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PubMed1981

Beta Blocker Heart Attack Trial: design features.

The Beta Blocker Heart Attack Trial (BHAT) is a multicenter, randomized, double-blind, placebo control clinical trial sponsored by the National Heart, Lung, and Blood Institute designed to test the effectiveness of regular propranolol administration in reducing total mortality in patients who have survived a recent acute myocardial infarction. A number of other fatal and nonfatal response variables are also being monitored. Three thousand eight hundred thirty-seven patients, ages 30-69, are being followed at 31 clinical centers for a minimum of about 2 and a maximum of 4 years after the infarction. A number of design features of BHAT are discussed. These include maintenance of patient logs, guidelines for obtaining informed consent of patients, assessment of patient knowledge about BHAT, adjustment of study drug dose based on serum levels, and comparison of 1-hr and 24-hr ambulatory electrocardiogram readings.

Adrenergic beta-Antagonists↗
PubMed1998

What are heart attacks? Rethinking some aspects of medical knowledge.

There has been a modern epidemic of heart attacks in the western world, and this paper is concerned with this 'new' medical condition and how it arose. Two competing theories are commonly proposed, relating either to conventional accounts of medical science, or to social construction. Whilst recognising that aspects of both theories have some validity, it is claimed that neither is wholly adequate. This issue has particular relevance for heart attacks and is explored in some detail, but it also points to some more general conclusions. First that medical knowledge cannot be separated into 'scientific' and 'social' compartments but is united by its human aspect; and second that although medical knowledge has a special dimension, when understood in this way, it may also resonate with a more general re-examination of the relationship between scientific and human knowledge.

Humans↗
PubMed2006

Role of diuretics in the prevention of heart failure: the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial.

BACKGROUND: Hypertension is a major cause of heart failure (HF) and is antecedent in 91% of cases. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) stipulated assessment of the relative effect of chlorthalidone, lisinopril, and amlodipine in preventing HF. METHODS AND RESULTS: ALLHAT was a double-blind, randomized, clinical trial in 33,357 high-risk hypertensive patients aged > or =55 years. Hospitalized/fatal HF outcomes were examined with proportional-hazards models. Relative risks (95% confidence intervals; P values) of amlodipine or lisinopril versus chlorthalidone were 1.35 (1.21 to 1.50; <0.001) and 1.11 (0.99 to 1.24; 0.09). The proportional hazards assumption of constant relative risk over time was not valid. A more appropriate model showed relative risks of amlodipine or lisinopril versus chlorthalidone during year 1 were 2.22 (1.69 to 2.91; <0.001) and 2.08 (1.58 to 2.74; <0.001), and after year 1, 1.22 (1.08 to 1.38; P=0.001) and 0.96 (0.85 to 1.10; 0.58). There was no significant interaction between prior medication use and treatment. Baseline blood pressures were equivalent (146/84 mm Hg) and at year 1 were 137/79, 139/79, and 140/80 mm Hg in those given chlorthalidone, amlodipine, and lisinopril. At 1 year, use of added open-label atenolol, diuretics, angiotensin-converting enzyme inhibitors, and calcium channel blockers in the treatment groups was similar. CONCLUSIONS: HF risk decreased with chlorthalidone versus amlodipine or lisinopril use during year 1. Subsequently, risk for those individuals taking chlorthalidone versus amlodipine remained decreased but less so, whereas it was equivalent to those given lisinopril. Prior medication use, follow-up blood pressures, and concomitant medications are unlikely to explain most of the HF differences. Diuretics are superior to calcium channel blockers and, at least in the short term, angiotensin-converting enzyme inhibitors in preventing HF in hypertensive individuals.

Adrenergic beta-Antagonists↗
PubMed1998

The National Heart Attack Alert Program: Progress at 5 Years in Educating Providers, Patients, and the Public and Future Directions.

