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PubMed1980

[Influenza A virus infection, a precipitating factor for the major heart attack (author's transl)].

A report on 5 men aged from 53 to 75 years whose clinical symptoms were characterized by a major attack. There was a striking temporal relationship between the onset of this and an influenza infection which, in these 5 patients with chronic heart diseases led to a severe, and in the youngest patient, even to a fatal course. In an acute heart attack it seems rational to take into consideration an acute influenza virus infection as a precipitating factor in existing chronic heart disease and to institute virological studies.

Aged↗
PubMed1997

The physician's role in minimizing prehospital delay in patients at high risk for acute myocardial infarction: recommendations from the National Heart Attack Alert Program. Working Group on Educational Strategies To Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction.

Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.

Algorithms↗
PubMed1978

Infarct as a stress agent: life history and personality characteristics in improved versus not-improved patients after severe heart attack.

Fifty-eight male subjects admitted to an intensive coronary care unit were interviewed and underwent psychometric testing on the second--third day after a severe heart attack (infarct). Seven-ten days following admission, the clinical condition of the patients was evaluated by the attending cardiological staff and rated on a three point scale. The patients were divided, on the basis of the clinical rating, into two groups: improved (N = 25) and non-improved (N = 33). Life history characteristics, MMPI personality profiles, and State-Trait anxiety scores were then compared for the two groups. The not-improved group showed the higher scores on almost all the MMPI scales, higher anxiety scores and more work-related problems than the improved group. Such data give some empirical support to the hypothesis that the physiological and hemodynamical conditon of the cardiac patient is in some way correlated with the patient's style of coping with stress, and his history of previous life stress situations.

Adaptation, Psychological↗
PubMed1997

Inpatient deaths from acute myocardial infarction, 1982-92: analysis of data in the Nottingham heart attack register.

OBJECTIVE: To assess longitudinal trends in admissions, management, and inpatient mortality from acute myocardial infarction over 10 years. DESIGN: Retrospective analysis based on the Nottingham heart attack register. SETTING: Two district general hospitals serving a defined urban and rural population. SUBJECTS: All patients admitted with a confirmed acute myocardial infarction during 1982-4 and 1989-92 (excluding 1991, when data were not collected). MAIN OUTCOME MEASURES: Numbers of patients, background characteristics, time from onset of symptoms to admission, ward of admission, treatment, and inpatient mortality. RESULTS: Admissions with acute myocardial infarction increased from 719 cases in 1982 to 960 in 1992. The mean age increased from 62.1 years to 66.6 years (P < 0.001), the duration of stay fell from 8.7 days to 7.2 days (P < 0.001), and the proportion of patients aged 75 years and over admitted to a coronary care unit increased significantly from 29.1% to 61.2%. A higher proportion of patients were admitted to hospital within 6 hours of onset of their symptoms in 1989-92 than in 1982-4, but 15% were still admitted after the time window for thrombolysis. Use of beta blockers increased threefold between 1982 and 1992, aspirin was used in over 70% of patients after 1989, and thrombolytic use increased 1.3-fold between 1989 and 1992. Age and sex adjusted odds ratios for inpatient mortality remained unchanged over the study period. CONCLUSIONS: Despite an increasing uptake of the "proved" treatments, inpatient mortality from myocardial infarction did not change between 1982 and 1992.

Age Factors↗
PubMed1984

Coronary heart disease mortality/morbidity and risk in blacks. I: Clinical manifestations and diagnostic criteria: the experience with the Beta Blocker Heart Attack Trial.

A comparison was made of the clinical manifestations and diagnostic criteria of coronary artery disease in black and nonblack patients in the cohort of participants in the Beta Blocker Heart Attack Trial (BHAT). Although diagnostic criteria were uniform for all potential participants in the trial, examination of the baseline data indicates that black patients had a higher proportion of cardiomegaly and ECGs with left ventricular hypertrophy with ST-T wave changes and a lower percentage of transmural myocardial infarction in comparison to nonblack patients. Baseline data also show that blacks, in comparison to nonblacks, had a higher percentage of variables shown to be characteristic of the high-risk group, including current smoking status, rapid heart rate, angina, high blood pressure, elevated cholesterol, diuretic use, and vasodilator use. The Cox regression analysis confirmed the positive association of these risk descriptors with outcome for the overall study. Walker-Duncan multivariate regression analysis ascribed significance of these risk descriptors to nonblacks only. Blacks (n = 333) had placebo and treatment mortality rates of 15.9 and 11.7, compared to 9.8 and 7.2, respectively, for the overall study (n = 3837). Thus the reduction in mortality among blacks who received propranolol after a recent myocardial infarction was shown to be comparable to that of the other high-risk groups in the BHAT.

