73). Among non-diabetic subjects, men had a 17% excess risk of death compared to women (95% CI, 1.09, 1.25). No significant difference in long-term mortality was noted among diabetic persons. Thus, the "female advantage" observed in the non-diabetic population was eliminated among the diabetic patients. Randomized clinical trials are needed in the diabetic population to identify specific therapies to reduce their increased risk of death.
Aged↗
Hemorrhagic potential of combined diltiazem and recombinant tissue-type plasminogen activator administration.
In the Thrombolysis in Myocardial Infarction (TIMI) phase II study, use of calcium channel antagonists at study entry was associated with an increased risk of intracerebral hemorrhage. Whether the observed association was due solely to chance, underlying cerebrovascular disease, or an effect of calcium channel antagonists themselves was not determined. Accordingly, blood loss from standardized ear incisions was measured in six groups of anesthetized New Zealand white rabbits: (1) saline control, (2) intravenous diltiazem (20 micrograms/kg/min x 60 minutes), (3) intravenous recombinant tissue-type plasminogen activator (rTPA) (1.0 mg/kg over 60 minutes, 10% bolus), (4) diltiazem plus rTPA, (5) diltiazem daily for 3 consecutive days, and (6) diltiazem (3 days) plus rTPA given on day 3. The combination of rTPA plus diltiazem (3 days) resulted in significantly more blood loss than rTPA alone, diltiazem (60-minute infusion), or rTPA plus diltiazem (60-minute infusion) (p = 0.003). Similarly, diltiazem (3 days) resulted in more blood loss than either agent alone or rTPA plus diltiazem (60-minute infusion) (p < 0.05). Thus, in this animal model, prolonged exposure to diltiazem with or without rTPA was associated with increased bleeding. The potential for chronic use of oral calcium channel antagonist to increase hemorrhagic risk after rTPA administration requires further investigation.
Animals↗
The challenge of maintaining coronary arterial patency with intravenous heparin following tissue plasminogen activator administration.
It is widely accepted that coronary arterial patency, achieved early after symptom onset and maintained over time, is an absolute prerequisite for patient benefit following thrombolytic therapy. Conjunctive pharmacological agents such as heparin appear to play an important role in maintaining vessel patency, particularly following tissue plasminogen activator (t-PA) administration. Unfortunately, dosing strategies and monitoring have not kept pace with the rest of the field. Further investigation is encouraged.
Administration, Oral↗
A communitywide perspective of sex differences and temporal trends in the incidence and survival rates after acute myocardial infarction and out-of-hospital deaths caused by coronary heart disease.
BACKGROUND: The purpose of the study was to examine overall differences and temporal trends therein between men and women regarding the incidence rates, in-hospital and long-term survival after initial acute myocardial infarction (AMI), and out-of-hospital deaths caused by coronary disease. METHODS AND RESULTS: This nonconcurrent prospective study was carried out in 16 teaching and community hospitals in Worcester, Mass., in six time periods between 1975 and 1988. A total of 3,148 patients hospitalized with validated initial AMI comprised the study sample. The age-adjusted incidence rates of initial AMI increased between 1975 and 1981 in the two sexes, with a marked decrease thereafter; these rates declined by 26% in men and by 22% in women between 1975 and 1988. The overall unadjusted in-hospital case-fatality rates after initial AMI were significantly higher in women (21.7%) than in men (12.7%). Age- and multivariable-adjusted in-hospital case-fatality rates, however, were not significantly different for men compared with women (multivariate-adjusted OR, 0.90; 95% CI, 0.70, 1.16). No clear trends in in-hospital case-fatality rates were observed in men or women over the periods under study. There were no significant sex differences in the age-adjusted long-term survival rates of discharged hospital survivors of AMI. The multivariate-adjusted risk of total mortality among discharged hospital survivors, however, was significantly increased in men (multivariate-adjusted OR, 1.20; 95% CI, 1.03, 1.39); neither of the sexes experienced an improvement over time in long-term prognosis. The incidence rates of out-of-hospital deaths caused by coronary disease declined by 60% in men and 69% in women between 1975 and 1988. CONCLUSIONS: The results of this multihospital, community-based study suggest declines in the incidence rates of AMI and out-of-hospital deaths caused by coronary disease in men and women over the period under study (1975-1988). No significant sex differences in in-hospital survival were observed, whereas a poorer long-term survival experience after hospital discharge was observed for men compared with women after controlling for potentially confounding prognostic factors.