The National Heart Attack Alert Program (NHAAP) was launched by the National Heart, Lung, and Blood Institute in 1991 with the goal of reducing morbidity and mortality from acute myocardial infarction (AMI) through the rapid identification and treatment of individuals with symptoms and signs of an AMI. To achieve this goal, the NHAAP established objectives for each of three phases of action where treatment delays can occur: in the hospital, the prehospital setting, and the patient/bystander arena. The NHAAP initially directed its educational efforts toward emergency department professionals. Recommendations for reducing delays in emergency department identification of patients presenting with heart attack symptoms were developed by a working group convened in late 1991. These recommendations were published in February 1994 in a peer-reviewed journal reaching more than 17,000 emergency physicians. The NHAAP worked in a partnership with its coordinating committee, representing 40 health professional, voluntary, and government organizations, to extend the reach of the report's recommendations to their members. Strategies for promoting the emergency department recommendations included publication of excerpts in newsletters and journals of the medical, nursing, and prehospital provider organizations represented on the NHAAP Coordinating Committee, and through symposia at annual meetings. Industry assisted with dissemination efforts and with implementing a continuous quality improvement program based on the paper's recommendations. The NHAAP also developed, with the Joint Committee on Accreditation of Health Care Organizations, a time-to-treatment indicator for thrombolytic therapy to be incorporated into their Indicator Measurement System (IMSystem). To track achievement of the objectives related to the Hospital Action Phase, national data sources for emergency department management of patients with AMI were evaluated at the 5-year point of the NHAAP. Data from a national registry showed that the median time from presentation at the emergency department to receiving thrombolytic therapy declined by about one third between 1992 and the last half of 1995. The percentage of all Medicare patients receiving thrombolytic therapy within the recommended 30 minutes after emergency department arrival nearly doubled between 1992 and 1995. Based on these and other results presented at the 5-year juncture of the program, the NHAAP Coordinating Committee assessed progress and identified new areas of focus for the next 5 years. Improvements in emergency departments' ability to identify and treat AMI patients progressed during the first 5 years of the NHAAP, when the program was highlighting this as a priority. This model is continuing to be used to address delays in the Prehospital Action Phase. Further research from a National Heart, Lung, and Blood Institute (NHLBI) community intervention trial will guide the program in its plans for full-scale public education to address the Patient/Bystander Recognition and Action Phase.

Journal Article↗
PubMed1997

Early heart attack care on the World Wide Web.

UNLABELLED: The Internet is an excellent medium for storing and quickly disseminating large amounts of information on a global basis. The ability to query information "storehouses" makes it even more powerful for end users. This brief article demonstrates key features of the Early Heart Attack Care (EHAC) Web site. Basic navigation and search techniques are covered. The EHAC site contains one of the largest, if not the largest, collection of early heart attack care materials. It can be accessed easily, from virtually anywhere in the world, via the Internet using most standard Web browsers. The World Wide Web, with its graphic multimedia interface, is ideally suited for EHAC's mission of worldwide dissemination of early heart attack care concepts and information to both professionals and the community. DISCLAIMER: The Infobahn is still work in progress. It is not uncommon to hit traffic jams and dead-ends. We have tried to verify most links to the EHAC site but cannot assure their future maintenance.

Computer Communication Networks↗
PubMed2005

Effect of metabolic syndrome on heart attack and mortality in Mexican-American elderly persons: findings of 7-year follow-up from the Hispanic established population for the epidemiological study of the elderly.

PURPOSE: We aim to examine the effect of Metabolic syndrome (MetS) on heart attack and overall mortality in Mexican-American elderly persons over 7-year follow-up. METHODS: We studied 3050 Mexican Americans aged 65 or older from the Hispanic Established Population for the Epidemiological Study of the Elderly conducted in five Southwestern states of the United States. Participants were categorized into two groups: those with or without MetS. A total of 333 (11%) respondents at baseline had met the criteria of MetS (at least three of five characteristics--hyperinsulinemia or fasting plasma glucose > or =110 mg/dl, abdominal obesity, and hypertension--as defined by the World Health Organization). RESULTS: Of 333 participants with MetS, the mean age was 71.1 years and 68% were females (compared with 73.2 years and 56% in those without MetS). Eighty percent of participants with MetS rated their health as fair or poor, compared to 55% of those participants without MetS. Fifty-four percent and 65% of patients with MetS had arthritis and at least one impairment in instrumental activities of daily living (IADL), compared to 39% and 55% of those participants without MetS. MetS was significantly associated with increased incidence of heart attack (odds ratio: 2.75, 95% confidence interval: 1.67-4.54) and was a significant predictor for overall mortality (hazard ratio: 1.46, 95% confidence interval: 1.16-1.84) over a 7-year period after adjusting for other demographic and clinical variables. CONCLUSIONS: Among Mexican-American elderly participants, those with MetS had poorer self-rated health. MetS was significantly associated with increased incidence of heart attack and higher mortality over a 7-year period.

Activities of Daily Living↗
PubMed1996

A survey of treatment routines and educational level of health care providers in the initial phase of suspected acute myocardial infarction in Sweden in 1994. Swedish Working Group on Early Heart Attack Care.

