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PubMed1993

Snow fall and heart attacks.

Total numbers of daily hospital admissions for cardiac emergencies were obtained from 3 hospitals within the Sudbury Basin in Canada for November through March for each of 4 consecutive years (1983-1986). Major diagnostic categories were also differentiated. No statistically significant correlations were found between the amount of snowfall during the day of or the days before or after admissions for the major categories of cardiac emergency. Specific analyses, conducted to reveal possible recondite associations between extreme or cumulative snowfalls and the most extreme days of cardiac emergencies, indicated a chance association. We conclude that the occurrence of heart attacks is independent of snowfall but that, when they occur, they are attributed to shoveling if there has been a recent major snow storm.

Coronary Disease↗
PubMed1998

Effects of propanolol in patients entered in the Beta-Blocker Heart Attack Trial with their first myocardial infarction and persistent electrocardiographic ST-segment depression.

OBJECTIVE/BACKGROUND: It has been shown that patients with an acute myocardial infarction and persistent electrocardiographic ST-segment depression are at high risk for subsequent cardiac events. The purpose of this retrospective analysis was to examine the long-term effects of propranolol therapy in patients with their first acute myocardial infarction and persistent electrocardiographic ST-segment depression. METHODS: The outcomes of 2877 patients enrolled in the Beta-Blocker Heart Attack Trial (BHAT) with their first myocardial infarction (75% of patients in BHAT) were reviewed. Patients were divided into three groups on the basis of presence or absence of > or =1 mm ST-segment depression in two contiguous leads of the 12-lead electrocardiogram obtained soon after admission or at the time of randomization, which occurred 10.1+/-3.5 days after the index myocardial infarction. Group 1 included 774 patients (392 randomly assigned to placebo and 382 to propranolol) with no ST-segment depression; group 2 included 1447 patients (713 placebo, 734 propranolol) with ST-segment depression at admission or at the time of randomization (labeled as transient); and group 3 included 656 patients (339 placebo and 317 propranolol) who had electrocardiographic ST-segment depression from the time of admission to the time of randomization (labeled as persistent). RESULTS: In group 3, patients with persistent electrocardiographic ST depression, the mortality rate in patients randomly assigned to placebo was 13.6% compared with 7.6% in patients with propranolol (p = 0.012; log rank test). Sudden death in the placebo arm was 9.7% compared with 4.7% in the propranolol group (p = 0.012, log rank test). The results of the Cox regression analysis, adjusting for all baseline variables with p values <0.25, showed the relative risk of overall mortality rate and the relative risk of sudden death were 2.13 ( 1.22, 3.70) and 2.56 (1.27, 5.26), respectively, for the placebo group compared with the propranolol group. Patients with persistent ST-segment depression had the greatest benefit from propranolol (47.2 fewer events [deaths/reinfarctions] per 1000 person-years compared with 78 and 2.1 fewer events in patients with transient and no ST-segment depression, respectively). CONCLUSIONS: It appears that the greatest benefit for beta-blocker therapy in patients after myocardial infarction is observed in patients with persistent ST-segment depression who are at greatest risk for death and reinfarction. Definitive conclusions regarding therapy with beta-adrenergic blocking agents in patients with persistent ST-segment depression cannot be made because our analysis, given its retrospective nature, is only hypothesis generating.

Adrenergic beta-Antagonists↗
PubMed1994

Aspirin to prevent heart attack or stroke.

Each year in the United Kingdom about 250,000 people die from acute myocardial infarction, other ischaemic heart disease or stroke. Many will already have evidence of established vascular disease that predisposes to such an event--such as angina, peripheral vascular disease, atrial fibrillation, transient ischaemic attacks or a previous myocardial infarction or stroke. Others will have risk factors such as hypertension, diabetes mellitus or hyperlipidaemia, but the stroke or heart attack is the first evidence of established vascular disease. Aspirin was first discovered to have antiplatelet properties 30 years ago and since then many randomised clinical trials have sought to determine whether it (or other antiplatelet agents) can protect patients from heart attack or stroke. In this article we review the evidence and update our earlier conclusions on stroke, myocardial infarction, and unstable angina, arguing that aspirin should be widely used to reduce cardiovascular morbidity and mortality in certain high-risk patients.

