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PubMed2006

Antihypertensive prescribing practices: impact of the antihypertensive and lipid-lowering treatment to prevent heart attack trial.

This national study examines the impact of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) on the prescribing of thiazide-type diuretics and other antihypertensive medications for patients with newly diagnosed hypertension. A cross-sectional analysis was conducted using data from a national network of electronic health records for 2 groups with newly diagnosed hypertension and started on antihypertensive medications: one a year before and the other a year after the publication of ALLHAT. The percentage of new hypertensives started on thiazides increased from 29% pre-ALLHAT to 39% post-ALLHAT. An increase was also seen for angiotensin receptor blockers, while prescribing for angiotensin-converting enzyme inhibitors, calcium channel blockers, and beta-blockers declined. There was no significant change in prescriptions for alpha-blockers. Prescriptions for thiazides for patients with newly diagnosed hypertension increased after the publication of ALLHAT. Data from large national trials can have a considerable impact on prescribing practices.

Adrenergic alpha-Antagonists↗
PubMed1976

Mode of referral to hospital of patients with heart attacks: relevance to home care and special ambulance services.

Out of 1250 consecutive patients brought to hospital with heart attacks 956 (76%) were at home when their symptoms began. Of these, 587 (61%) called their general practitioner, and for the remainder an ambulance was summoned by a member of the public. Of the 294 patients who were away from home when the attack occurred 291 were brought to hospital by ambulance. Of these, only 70 (24%) were attended by a general practitioner. Patients for whom ambulances were called by a general practitioner had had their symptoms significantly longer and had significantly lower prehospital and hospital mortalities than those for whom ambulances were summoned by members of the public. Special "cardiac" ambulances appear to be inappropriate for patients who have been seen by a general practitioner, and for this group home care may well be as effective as hospital admission.

Ambulances↗
PubMed2003

Premature parental heart attack is heralding elevated risk in their offspring.

A small subgroup of children, whose parents have suffered a heart attack in their late thirties and early forties, may be at particularly high cardiovascular risk. University Hospital "Split" gives tertiary health care to some 700,000 people in southern Croatia and treats about 300 acute myocardial infarctions per year, with a 3-5% share in the age under 45 years. This cross-sectional, clinical and laboratory study included all the patients below the age limit of 45 years, treated for acute myocardial infarction between 1990 and 1995, complexively 55 of them, and their natural children, 97 all in all. The results were compared to those of a stratified children's sample taken from the population of the same region. The relative weight, blood pressure, and plasma cholesterol were significantly higher in these children than in the control group (p < 0.05). In 50 of these offspring (51.5%), in addition to the obviously positive family history, detected were further cardiovascular risk factors, defined as values above the 95th distribution percentile for age and gender. The average blood pressure, relative weight and cholesterol levels were even higher in these, "risky" children than in the studied sample (p < 0.05), and much more elevated than in the matching control pupils (p < 0.001). The most often detected risk factors were elevated cholesterol (in 44%), arterial hypertension (in 40%), obesity (in 32%), and smoking (in 24%). Most of the children (64%) had only one additional risk factor, while in the remaining 36% the most prevalent risk factors were overweight (in 14 out of 18) and arterial hypertension (in 11 out of 18). It is concluded that cardiovascular risk factor screening among children with a positive family history of premature atherosclerotic complications is appropriate and cost-effective.

Adolescent↗
PubMed2004

The prevalence of reduced glomerular filtration rate in older hypertensive patients and its association with cardiovascular disease: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.