Actuarial Analysis↗
PubMed1998

Access to Timely and Optimal Care of Patients with Acute Coronary Syndromes - Community Planning Considerations: A Report by the National Heart Attack Alert Program.

Age-adjusted mortality due to cardiovascular disease (CVD) has declined by more than 50% over the past three decades; however, CVD continues to be the leading cause of death in the United States. In 1994, 1.25 million people experienced an acute myocardial infarction (AMI). Nearly 500,000 Americans died from CVD, and more than half of these deaths occurred suddenly, within 1 hour of symptom onset, outside the hospital setting. The National Heart Attack Alert Program (NHAAP) endorses the view of the American Heart Association that the community should be recognized as the "ultimate coronary care unit." Rapid identification and early treatment are supported by research that demonstrates time is a fundamental factor in reducing morbidity and mortality from AMI and cardiac arrest. A dramatic relationship has been shown between the onset of AMI symptoms, reperfusion treatment, and outcome for patients treated within the first hour after the onset of symptoms. The golden hour has become a widely recognized term in the trauma field, and communities and states are encouraged to develop and implement regional and statewide plans to ensure that trauma patients receive appropriate care within 1 hour of injury. The primary premise of this report - that planning by communities for rapid recognition and triage of patients with symptoms and signs of acute coronary syndromes will result in better outcomes for patients with AMI, including sudden cardiac arrest - is largely based on experience with trauma patients, a population that is benefitting from similar community planning efforts. This NHAAP report reviews community planning considerations and the essential components of an effective community plan (i.e., action plans and protocols, equipment and resources, education and training, and continuous quality improvement evaluation and research) and provides recommendations for each component. The report also presents strategies to guide communities in developing community cardiac emergency action plans.

Journal Article↗
PubMedDate not supplied

Experimental approaches to determining the choice of first-step therapy for patients with hypertension. The ALLHAT Research Group Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.

Detection, treatment and control of hypertension is one of the best proven approaches to prevention of cardiovascular disease. Antihypertensive treatment trials have convincingly demonstrated that diuretics and beta-blockers reduce the risk of stroke and coronary heart disease. Corresponding information is not yet available for newer classes of antihypertensive drug therapy such as calcium channel blockers, angiotensin converting enzyme inhibitors and alpha 1 receptor blockers. Several experimental studies are now addressing this question. The largest such trial (n = 40,000) is the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). This manuscript describes two studies (TOMHS and the VA study on antihypertensive agents) that compared several classes of antihypertensive drugs with regard to blood pressure outcomes and ALLHAT, which is comparing the effect of four first-step approaches to antihypertensive therapy on combined incidence of fatal coronary heart disease and non-fatal myocardial infarction.

Aged↗
PubMed1991

Natural history of the first non-Q wave myocardial infarction in the placebo arm of the Beta-Blocker Heart Attack Trial.

Despite extensive investigation, the prognostic significance of the first non-Q wave acute myocardial infarction (AMI), when compared with Q wave AMI, remains controversial. The placebo arm of the Beta-Blocker Heart Attack Trial (BHAT) provides a unique opportunity to compare the long-term cardiac events in patients suffering from their first and uncomplicated Q wave or non-Q wave AMI. Of a total 3837 patients enrolled in the BHAT, 3375 were classifiable in terms of appearance or absence of Q waves during the prerandomization period. Of these, 1444 patients with their first AMI were randomized to placebo. Of these, 1186 experienced a Q wave AMI; the remaining 258 suffered a non-Q wave AMI. At 36 months of follow-up, the mortality was 8.4% in the Q wave AMI group and 7.4% in the non-Q wave AMI group. Sudden death was 5.4% in the Q wave AMI group and 4.7% in the non-Q wave AMI group. The reinfarction rate was 5.5% in the Q wave AMI patients and 7.4% in the non-Q wave AMI patients. More patients developed angina (44.6%) in the non-Q wave AMI group compared with 35.2% in the Q wave AMI group. Despite similar long-term cardiac event rates within the two groups, the 1-year mortality rate for patients with Q wave AMI appeared higher than in the non-Q wave AMI group, 5.2% versus 3.1%, respectively. In contrast, the rate of reinfarction appeared higher at the 12-month follow-up period in the non-Q wave AMI group, 4.7% versus 3.4%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)c