The aim of this survey was to explore treatment routines with regard to early heart attack care at various hospitals in Sweden. All the hospitals in Sweden with a coronary care unit or its equivalent were sent a postal enquiry about early heart attack care including use of various medications and educational level of health care providers. In all, 84 of 86 hospitals (98%) answered the enquiry. Prior to hospital admission, 10% of the hospitals used thrombolytic agents, 10% used beta-blockers and 55% used aspirin. In only 4% of hospitals was thrombolytic treatment initiated in the emergency department and in 17% beta-blockers were initiated. The proportion of acute myocardial infarction (AMI) patients who received thrombolytic treatment varied from 10% to more than 80%, with a mean value of 41%. The proportion of AMI patients who received intravenous beta-blockade varied from 0 to 93%, with a mean value of 24%. This survey indicates that the vast majority of hospitals in Sweden use thrombolytic agents in more than 30% of AMI patients and aspirin in more than 80% of AMI patients. The use of intravenous beta-blockade is lower than expected. Considering the strong association between the delay before instituting therapy and outcome, it is surprising that treatment is not initiated more frequently outside hospital or in the emergency department.

Adrenergic beta-Antagonists↗
PubMed1992

Lewis K. Dahl Memorial Lecture. The renin system and four lines fo hypertension research. Nephron heterogeneity, the calcium connection, the prorenin vasodilator limb, and plasma renin and heart attack.

As the major regulator of arterial blood pressure and sodium balance, the renin axis supports normotension or hypertension via angiotensin-mediated vasoconstriction and angiotensin plus aldosterone-induced renal sodium retention. In this endocrine servo control, renal renin is released by hypotension or salt depletion; conversely, with hypertension or volume excess, plasma renin activity falls to zero. Accordingly, any renal renin secretion is abnormal in the face of arterial hypertension. Human hypertensive disorders comprise a spectrum of abnormal vasoconstriction-volume products (renin-sodium profiles). Excess plasma renin activity for the sodium balance is created by nephron heterogeneity in which a subpopulation of ischemic nephrons hypersecretes renin and retains sodium. This excess renin impairs adaptive natriuresis of neighboring normal nephrons. Research defining the pivotal role of vascular cytosolic calcium for transducing sodium or renin-mediated vasoconstriction explains the selective value of calcium antagonists for correcting the sodium-volume-mediated, and beta-blockers or angiotensin converting enzyme inhibitors for correcting renin-mediated, arteriolar vasoconstriction. The renin precursor prorenin appears to be physiologically active, causing selective vasodilation that offsets renin-mediated vasoconstriction. Overactivity of prorenin may be involved in the hyperperfusion vascular injuries of diabetes mellitus and toxemias. Prorenin underactivity may facilitate renin-mediated ischemic vascular injury. In essential hypertension, undue plasma renin activity is powerfully and independently associated with heart attack risk. Conversely, patients with low renin activity are protected from heart attack despite higher blood pressures and greater age. Also, renin or angiotensin administration consistently causes vascular injury in the heart, brain, and kidneys of animals. These data suggest new potentials for the prevention of cardiovascular sequelae (heart attack and stroke) by using explicit strategies to curtail plasma renin activity.

Calcium↗
PubMedDate not supplied

Lifestyle and 15-year survival free of heart attack, stroke, and diabetes in middle-aged British men.

BACKGROUND: To examine the relationship between modifiable lifestyle factors (smoking, physical activity, alcohol intake, and body mass index [BMI]) and the likelihood of 15-year survival free of major cardiovascular end points and diabetes in middle-aged men. METHODS: A prospective study of 7142 men aged 40 to 59 years at screening with no history of coronary heart disease, diabetes, and stroke drawn from 1 general practice in each of 24 British towns and followed up for 15 years. MAIN OUTCOME MEASURES: Death from any cause and a combined end point, including survival free of heart attacks or stroke or the development of diabetes over a follow-up of 15 years for each man. RESULTS: During the 15-year follow-up, there were 1064 deaths from all causes, 770 major heart attacks (fatal and nonfatal), 247 stroke events (fatal and nonfatal), and 252 cases of diabetes among the 7142 men. After adjustment for age and each of the other modifiable lifestyle factors, the risk of the combined end point (death or having a heart attack, stroke, or diabetes) went up significantly with increasing smoking levels and from BMI levels of 26 kg/m2 or higher, and decreased significantly with increasing levels of physical activity up to levels of moderate activity with no further benefit thereafter (heavy smoking vs never: relative risk [RR] [odds], 2.50; 95% confidence interval [CI], 2.12-2.94; BMI > or = 30 vs 20-21.9 kg/m2: RR, 2.11; 95% CI, 1.71-2.62; moderate vs inactive: RR, 0.60; 95% CI, 0.50-0.72). Light drinking (vs occasional) showed a relatively small but significant reduction in risk (RR, 0.84; 95% CI, 0.74-0.96). Using Cox predictive survival models, the estimated probability of surviving 15 years free of cardiovascular events and diabetes in a man aged 50 years ranged from 89% in a moderately active man at BMI levels of 20 to 24.0 kg/m2 who had never smoked to 42% in an inactive smoker with BMI level of 30 kg/m2 or higher. CONCLUSIONS: Modifiable lifestyles (smoking, physical activity, and BMI) in middle-aged men play an important role in long-term survival free of cardiovascular disease and diabetes. These findings should provide encouragement for public health promotion directed toward middle-aged men.