Aspirin↗
PubMed2006

Fasting glucose levels and incident diabetes mellitus in older nondiabetic adults randomized to receive 3 different classes of antihypertensive treatment: a report from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

BACKGROUND: Elevated blood glucose levels are reported with thiazide-type diuretic treatment of hypertension. The significance of this finding is uncertain. Our objectives were to compare the effect of first-step antihypertensive drug therapy with thiazide-type diuretic, calcium-channel blocker, or angiotensin-converting enzyme inhibitor on fasting glucose (FG) levels and to determine cardiovascular and renal disease risks associated with elevated FG levels and incident diabetes mellitus (DM) in 3 treatment groups. METHODS: We performed post hoc subgroup analyses from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) among nondiabetic participants who were randomized to receive treatment with chlorthalidone (n = 8419), amlodipine (n = 4958), or lisinopril (n = 5034) and observed for a mean of 4.9 years. RESULTS: Mean FG levels increased during follow-up in all treatment groups. At year 2, those randomized to the chlorthalidone group had the greatest increase (+8.5 mg/dL [0.47 mmol/L] vs +5.5 mg/dL [0.31 mmol/L] for amlodipine and +3.5 mg/dL [0.19 mmol/L] for lisinopril). The odds ratios for developing DM with lisinopril (0.55 [95% confidence interval, 0.43-0.70]) or amlodipine (0.73 [95% confidence interval, 0.58-0.91]) vs chlorthalidone at 2 years were significantly lower than 1.0 (P<.01). There was no significant association of FG level change at 2 years with subsequent coronary heart disease, stroke, cardiovascular disease, total mortality, or end-stage renal disease. There was no significant association of incident DM at 2 years with clinical outcomes, except for coronary heart disease (risk ratio, 1.64; P = .006), but the risk ratio was lower and nonsignificant in the chlorthalidone group (risk ratio, 1.46; P = .14). CONCLUSIONS: Fasting glucose levels increase in older adults with hypertension regardless of treatment type. For those taking chlorthalidone vs other medications, the risk of developing FG levels higher than 125 mg/dL (6.9 mmol/L) is modestly greater, but there is no conclusive or consistent evidence that this diuretic-associated increase in DM risk increases the risk of clinical events.

Aged↗
PubMed2000

Major cardiovascular events in hypertensive patients randomized to doxazosin vs chlorthalidone: the antihypertensive and lipid-lowering treatment to prevent heart attack trial (ALLHAT). ALLHAT Collaborative Research Group.