BACKGROUND: The prevalence of reduced glomerular filtration rate (GFR) in older hypertensive patients and the relationship between level of GFR and cardiovascular disease (CVD) and its risk factors are not well known. METHODS: We evaluated baseline renal function in 40 514 hypertensive patients 55 years or older who were enrolled in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). We used the simplified Modification of Diet in Renal Disease study equation to estimate GFR and examined the prevalence of CVD in patients with different levels of GFR. RESULTS: Fifty-seven percent of patients had mild (60-89 mL/min per 1.73 m(2)), 17.2% had moderate (30-59 mL/min per 1.73 m(2)), and 0.6% had severe (<or=29 mL/min per 1.73 m(2)) reductions in GFR. Compared with patients with normal or mildly reduced GFR, patients with moderate or severe reductions in GFR were more likely to have had a prior myocardial infarction or stroke (19.2% and 23.4% vs 28.7% and 26.9%, respectively), have ischemic changes on electrocardiography (ECG) (16.0% and 18.9% vs 24.6% and 34.1%, respectively), and have left ventricular hypertrophy on ECG (ECG-LVH) (3.9% and 4.2% vs 6.0% and 11.2%, respectively). A decrease in GFR of 10 mL/min per 1.73 m(2) was independently associated with a 6% higher risk for CVD and 14% higher risk for ECG-LVH. The increase in risk was marked at a GFR of approximately 60 to 70 mL/min per 1.73 m(2). CONCLUSIONS: The prevalence of reduced GFR is high in older hypertensive patients. Patients with moderate or severe reduction in GFR are more likely to have a history of CVD and ECG-LVH. Even modest reductions in GFR are independently associated with a higher prevalence of CVD and ECG-LVH.

Cardiovascular Diseases↗
PubMed1976

The heart attack and doctor/patient communication.

In patients with recent proven or suspected myocardial infarction, understanding of the nature of a heart attack was explored. A wide range of misconceptions, some of them frightening, was revealed; there was a poor understanding of some terms commonly used in discussion with patients; the potential for creation of new misconceptions by doctors and nurses was highlighted.

Attitude to Health↗
PubMed2003

Platelet/endothelial biomarkers in depressed patients treated with the selective serotonin reuptake inhibitor sertraline after acute coronary events: the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART) Platelet Substudy.

BACKGROUND: Depression after acute coronary syndromes (ACSs) has been identified as an independent risk factor for subsequent cardiac death. Enhanced platelet activation has been hypothesized to represent 1 of the mechanisms underlying this association. Selective serotonin reuptake inhibitors (SSRIs) are known to inhibit platelet activity. Whether treatment of depressed post-ACS patients with SSRIs alters platelet function was not known. Accordingly, we serially assessed the release of established platelet/endothelial biomarkers in patients treated with sertraline vs placebo in the Sertraline AntiDepressant Heart Attack Randomized Trial (SADHART). METHODS AND RESULTS: Plasma samples (baseline, week 6, and week 16) were collected from patients randomized to sertraline (n=28) or placebo (n=36). Anticoagulants, aspirin, and ADP-receptor inhibitors were permitted in this study. Platelet factor 4, beta-thromboglobulin (betaTG), platelet/endothelial cell adhesion molecule-1, P-selectin, thromboxane B2, 6-ketoprostaglandin F1a, vascular cell adhesion molecule-1, and E-selectin were measured by ELISA. Treatment with sertraline was associated with substantially less release of platelet/endothelial biomarkers than was treatment with placebo. These differences attained statistical significance for betaTG (P=0.03) at weeks 6 and 16 and for P-selectin (P=0.04) at week 16. Repeated-measures ANOVA revealed a significant advantage for sertraline vs placebo for diminishing E-selectin and betaTG concentrations across the entire treatment period. CONCLUSIONS: Treatment with sertraline in depressed post-ACS patients is associated with reductions in platelet/endothelial activation despite coadministration of widespread antiplatelet regimens including aspirin and clopidogrel. The antiplatelet and endothelium-protective properties of SSRIs might represent an attractive additional advantage in patients with depression and comorbid coronary artery and/or cerebrovascular disease.

Biomarkers↗
PubMed2005

Prescribing patterns for antihypertensive drugs after the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial: report of experience in a health maintenance organization.