Aged↗
Patient selection issues in the use of thrombolytic therapy in patients with acute myocardial infarction.
The proportion of patients with acute myocardial infarction who are currently being treated with thrombolytic therapy is small. It is not readily apparent why the use of thrombolytic therapy is not more widespread. Several factors have been raised to explain the limited use of thrombolytic therapy, including patient age and late presentation after symptom onset. Recent data suggests that the benefits of thrombolytic therapy should be extended to these selected high-risk subgroups. A philosophy of finding a reason not to treat with thrombolytic therapy should be adopted by all practicing clinical cardiologists.
Drug Administration Schedule↗
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.
Adolescent↗
Cardiovascular disease.
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Angioplasty, Balloon, Coronary↗
Prognosis of acute myocardial infarction complicated by complete heart block (the Worcester Heart Attack Study).
As part of a community-based study of patients hospitalized with acute myocardial infarction (AMI) in the Worcester, Massachusetts, metropolitan area, changes over time in the incidence rates of complete heart block (CHB) complicating AMI, and the prognostic impact of CHB on the in-hospital and long-term survival of these patients were examined. In all, 4,762 patients with validated AMI hospitalized at 16 hospitals in the Worcester metropolitan area during 1975, 1978, 1981, 1984, 1986 and 1988 constituted the study sample. The incidence rates of CHB complicating AMI remained relatively stable at 5.8% over the 13-year (1975 to 1988) period studied. The incidence rates of CHB were approximately twice as high in patients with inferior/posterior wall AMI (7.7%) as in those with anterior wall AMI (3.9%). Use of a multivariate regression analysis to control for factors affecting the incidence rates of CHB revealed that patients were at highest risk for developing CHB during the latter 2 study years (1986 and 1988). Patients with AMI developing CHB had higher in-hospital case fatality rates than did those without CHB overall, as well as during each of the 6 periods studied. The in-hospital survival associated with CHB did not improve over time. After use of a multivariate regression analysis to control for additional prognostic factors, the independent effect of CHB on in-hospital prognosis remained (adjusted risk of dying = 2.10; 95% confidence intervals = 1.37, 3.21). Patients with inferior wall AMI complicated by CHB were at significantly increased risk of dying during hospitalization compared with those without CHB (adjusted risk of dying = 2.71; 95% confidence intervals = 1.60, 4.59).(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Ischemic stroke and intracranial hemorrhage following thrombolytic therapy for acute myocardial infarction: a risk-benefit analysis.
Stroke is a potentially serious complication of acute myocardial infarction (AMI). In the prethrombolytic era, most strokes were attributed to cerebral embolism. On the basis of available information, the occurrence of stroke in the thrombolytic era appears to be less than in the prethrombolytic era. In the thrombolytic era, the occurrence of various forms of intracranial hemorrhage has increasingly been documented in addition to cerebral embolism, with intriguing features. In general, however, the delineation of specific stroke subtypes has been imprecise and must take into account factors that are unique to this setting. Age is a risk factor for both ischemic and hemorrhagic stroke. Potential risk factors for intracranial hemorrhage include hypertension, dosage of fibrinolytic agents, and prior neurologic disease. Potential causes of intracranial hemorrhage include combined fibrinolytic/adjunctive therapies, various cerebrovascular lesions, and head trauma. Existing data suggest that mortality related to stroke complicating AMI is on the decline as well. More research is needed in order to quantify precisely the occurrence and proportions of stroke subtypes, risk factors, and causes in order to define mechanisms and preventive measures.
Brain Ischemia↗
Beta-blocker therapy in acute myocardial infarction: evidence for underutilization in the elderly.