CONTEXT: Hypertension is associated with a significantly increased risk of morbidity and mortality. Only diuretics and beta-blockers have been shown to reduce this risk in long-term clinical trials. Whether newer antihypertensive agents reduce the incidence of cardiovascular disease (CVD) is unknown. OBJECTIVE: To compare the effect of doxazosin, an alpha-blocker, with chlorthalidone, a diuretic, on incidence of CVD in patients with hypertension as part of a study of 4 types of antihypertensive drugs: chlorthalidone, doxazosin, amlodipine, and lisinopril. DESIGN: Randomized, double-blind, active-controlled clinical trial, the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial, initiated in February 1994. In January 2000, after an interim analysis, an independent data review committee recommended discontinuing the doxazosin treatment arm based on comparisons with chlorthalidone. Therefore, outcomes data presented herein reflect follow-up through December 1999. SETTING: A total of 625 centers in the United States and Canada. PARTICIPANTS: A total of 24,335 patients (aged > or = 55 years) with hypertension and at least 1 other coronary heart disease (CHD) risk factor who received either doxazosin or chlorthalidone. INTERVENTIONS: Participants were randomly assigned to receive chlorthalidone, 12.5 to 25 mg/d (n=15,268), or doxazosin, 2 to 8 mg/d (n=9067), for a planned follow-up of 4 to 8 years. MAIN OUTCOME MEASURES: The primary outcome measure was fatal CHD or nonfatal myocardial infarction (MI), analyzed by intent to treat; secondary outcome measures included all-cause mortality, stroke, and combined CVD (CHD death, nonfatal MI, stroke, angina, coronary revascularization, congestive heart failure [CHF], and peripheral arterial disease); compared by the chlorthalidone group vs the doxazosin group. RESULTS: Median follow-up was 3.3 years. A total of 365 patients in the doxazosin group and 608 in the chlorthalidone group had fatal CHD or nonfatal MI, with no difference in risk between the groups (relative risk [RR], 1.03; 95% confidence interval [CI], 0.90-1.17; P=.71). Total mortality did not differ between the doxazosin and chlorthalidone arms (4-year rates, 9.62% and 9.08%, respectively; RR, 1.03; 95% CI, 0.90-1.15; P=.56.) The doxazosin arm, compared with the chlorthalidone arm, had a higher risk of stroke (RR, 1.19; 95% CI, 1.01-1.40; P=.04) and combined CVD (4-year rates, 25.45% vs 21.76%; RR, 1.25; 95% CI, 1.17-1.33; P<.001). Considered separately, CHF risk was doubled (4-year rates, 8.13% vs 4.45%; RR, 2.04; 95% CI, 1.79-2.32; P<.001); RRs for angina, coronary revascularization, and peripheral arterial disease were 1.16 (P<.001), 1.15 (P=.05), and 1.07 (P=.50), respectively. CONCLUSION: Our data indicate that compared with doxazosin, chlorthalidone yields essentially equal risk of CHD death/nonfatal MI but significantly reduces the risk of combined CVD events, particularly CHF, in high-risk hypertensive patients.

Adrenergic alpha-Antagonists↗
PubMed1983

What do subgroup analyses reveal about differential response to beta-blocker therapy? The Beta-Blocker Heart Attack Trial experience.

Results based on small subgroups are prone to much random variation and firm conclusions based on subgroup analyses should be avoided. Caution is advisable, especially with regard to post hoc and multiple analyses. Subgroup findings for which a reasonable biologic explanation can be given and those supported by independent results from other subgroups within the trial are more likely to be real. The strongest support for a subgroup finding in one trial is a replication from another trial. Post hoc analyses from the Beta-Blocker Heart Attack Trial suggest, and are supported by the Norwegian Timolol Study, that myocardial infarction patients older than age 60 years and those with arrhythmic and other complications not severe enough to preclude treatment benefit the most in absolute terms from beta blockers.

Adrenergic beta-Antagonists↗
PubMed2001

Baseline Characteristics of Participants in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

-Diuretics and ss-blockers have been shown to reduce the risk of cardiovascular morbidity and mortality in people with hypertension in long-term clinical trials. No study has compared newer more costly antihypertensive agents (calcium antagonists, ACE inhibitors, and alpha-adrenergic blockers) with diuretics for reducing the incidence of cardiovascular disease in an ethnically diverse group of middle-aged and elderly hypertensive patients. The study is a randomized, double-blind, active-controlled clinical trial designed to determine whether the incidence of the primary outcome, fatal coronary heart disease or nonfatal myocardial infarction, differs between treatment initiation with a diuretic versus each of 3 other antihypertensive drugs. Men and women aged >/=55 years with at least 1 other cardiovascular disease risk factor were randomly assigned to chlorthalidone (12.5 to 25 mg/d), amlodipine (2.5 to 10 mg/d), lisinopril (10 to 40 mg/d), or doxazosin (2 to 8 mg/d) for planned follow-up of 4 to 8 years. This report describes the baseline characteristics of the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) participants. A total of 42 448 participants were randomized from 625 sites in the United States, Canada, Puerto Rico, and the US Virgin Islands. The mean age was 67 years, with 35% aged >/=70 years. Among those randomized, 36% were black, 19% were Hispanic, and 47% were women. The sample includes a high proportion of people with diabetes (36%), patients with existing cardiovascular disease (47%), and smokers (22%). There were no important differences between the randomized treatment groups at baseline. ALLHAT will add greatly to our understanding of the management of hypertension by providing an answer to the following question: are newer antihypertensive agents similar, superior, or inferior to traditional treatment with diuretics?