BACKGROUND: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) reported that primary cardiovascular outcomes were the same in hypertensive patients treated with thiazide-type diuretics as in those treated with calcium channel blockers or angiotensin-converting enzyme inhibitors. The aim of this study was to assess prescribing patterns of antihypertensive agents in a health maintenance organization (HMO) before and after the publications of ALLHAT results. METHODS: Our analysis used computer-stored information from the pharmacy system of the HMO for the period between January 1, 1996, and December 31, 2003. The study assessed prescribing patterns for antihypertensive drugs in six classes: thiazide-type diuretics, other-type antihypertensive diuretics, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, calcium channel blockers, beta-blockers, and alpha-blockers. The monthly total number and relative percentage of dispensed prescriptions for each class of antihypertensive agent, including new prescriptions and refills, were calculated. RESULTS: The use of alpha-blockers for all prescriptions began to decrease after the closure of the alpha-blocker (doxazosin) arm of ALLHAT in January 2000. Prescriptions for the thiazide-type diuretics immediately increased after the ALLHAT publication in December 2002. During the first 6 months of 2003, the percentages of thiazide-type diuretics were statistically significantly higher compared with the predicted values. This pattern held for all as well as for new antihypertensive prescriptions. CONCLUSIONS: The ALLHAT publications had large effects on the antihypertensive prescribing patterns in our population. Prescription of thiazide-type diuretics significantly increased after the ALLHAT publication. Our findings establish that the response of physicians to new clinical evidence can be very rapid.

Adrenergic alpha-Antagonists↗
PubMed1988

Breathlessness, lung function and the risk of heart attack.

Men with moderate or severe breathlessness had a greater than two-fold risk of suffering a major ischaemic heart disease (IHD) event compared to men with no evidence of breathlessness, based on 7.5-year follow-up in a prospective study of 7735 British men aged 40-59 years. Even after adjustment for other risk factors, including cigarette smoking, the relative risk remained two-fold. Men in the lowest fifth of the forced expiratory volume is 1 s (FEV1) distribution also had a two-fold risk of IHD compared to men in the highest fifth after similar adjustment. In part, the role of breathlessness as a risk factor for major IHD events was explained by its strong association with pre-existing, but usually undiagnosed, IHD. However, breathlessness was associated with an increased risk of heart attack even in men without any evidence of pre-existing IHD at screening. FEV1 was related to risk of a major IHD event in men without evidence of pre-existing IHD at screening and in men with previously undiagnosed IHD detected at screening. Measures of breathlessness and lung function could be more widely used in clinical situations and in screening as additional independent indicators of both unrecognized IHD and of risk for major IHD events.

Adult↗
PubMed1980

Importance of age in prehospital and hospital mortality of heart attacks.

Prehospital and hospital fatality rates were calculated for each 10-year age group of 2788 patients transported to hospital with heart attacks. The prehospital fatality rate rose progressively from 4 per cent in the youngest age group to 45 per cent in the oldest. There was no age-related difference between the groups in the interval between the onset of symptoms and the first call for help, and a similar proportion of each group summoned a general practitioner. Among those admitted to hospital there was a progressive rise with age in the proportion eventually found to have had a definite or probable myocardial infarction, and among such patients the hospital fatality rate rose from 8 per cent in the youngest group to 35 per cent in the oldest. There was a progressive rise with age in the symptoms and signs of, and treatment for, heart failure. Reported fatality rates from myocardial infarction can only be interpreted if the ages of the patients are known in detail.

Adult↗
PubMed1998

Thrombolytic therapy in Missouri hospital emergency departments: compliance with the National Heart Attack Alert Program guidelines.

A self-administered questionnaire concerning the current practice of thrombolytic administration, and the use of National Heart Attack Alert Program (NHAAP) guidelines was mailed to the medical directors of Missouri acute care emergency departments (EDs). Responses from 75% of the EDs surveyed were received. There were standing orders to perform an electrocardiogram at 92% of the EDs surveyed. Thrombolytics were stocked in 80% of EDs and thrombolytics were administered in the ED rather than the ICU or CCU at 98%. The emergency physician (EP) was authorized to make thrombolytic treatment decisions at 87% of the institutions; however, in 24% of the hospitals EPs were required to contact another physician prior to giving thrombolytics. An Acute Myocardial Infarction (AMI) Continuous Quality Improvement (CQI) program was in place at 67%, and 44% of the institutions had an interdepartmental AMI protocol. Less than half of the EDs reported a door-to-drug time of less than 30 minutes. The primary delay in starting thrombolytic therapy was identified as decision-making on the part of the emergency physician and/or consultants. Missouri EDs report that they generally follow the NHAAP guidelines for rapid identification and treatment of AMI, but, there were still significant delays reported in the administration of thrombolytics.