Double-Blind Method↗
PubMed1989

Hypertension: possible differential risk for blacks in Beta-Blocker Heart Attack Trial (BHAT).

Previously reported data document that efficacy of beta-adrenergic antagonists in lowering mortality rates after acute myocardial infarction. Similarly, the higher observed mortality rates among blacks in the Beta-Blocker Heart Attack Trial (BHAT) have been addressed. In this report, we further emphasize the apparent role of prior high blood pressure in the high risk profile of black patients radomized in the BHAT and the similarity in response to therapy to other high risk patients in this study.

Adrenergic beta-Antagonists↗
PubMed2006

Incidence and predictors of angioedema in elderly hypertensive patients at high risk for cardiovascular disease: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

Angioedema is a rare, potentially life-threatening condition that has been associated with angiotensin-converting enzyme inhibitors since their introduction in the 1980s. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), the largest antihypertensive study conducted to date, randomized 42,418 participants to a diuretic (chlorthalidone), a calcium channel blocker (amlodipine), an angiotensin-converting enzyme inhibitor (lisinopril), or an alpha-blocker (doxazosin). Patients who developed angioedema were compared for baseline characteristics and changes in antihypertensive drug administration. Fifty-three participants developed angioedema during active follow-up: 55% were black, 60% men, and 70% were assigned to lisinopril (including 62% of black participants with angioedema), 15% to chlorthalidone, 9% to doxazosin, and 6% to amlodipine. Six percent occurred within a day of randomization and 23% within the first week. Over half did not have an increase in their assigned (blinded) antihypertensive drug before angioedema onset; 3 (6%) had a dose increase within a week before onset. One patient died following an angioedema episode. The occurrence of angioedema in the angiotensin-converting enzyme inhibitor arm corresponds with previously reported angioedema-angiotensin-converting enzyme inhibitor associations.

Aged↗
PubMed2005

Renal outcomes in high-risk hypertensive patients treated with an angiotensin-converting enzyme inhibitor or a calcium channel blocker vs a diuretic: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

BACKGROUND: This study was performed to determine whether, in high-risk hypertensive patients with a reduced glomerular filtration rate (GFR), treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers the incidence of renal disease outcomes compared with treatment with a diuretic. METHODS: We conducted post hoc analyses of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). Hypertensive participants 55 years or older with at least 1 other coronary heart disease risk factor were randomized to receive chlorthalidone, amlodipine, or lisinopril for a mean of 4.9 years. Renal outcomes were incidence of end-stage renal disease (ESRD) and/or a decrement in GFR of 50% or more from baseline. Baseline GFR, estimated by the simplified Modification of Diet in Renal Disease equation, was stratified into normal or increased (> or =90 mL /min per 1.73 m(2), n = 8126), mild reduction (60-89 mL /min per 1.73 m(2), n = 18 109), or moderate-severe reduction (<60 mL /min per 1.73 m(2), n = 5662) in GFR. Each stratum was analyzed for effects of the treatments on outcomes. RESULTS: In 448 participants, ESRD developed. Compared with patients taking chlorthalidone, no significant differences occurred in the incidence of ESRD in patients taking amlodipine in the mild (relative risk [RR], 1.47; 95% confidence interval [CI], 0.97-2.23) or moderate-severe (RR, 0.92; 95% CI, 0.68-1.24) reduction in GFR groups. Compared with patients taking chlorthalidone, no significant differences occurred in the incidence of ESRD in patients taking lisinopril in the mild (RR, 1.34; 95% CI, 0.87-2.06) or moderate-severe (RR, 0.98; 95% CI, 0.73-1.31) reduction in GFR groups. In patients with mild and moderate-severe reduction in GFR, the incidence of ESRD or 50% or greater decrement in GFR was not significantly different in patients treated with chlorthalidone compared with those treated with amlodipine (odds ratios, 0.96 [P = .74] and 0.85 [P = .23], respectively) and lisinopril (odds ratios, 1.13 [P = .31] and 1.00 [P = .98], respectively). No difference in treatment effects occurred for either end point for patients taking amlodipine or lisinopril compared with those taking chlorthalidone across the 3 GFR subgroups, either for the total group or for participants with diabetes at baseline. At 4 years of follow-up, estimated GFR was 3 to 6 mL /min per 1.73 m(2) higher in patients assigned to receive amlodipine compared with chlorthalidone, depending on baseline GFR stratum. CONCLUSIONS: In hypertensive patients with reduced GFR, neither amlodipine nor lisinopril was superior to chlorthalidone in reducing the rate of development of ESRD or a 50% or greater decrement in GFR. Participants assigned to receive amlodipine had a higher GFR than those assigned to receive chlorthalidone, but rates of development of ESRD were not different between the groups.