Journal Article↗
PubMed1995

9-1-1: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee.

The sooner a person who is experiencing symptoms and signs of an acute myocardial infarction (AMI) (including out-of-hospital cardiac arrest) receives medical treatment, the greater his or her chances of survival and limitation of infarct size. A universal 9-1-1 emergency telephone system makes it possible for AMI patients or those around them to easily and quickly call for help and for emergency medical services (EMS) personnel to rapidly and accurately locate the patient. This article by the Access to Care Subcommittee of the National Heart Attack Alert Program (NHAAP) Coordinating Committee describes the history of 9-1-1, its key elements, its current implementation status, and existing State legislation and standards. Currently, approximately 78% of the United States population, mainly in urban areas, has access to a 9-1-1 system. Approximately 195 United States cities with a population of greater than 100,000 people have access to enhanced 9-1-1. It is the contention of the NHAAP that 9-1-1 services should be universally available to all Americans to ensure seamless access to EMS and, potentially, early detection, evaluation, and treatment for AMI. This article reports several key recommendations for achieving this goal.

Death, Sudden, Cardiac↗
PubMed1995

Staffing and equipping emergency medical services systems: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee.

Each year, about 1,250,000 people in the United States experience an acute myocardial infarction (AMI). Emergency medical services (EMS) systems play a key part in the prehospital care and transportation of AMI patients. Rapid, state-of-the-art treatment by EMS personnel is essential for improving AMI survival and outcomes, as dramatized by the patient who is the victim of out-of-hospital cardiac arrest. In order to improve the prehospital care provided to AMI patients, this article by the Access to Care Subcommittee of the National Heart Attack Alert Program Coordinating Committee makes a number of recommendations regarding the staffing and equipping of EMS systems. The recommendations cover the "chain of survival" concept, universal and enhanced 9-1-1, emergency medical dispatching, ground ambulance specifications, automated external defibrillators, advanced life support coverage, medical direction, 12-lead electrocardiograms, and prehospital thrombolysis.

Ambulances↗
PubMed2000

Serum total homocysteine concentration is related to self-reported heart attack or stroke history among men and women in the NHANES III.

High circulating total homocysteine (tHcy) concentration, which is influenced by folate and vitamin B-12 status, is a suspected cause of cardiovascular events. This relation has been investigated in both case-control and prospective studies but has not been evaluated for different sex x age subgroups of the general U.S. population. We used data on adult (i.e., aged > or =40 y) male (n = 1097) and female (n = 1107) participants in the third National Health and Nutrition Examination Survey, excluding diabetics and those supplemented with estrogen, vitamins or minerals, to evaluate the association between serum tHcy concentration and self-report of heart attack or stroke. After adjustment for age, race-ethnicity, smoking, blood pressure, blood pressure medication, body mass index and serum concentrations of creatinine and cholesterol, past events were reported 2.4 (95% confidence interval 1.0-5.5) times as often by men with tHcy concentration of >12 micromol/L as by men with lower values. The odds ratio for women was 2.6 (95% confidence interval 1.1-6.6) after adjustment for the same factors plus menopausal status. A stronger relation in men aged < or =60 y compared with older men may help reconcile conflicting results of earlier studies.

Adult↗
PubMed1987

Survival analysis of adverse effects data in the Beta-Blocker Heart Attack Trial.

Monitoring for adverse effects in an integral part of controlled clinical trials. Traditionally the results of monitoring are reported as either cumulative percentages at the end of the study or cross-sectional percentages at a given time in the study. These results are likely to underestimate the true number of complaints because participants may be withdrawn (e.g., deaths, losses to follow-up, and refusals) before they ever complain of an adverse effect. However, survival analysis methods can be used to compare the distributions of "time to first complaint" in the active and placebo treatment groups, taking into account withdrawals. Participants in the Beta-Blocker Heart Attack Trial were monitored for possible adverse effects. On each follow-up visit they were asked whether they had had any of four conditions (blacking out, fatigue, depression, and bronchospasm) since their previous visit about 3 months earlier. The patients were followed for up to 30 months. For fatigue and bronchospasm, the complaint-free time was significantly longer in the placebo vs. active (propranolol) treatment group (P less than 0.005).