Chi-Square Distribution↗
PubMedDate not supplied

Heart attacks and the Newcastle earthquake.

OBJECTIVE: To test the hypothesis that stress generated by the Newcastle earthquake led to increased risk of heart attack and coronary death. DESIGN: A natural experiment. SUBJECTS: People living in the Newcastle and Lake Macquarie local government areas of New South Wales, Australia. INTERVENTION: At 10.27 a.m. on 28 December 1989 Newcastle was struck by an earthquake measuring 5.6 on the Richter scale. OUTCOME MEASURES: Myocardial infarction and coronary death defined by the criteria of the WHO MONICA Project and hospital admissions for coronary disease before and after the earthquake and in corresponding periods in previous years. Well established, concurrent data collection systems were used. RESULTS: There were six fatal myocardial infarctions and coronary deaths among people aged under 70 years after the earthquake in the period 28-31 December 1989. Compared with the average number of deaths at this time of year this was unusually high (P = 0.016). Relative risks for this four-day period were: fatal myocardial infarction and coronary death, 1.67 (95% confidence interval [Cl]: 0.72, 3.17); non-fatal definite myocardial infarction, 1.05 (95% Cl: 0.05, 2.22); non-fatal possible myocardial infarction, 1.34 (95% Cl: 0.67, 1.91); hospital admissions for myocardial infarction or other ischaemic heart disease, 1.27 (95% Cl: 0.83, 1.66). There was no evidence of increased risk during the following four months. CONCLUSION: The magnitude of increased risk of death was slightly less than that previously reported after earthquakes in Greece. The data provide weak evidence that acute emotional and physical stress may trigger myocardial infarction and coronary death.

Adult↗
PubMed1977

Comparison of mortality of patients with heart attacks admitted to a coronary care unit and an ordinary medical ward.

During a 32-month period 2047 patients suspected of having heart attacks were admitted to hospital and were followed up prospectively. Out of 1480 eventually found to have definite or probable myocardial infarction, 483 had initially been admitted to an ordinary medical ward because of the shortage of coronary care unit (CCU) beds. More patients aged over 65 had been admitted to a ward than to a CCU, and more patients aged 65 or less had been admitted initially to a CCU. Within each age group, however, patients admitted initially to a CCU were clinically similar to those admitted initially to a ward. There was a higher proportion of successful resuscitations among patients admitted to a CCU, but there was no significant difference in mortality in either age group between patients admitted to a CCU and a ward.

Age Factors↗
PubMed1990

Propranolol and the morning increase in sudden cardiac death: (the beta-blocker heart attack trial experience).

To provide insight into the protective effect of propranolol on mortality after myocardial infarction observed in the beta-Blocker Heart Attack Trial, the time of occurrence of sudden cardiac death was examined in this population. Between 5 A.M. and 11 A.M., 25 of the 56 total deaths (38%) occurred in the placebo patients compared with 11 of 45 (24%) in the propranolol patients. Excluding this period, there were nearly equal numbers of sudden cardiac deaths in the propranolol and placebo groups. This retrospective analysis suggests that beta blockade is protective during the morning hours when a surge of sympathetic activity may increase the risk of sudden cardiac death.

Adult↗
PubMed1985

Association of digitalis therapy with mortality in survivors of acute myocardial infarction: observations in the Beta-Blocker Heart Attack Trial.