Aged↗
PubMed1985

The Beta-blocker Heart Attack Trial.

The preventive effect of long-term beta-blocker therapy in patients who have survived the acute phase of myocardial infarction has been examined in several controlled clinical trials. The largest, the Beta-Blocker Heart Attack Trial, has convincingly demonstrated that propranolol in a daily dose of 180 to 240 mg given to patients without absolute or relative contraindications to the drug, prolongs life while producing moderate side effects. The predominant benefit appears to be in the first 12-18 months. The prime candidates for treatment seem to be patients at high risk, i.e. with complicated infarctions or complex arrhythmias. The likely mechanisms of action are anti-arrhythmic and anti-ischemic. Beta-2 blockade may be a contributing factor.

Adrenergic beta-Antagonists↗
PubMed1989

Blood pressure, cigarette smoking and heart attack in the WHO co-operative trial of clofibrate.

In the WHO sponsored trial of clofibrate and its follow-up, about 15,000 men were observed for a mean period of 13.2 years. As expected, incidence of heart attacks (HA) was directly related to serum cholesterol, blood pressure (BP) and cigarette smoking. The previously reported lower incidence of HA in men receiving clofibrate compared with controls was most noticeable in hypertensive heavy smokers (P less than 0.01). BP was slightly lower in smokers than non-smokers (P less than 0.01). The difference in BP was greater in the trial visit before HA. Smokers also had higher plasma fibrinogen levels (P less than 0.05). The combination of reduced diastolic BP, and therefore myocardial perfusion pressure, with an increased thrombogenic tendency, might explain the high incidence of HA in smokers. Clofibrate apparently reduced fibrinogen levels, which might account for its specially good effect in preventing HA in smokers. However, the ill effects of smoking are still evident at a lower level in the men taking clofibrate and the drug is no substitute for giving up the habit. Clofibrate is not recommended for widespread use, except in subjects with marked lipid and/or blood fibrinogen abnormalities after dietary measures have been tried.

Bezafibrate↗
PubMedDate not supplied

Technological change around the world: evidence from heart attack care.

Although technological change is a hallmark of health care worldwide, relatively little evidence exists on whether changes in health care differ across the very different health care systems of developed countries. We present new comparative evidence on heart attack care in seventeen countries showing that technological change--changes in medical treatments that affect the quality and cost of care--is universal but has differed greatly around the world. Differences in treatment rates are greatest for costly medical technologies, where strict financing limits and other policies to restrict adoption of intensive technologies have been associated with divergences in medical practices over time. Countries appear to differ systematically in the time at which intensive cardiac procedures began to be widely used and in the rate of growth of the procedures. The differences appear to be related to economic and regulatory incentives of the health care systems and may have important economic and health consequences.

Delivery of Health Care↗
PubMed1989

Safe treatment of the post-heart-attack patient.