Adult↗
PubMed1991

Abnormal sodium metabolism and plasma renin activity (renal renin secretion) and the vasoconstriction volume hypothesis: implications for pathogenesis and treatment of hypertension and its vascular consequences (heart attack, stroke).

Arterial hypertension is sustained by either of two long-term mechanisms of arteriolar vasoconstriction or by an inappropriate reaction between them. One mechanism is renin-mediated, the other is related to antecedent renal sodium retention. The plasma renin value directly reflects the presence and degree of renin-mediated vasoconstriction, and, inversely, defines the predominance of sodium-related vasoconstriction. A hypotensive response, or lack of it, to angiotensin-converting enzyme inhibitor is similarly informative. Because the normal kidney exposed to high arterial pressure and normal salt intake will reduce its renin secretion to near zero, any renin secretion in a hypertensive setting can be considered abnormal. Typically, high-renin hypertensive patients are more vasoconstricted than low-renin patients with similar blood pressures. The intense vasoconstriction leads to relative hypovolemia, hemoconcentration, hyperviscosity, postural hypotension, and in severe forms even to acrocyanosis, all of which are dramatically reversed with anti-renin therapy. Conversely, low-renin equally hypertensive patients have relatively more sodium volume and are less vasoconstricted; they are generally responsive to natriuretic drugs (e.g., diuretics or calcium antagonists) and appear relatively protected from vascular sequelae such as stroke and heart attack. These observations provide a new means for evaluating prognosis and a basis for mechanistically differentiating and treating hypertensive patients, allowing increasingly simpler and more-specific long-term therapies.

Animals↗
PubMed1995

Emergency medical dispatching: rapid identification and treatment of acute myocardial infarction. National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee.

Emergency medical telephone calls (ie, those made to 9-1-1 or 7-digit emergency numbers) are directed to emergency medical dispatchers (EMDs) who are responsible for quickly obtaining critical pieces of information from the caller, then activating an appropriate level of emergency medical services (EMS) response and providing the caller with patient care instructions until medical help arrives. The impact of well-trained, medically managed EMDs on the early care of potential acute myocardial infarction (AMI) patients is believed to be beneficial. However, standards for emergency medical dispatching vary widely across the nation. To improve emergency medical dispatching for AMI patients in the United States, this article by the Access to Care Subcommittee on behalf of the National Heart Attack Alert Program makes a number of recommendations regarding the use of medical dispatch protocols, provision of dispatch life support, EMD training, EMD certification, and emergency medical dispatch quality control and improvement processes.

Certification↗
PubMed2002

Information women receive about heart attacks and how it affects their knowledge, beliefs, and intentions to act in a cardiac emergency.

In this study we investigate (a) what information women receive on acute myocardial infarction (AMI) from different information sources, (b) how women evaluate this information, and (c) how information acquisition is related to women's knowledge of AMI, personal risk perceptions, and behavioral intentions regarding a cardiac emergency. A random sample of 844 women 50 years and over were telephoned in the state of Washington. Repeated measures regression analyses showed that women receive most of their information on AMI from the mass media, even though they evaluated the media as less believable, less useful, less clear, and making less of an impression than information received from health care providers. Logistic regression analyses showed that the total number of information sources from which heart attack information was received in the past year was positively related to knowledge of AMI symptoms, beliefs about AMI, and personal risk perceptions. The results are discussed in terms of their pragmatic implications.

Adaptation, Psychological↗
PubMed2004

["Heart attack in humans"--the health belief model in comparison with the health reality of patients with myocardial infarction].