The influence of digitalis therapy on survivors of acute myocardial infarction was examined in the placebo-treated patients from the Beta-Blocker Heart Attack Trial (BHAT). Two hundred fifty (13%) of the 1,921 placebo-treated patients were receiving digitalis at the time of randomization. Patients receiving digitalis differed from those not receiving digitalis in such baseline characteristics as age, prior history of heart failure, prior myocardial infarction and angina pectoris. They also experienced a higher proportion of in-hospital complications including pulmonary edema, persistent hypotension, atrial fibrillation and heart failure in addition to a greater prevalence of complex ventricular premature beats. The total mortality rate over a mean 25 month follow-up period for digitalis-treated patients was 20.4% compared with 8.2% for patients not receiving digitalis; the odds ratio was 2.87 (p less than 0.05). When the mortality rates were adjusted for heart failure and ventricular premature beat complexity, patients receiving digitalis again demonstrated a higher mortality rate, although the adjusted odds ratio was now lower (1.70). When the patients receiving or not receiving digitalis were compared by a multiple logistic regression analysis adjusting for 17 independent variables predictive of mortality, the use of digitalis was no longer independently predictive of total mortality (adjusted odds ratio 1.07). These data indicate that patients receiving digitalis had more extensive cardiovascular disease and greater morbidity than patients not receiving digitalis. Their subsequent higher mortality rate was probably related to these factors rather than to digitalis therapy.

Adult↗
PubMed1999

Ischemic heart attacks following cessation of aspirin before coronary artery bypass surgery: A report of two cases.

We present herein two patients who suffered life-threatening ischemic heart attacks following the preoperative discontinuation of aspirin. Since their cardiac conditions were stable in the long-term while under medication, the cessation of aspirin was highly suspected to have caused or at least to have contributed to their ischemic events. We thus discuss the appropriate timing for discontinuation of aspirin before surgery in patients with ischemic heart disease.

Aged↗
PubMed1982

THe beta-Blocker Heart Attack Trial: studies of platelets and factor VIII.

Serial studies of platelets and factor VIII were performed in 16 patients enrolled in the Beta Blocker Heart Attack Trial. Eight patients received placebo, and eight were treated with propranolol, in doses ranging from 40 to 320 mg per day for periods of from 6 to 31 months. No differences in platelet-collagen affinity, factor VIII coagulant activity, factor VIII related antigen, or ristocetin cofactor activity were observed between treated and untreated patients. However, circulating platelet aggregates, which were initially increased in both groups, significantly declined in those receiving propranolol (p less than 0.05). This indicates that customarily used doses of propranolol affect platelet reactivity in vivo.

Adenosine Diphosphate↗
PubMed1985

Assessment of angina pectoris after myocardial infarction: comparison of "Rose Questionnaire" with physician judgment in the Beta-Blocker Heart Attack Trial.

The London School of Hygiene Cardiovascular Questionnaire (Rose Questionnaire) was compared with physician opinion in assessment of angina pectoris in the Beta-Blocker Heart Attack Trial, a long-term (June 1978-October 1981), multicenter study of 3,837 post-myocardial infarction patients, half of whom were treated with propranolol and half with placebo. At baseline, about three times as many patients were thought to have angina by the physician as were diagnosed by the Questionnaire (36.1% vs. 11.5%). Over the average 25-month follow-up period, angina was identified by the physician 50% more often than by the Questionnaire (60.3% vs. 38.6%). The results for each treatment group (propranolol or placebo) were very similar to these overall results. Associations between diagnosis of angina and other patient characteristics were similar for the two measures at baseline. Although the physician diagnosis of angina identified more patients who suffered a subsequent fatal or nonfatal event than did the Questionnaire, it also diagnosed more angina patients who did not have an event. Thus, each of the measures of angina predicted total mortality and coronary heart disease mortality to similar extents (comparable relative risks), even after adjustment for covariates. Neither measure was significantly predictive of recurrent nonfatal myocardial infarction. One measure is not clearly superior to the other in this population. Other factors, such as cost and type of personnel available to conduct the study, may determine which measure is preferred.

Angina Pectoris↗