No dental patient represents a greater risk of serious illness or sudden death related to the emotional and physical stresses of dental treatment than the patient who presents for emergency or routine care with a history of heart attack (acute myocardial infarction, MI). Yet most post-MI patients can be treated effectively with basic treatment modifications that reduce risk to a minor and acceptable level, allowing comprehensive care rather than the simple emergency treatment or basic esthetic care so often reserved for these patients. This article reviews methods of safe and complete care for the post-MI patient.

Anesthesia, Dental↗
PubMed1993

Prognostic significance of electrocardiographic persistent ST depression in patients with their first myocardial infarction in the placebo arm of the Beta-Blocker Heart Attack Trial.

The prognostic significance of ST segment depression in patients with their first acute myocardial infarction was investigated in 1444 patients with an acute myocardial infarction, who were randomly assigned to the placebo arm of the Beta-Blocker Heart Attack Trial (BHAT). Patients were divided retrospectively into three groups based on the presence or absence of > or = 1 mm ST segment depression in two contiguous leads of a 12-lead electrocardiogram obtained during the first few days after admission and at the time of randomization, which occurred at 9.7 +/- 3.3 days after the index myocardial infarction. Group 1 included 392 patients with no ST segment depression, group 2 comprised 713 patients with transient ST segment depression in the first few days after admission or at the time of randomization, and group 3 included 339 patients with persistent ST segment depression in the first few days after admission and at the time of randomization. At a median follow-up of 26 months, the mortality rate was 4.9% in group 1, 7.6% in group 2, and 13.6% in group 3. When Cox regression was used to adjust for baseline differences in other variables, the differences between the three groups continued to be highly significant (p = 0.005; 95% confidence intervals [0.6 and 1.4]). We conclude that persistent and transient ST segment depression in patients with their first myocardial infarction are strong predictors of increased long-term mortality when compared to patients without ST segment depression. These findings should be taken into consideration when stratifying patients at risk in the post-myocardial infarction period.

Electrocardiography↗
PubMed1988

Parental death from heart disease and the risk of heart attack.

In the British Regional Heart Study, 7735 men aged 40-59 years were asked at initial screening whether their father or mother was alive or dead and to what cause any death had been attributed. They were followed up for the occurrence of major ischaemic heart disease events. At screening the men reported that 23% of the fathers and 43% of the mothers were alive and that 19% of the fathers and 11% of the mothers had died of heart trouble. In a sample of parental deaths, the death certificate was obtained and it was found that a son's report of a parental death from 'heart trouble' was a reliable indication that death had been certified to ischaemic heart disease. However, about half of the parental deaths certified as ischaemic heart disease were not reported as 'heart trouble' by their sons. A major ischaemic heart disease event was experienced by 336 men over an average follow-up of 6.2 years. Men who said their father had died from 'heart trouble' were at twice the risk of a major ischaemic heart disease event compared with men whose fathers were still alive and 1.5 times the risk of men who reported their father to be dead from another or unknown cause, even after accounting for age, systolic blood pressure, serum total cholesterol, cigarette smoking and serum HDL-cholesterol. For men with mother dead from heart trouble, the corresponding figures were 1.3 and 1.0.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Impact of a national educational campaign to reduce patient delay in possible heart attack.

In 1989 the National Heart Foundation (NHF) of Australia's Heart Week campaign was directed towards encouraging those with symptoms of possible myocardial infarction (MI) to seek help as promptly as possible. To evaluate its effect, three surveys were conducted of patients admitted to 22 coronary care units (CCUs). Two (335 and 221 patients) preceded and one (253 patients) followed the public education campaign. During the third survey a subset of patients were asked why they delayed, how long they thought one should wait before seeking help, whether they were aware of the media campaign and whether this had influenced their behaviour. Overall, only 42% of 809 patients sought help within one hour (median delay 1.2 hours). The median time of arrival and the proportion of patients arriving within one, two and four hours was not altered after this campaign. Those who admitted to having been aware of the campaign sought help no more promptly. The Heart Week campaign could not be shown to have produced any clinically important change in patient delay. Future campaigns will need to be modified in the light of this experience.

Female↗