Myocardial infarction (MI) is the direct cause of 40% of all deaths, independently of the high standard of medical treatment. The main aim of the study was to define the relationship between the declarative health model (declarations) and the real health activity of the sufferers (realization). The research was performed on 107 patients after acute MI, hospitalized in the Cardiology Department Medical University of Silesia. They were questioned in direct interviews. In addition, the modified form of Shalit's circle was applied. The results indicated the coexistence of two health models of patients. In declarations, there is a model of person with interior attribution of MI (90.65%) that has a feeling of ability to influence his/her health (e.g. through the lifestyle: 63.55%; an individual's character: 41.12%). In realization, there is a model of sick patient with exterior attribution of heart attack (e.g. political and economic crisis, innate predisposition). A similar tendency in the perception of health factors and planning of changes after MI was observed. For instance, 50.47% patients talked about "the increase caution" or "slowing down" as a new planned form of activity. Moreover, of 92% patients who have the social support only 33.64% consider that as an important factor for health. The results suggest a divergence between declarations and real health activity. The launched health model of beliefs seems to be too costly and not attractive enough. Taking into consideration the complete risk factors in MI and making the proposed health belief system more accessible seem to be essential for creating an adequate prevention program.

Adult↗
PubMed1991

Discordant nephron function. A pathogenic factor in hypertension and its vascular complications of stroke and heart attack.

Morphologic evidence from patients with essential hypertension and Goldblatt-type hypertension reveals a subpopulation of narrowed afferent arterioles to ischemic nephrons. These ischemic nephrons, responding individually to their perception of underperfusion, secrete renin. In response, the normal nephrons are in adaptive natriuresis and have appropriately shut off their renin production. Nevertheless, they are affected adversely by the discordant renin-angiotensin II arising from the ischemic nephrons' presence, which exerts an unwanted sodium-retaining effect on the proximal tubules of the adapting nephrons. The end result is elevated blood pressure from too much sodium retention for the level of renin activity, that is, an abnormal renin-sodium product. Thus, "normal" renin levels in a hypertensive individual are abnormal because healthy kidneys shut off renin production entirely when blood pressure rises. This construction explains why angiotensin converting enzyme inhibition often corrects "normal" renin hypertension. Although such hypertension may be partly sodium-mediated as a consequence of inappropriate sodium retention by the normal and ischemic nephrons, the source of the problem lies in the renin production from ischemic nephrons. The correct treatment, then, is an antirenin therapy designed to block renin synthesis or secretion or angiotensin II formation or action. In view of modern studies suggesting that renin excesses also correlate with an increased risk of heart attack and stroke, the role of antirenin and antiangiotensin agents in treatment assumes additional relevance.

Blood Pressure↗
PubMed1982

Criticisms of exercise after heart attack--variations on an old theme?

In many countries it is accepted medical practice for selected patients to undertake carefully prescribed programmes of physical exercise after acute myocardial infarction or coronary bypass surgery. This situation has evolved despite considerable initial and ongoing medical resistance, some of which is now surfacing in this country. The most popular criticisms of exercise programmes for cardiac patients are that such programmes are unsafe, do not provide any medical benefit and are too costly, and that there are insufficient facilities and trained personnel to develop a realistic nationwide rehabilitation service. It is of interest that these criticisms are the same as those which were initially used to counter the proponents of coronary bypass surgery. It can be shown that these arguments are not scientifically valid. The risks of exercise for cardiac patients are minimal and considerably less than those posed by cardiac surgery. There is encouraging evidence that exercise training may reduce morbidity and mortality, but even if such hopes are not fulfilled the improved quality of life enjoyed by cardiac patients who take part in an exercise programme is sufficient to justify this therapy. The additional costs imposed by these programmes are minimal, as are the staffing requirements. It seems likely that just as coronary bypass surgery has overcome widespread medical opposition in this and other countries, so too will the concept of formal exercise training programmes for selected patients after heart attack or coronary bypass surgery.

Coronary Artery Bypass↗
PubMed1998

Heart attacks: exploring new preventive strategies.

Ischaemic heart disease is an emerging public health problem in Sri Lanka. Implementation of programs for lifetime control and prevention of established coronary risk factors such as smoking, hyperlipidaemia, hypertension, diabetes and hereditary risk are costly and unaffordable in countries such as Sri Lanka with limited resources for health care. Other potential risk factors which are less expensive with regard to prevention require investigation. This paper summarises several studies done over the past decade at Peradeniya, to investigate three such potential coronary risk factors of IHD, namely homocysteine, vitamin C and dietary fat.

Adult↗