PURPOSE: To assess the impact of patient age on the use of beta-blocker therapy in the management of acute myocardial infarction. PATIENTS AND METHODS: The population studied consisted of 4,762 patients hospitalized with validated acute myocardial infarction in 16 hospitals in the Worcester, Massachusetts, Standard Metropolitan Statistical Area during the years 1975, 1978, 1981, 1984, 1986, and 1988. Logistic regression analysis was employed to control for relevant demographic and clinical variables in evaluating the independent effect of patient age as a determinant of receipt of beta-blocker therapy during the hospitalization. RESULTS: A consistent trend toward reduced use of beta-blocker therapy in older patients was demonstrated. After adjustment for demographic and clinical variables (gender; prior history of angina, hypertension, or diabetes mellitus; myocardial infarction characteristics; complications including congestive heart failure and shock; and use of digoxin and diuretics), odds ratios for receipt of beta-blocker therapy relative to patients less than 55 years of age were 0.61 for those 55 to 64; 0.52 for those 65 to 74; 0.36 for those 75 to 84; and 0.26 for those 85 or older. Analyses performed for each study year demonstrated results consistent with those for the overall study population. CONCLUSION: The results of this population-based study suggest that there are substantial opportunities for expanded use of beta-blocker therapy in elderly patients who have sustained an acute myocardial infarction.
Adrenergic beta-Antagonists↗
ST segment depression in right-sided electrocardiographic leads in patients with acute myocardial infarction.
The presence of ST segment depression in right-sided electrocardiographic leads has been infrequently reported in the literature. We report the cases of two patients with anterolateral and posterior myocardial infarctions with ST segment depression in right-sided electrocardiographic leads. We hypothesize that this electrocardiographic change is a reciprocal expression of ST segment elevation of the opposing left ventricular wall.
Aged↗
Prevention of severe neurologic events in the thrombolytic era.
The occurrence of various forms of severe neurologic events has been increasingly reported in acute myocardial infarction patients receiving thrombolytic therapy. Strokes have long been known to complicate acute myocardial infarction. The recent attention on severe neurologic events has focused primarily on probable cerebral bleeds. The various forms of severe neurologic events that clinicians are confronted with have unique features and characteristics that will be delineated. The incidence of these events and patient risk factors for cerebral ischemia and cerebral hemorrhage will be outlined. Guidelines that should be adopted to minimize the chance of a patient's suffering a severe neurologic event while at the same time maximizing the number of patients who receive this lifesaving therapy are summarized.
Cerebrovascular Disorders↗
Hemorrhagic complications of thrombolytic therapy in the treatment of myocardial infarction and venous thromboembolism.
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Hemorrhage↗
Diagnostic testing in acute myocardial infarction: does patient age influence utilization patterns? The Worcester Heart Attack Study.
To assess the impact of patient age on the use of diagnostic testing in the management of acute myocardial infarction, the authors reviewed the hospital charts of 4,109 patients hospitalized for validated acute myocardial infarction in the Worcester, Massachusetts, metropolitan area during selected years between 1975 and 1986. Older patients were more likely to be female and to have a prior history of angina, hypertension, and diabetes mellitus (p less than 0.001). Acute myocardial infarctions among older patients were more likely to be recurrent, anterior in location, non-Q wave, smaller as reflected by peak creatine kinase levels, and complicated by congestive heart failure, cardiogenic shock, and atrial fibrillation (p less than 0.001). In-hospital mortality was directly related to increasing patient age (p less than 0.001). Patterns of utilization of the following diagnostic tests were examined: Holter monitoring, radionuclide ventriculography, echocardiography, exercise testing, pulmonary artery catheterization, and coronary arteriography. After adjustment for differences in demographic and clinical characteristics and in-hospital mortality, patients aged 65 years and older were significantly less likely to undergo exercise testing than were patients less than age 55. Patients older than age 75 were significantly less likely to undergo radionuclide ventriculography, pulmonary artery catheterization, and coronary arteriography than were younger patients. Sex-specific analyses did not produce results substantially different from those for the overall study population. The results of this community-wide study suggest that among patients hospitalized for acute myocardial infarction, chronologic age may be an independent determinant of utilization patterns of diagnostic testing. These findings suggest the need for a prospective evaluation of this issue, with an additional emphasis placed on the contributions of functional status and noncardiovascular illness to decision-making in the clinical management of acute myocardial infarction patients.
Age Factors↗
Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988.
BACKGROUND: Cardiogenic shock resulting from acute myocardial infarction is a serious complication with a high mortality rate, but little is known about whether its incidence or outcome has changed over time. As part of an ongoing population-based study of acute myocardial infarction, we examined trends over time in the incidence and mortality rate of cardiogenic shock after acute myocardial infarction. METHODS: We studied 4762 patients with acute myocardial infarction who were admitted to 16 hospitals in the Worcester, Massachusetts, metropolitan area between 1975 and 1988. We determined the incidence of and short-term and long-term mortality due to cardiogenic shock in each of six years during this study period. RESULTS: The incidence of cardiogenic shock complicating acute myocardial infarction remained relatively constant, averaging 7.5 percent. Multivariate regression analysis that controlled for variables affecting incidence revealed significant though inconsistent temporal trends in the incidence of cardiogenic shock. As compared with the risk in 1975, the adjusted relative risk (with 95 percent confidence interval) was 0.83 (0.54 to 1.28) in 1978, 0.96 (0.63 to 1.48) in 1981, 0.68 (0.42 to 1.12) in 1984, 1.16 (0.70 to 1.92) in 1986, and 1.65 (0.99 to 2.77) in 1988. The overall in-hospital mortality rate among patients with cardiogenic shock was significantly higher than that among patients without this complication (77.7 percent vs. 13.5 percent, P less than 0.001). The in-hospital mortality among the patients with shock did not improve between 1975 (73.7 percent) and 1988 (81.7 percent). Long-term survival during the 14-year follow-up period was significantly worse among patients who survived cardiogenic shock during hospitalization than among patients who did not have shock (P less than 0.001). CONCLUSIONS: The results of this observational, community-wide study suggest that neither the incidence nor the prognosis of cardiogenic shock resulting from acute myocardial infarction has improved over time. Both in-hospital and long-term survival remain poor for patients with this complication.
Aged↗
Hemorrhagic events during therapy with recombinant tissue-type plasminogen activator, heparin, and aspirin for acute myocardial infarction. Results of the Thrombolysis in Myocardial Infarction (TIMI), Phase II Trial.
OBJECTIVES: To assess the effects of invasive procedures, hemostatic and clinical variables, the timing of beta-blocker therapy, and the doses of recombinant plasminogen activator (rt-PA) on hemorrhagic events. DESIGN: A multicenter, randomized, controlled trial. SETTING: Hospitals participating in the Thrombolysis in Myocardial Infarction, Phase II trial (TIMI II). INTERVENTIONS: Patients received rt-PA, heparin, and aspirin. The total dose of rt-PA was 150 mg for the first 520 patients and 100 mg for the remaining 2819 patients. Patients were randomly assigned to an invasive strategy (coronary arteriography with percutaneous angioplasty [if feasible] done routinely 18 to 48 hours after the start of thrombolytic therapy) or to a conservative strategy (coronary arteriography done for recurrent spontaneous or exercise-induced ischemia). Eligible patients were also randomly assigned to either immediate intravenous or deferred beta-blocker therapy. MEASUREMENTS: Patients were monitored for hemorrhagic events during hospitalization. MAIN RESULTS: In patients on the 100-mg rt-PA regimen, major and minor hemorrhagic events were more common among those assigned to the invasive than among those assigned to the conservative strategy (18.5% versus 12.8%, P less than 0.001). Major or minor hemorrhagic events were associated with the extent of fibrinogen breakdown, peak rt-PA levels, thrombocytopenia, prolongation of the activated partial thromboplastin time (APTT) to more than 90 seconds, weight of 70 kg or less, female gender, and physical signs of cardiac decompensation. Immediate intravenous beta-blocker therapy had no important effect on hemorrhagic events when compared with delayed beta-blocker therapy. Intracranial hemorrhages were more frequent among patients treated with the 150-mg rt-PA dose than with the 100-mg rt-PA dose (2.1% versus 0.5%, P less than 0.001). The extent of the plasmin-mediated hemostatic defect was also greater in patients receiving the 150-mg dose. CONCLUSIONS: Increased morbidity due to hemorrhagic complications is associated with an invasive management strategy in patients with acute myocardial infarction. Our findings show the complex interaction of several factors in the occurrence of hemorrhagic events during thrombolytic therapy.
Aspirin↗
Cardiovascular disease.
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Cardiovascular Diseases↗