Adult↗
PubMed1987

The Beta Blocker Heart Attack Trial: recruitment experience.

The Beta Blocker Heart Attack Trial (BHAT) recruited 3837 patients who within the previous 5-21-day period had experienced a myocardial infarction. The purpose of the trial was to test the efficacy of propranolol in decreasing total mortality after such an event. Recruitment was carried out over a 28-month period and involved 31 clinics, 134 hospitals, and 136 acute coronary care units. Of the 157,771 patients admitted to these units, 16,358 met the BHAT criteria for a myocardial infarction, and 23% of those eligible were ultimately randomized. The use of a coronary care unit log was helpful for tracking patients to maximize recruitment and to provide information in regard to the universe from which patients were recruited.

Adrenergic beta-Antagonists↗
PubMed1983

Effect of propranolol on ventricular arrhythmia. The beta-blocker heart attack trial experience.

The Beta-Blocker Heart Attack Trial (BHAT) was a multicenter, randomized, double-blind, placebo-controlled trial that tested the effectiveness of propranolol in reducing the mortality rate in patients after myocardial infarction (MI). Twenty-four hour ambulatory ECG monitoring was done on 3279 of the 3837 enrolled patients at baseline (5-21 days after hospital admission) and repeated after 6 weeks of therapy in a random sample of 25% of the study population. Ventricular arrhythmias were divided into seven different categories and the prevalence of each category is presented. Ventricular arrhythmia at baseline appears to increase with patient age, past history of myocardial infarction, and use of diuretics. Other selected variables--sex, CPK ratio and history of smoking, diabetes and hypertension--appear to be less clearly associated with ventricular arrhythmia. Paired data analysis performed on 826 patients who had ambulatory electrocardiograms both at baseline and after 6 weeks of treatment showed an increased prevalence of ventricular arrhythmia at 6 weeks. This increase was blunted by propranolol therapy.

Adult↗
PubMed1980

Cognitive processes and recovery from heart attack: a review and theoretical analysis.

A review of the literature on psychosocial aspects of recovery from heart attack is presented with emphasis on psychological responses experienced by the patient. Several theoretical models have previously been proposed to explain these data: a psychodynamic view stressing the importance of denial as a coping mechanism, and a second perspective emphasizing patients' beliefs about their health status. A third model is proposed based on cognitive appraisal processes (perceived control and predictability) shown experimentally to mediate reactions to stressors in a wide variety of situations. Viewing heart attack as a crisis situation, it is assumed that particular aspects of illness will generally have a less negative impact on physiological and behavioral health outcomes to the extent they are perceived to be predictable and/or controllable. Specific interventions to alter these perceptions are discussed, and mechanisms linking various recovery outcomes are proposed. The validity of this model is examined with reference to existing research and suggestions for future research are made.

Adaptation, Psychological↗
PubMed1975

Survey of general practitioners' attitudes to management of patients with heart attacks.

Out of 305 general practitioners sent a questionnaire asking how they would treat three hypothetical patients with heart attacks 231 (76%) replied. Of these, only 179 were prepared to make an unqualified choice of home or hospital treatment for a middle-aged man with an uncomplicated attack, 70 (39%) saying that they would keep the patient at home. Practitioners qualifying before 1960 were more likely to do this than those qualifying in 1960 or later. If a patient declined hospital treatment 161 (70%) of the practitioners would keep him in bed for a week or less, but the date of the practitioners' qualification significantly affected the time they would advise him to remain off work. Faced with a patient acutely ill after a heart attack, 162 (70%) of the practitioners would arrange his immediate admission to hospital and 51 (22%) would send him to hospital after initial treatment at home. The numbers of partners in the practice, the nature of the premises, and the location of the practice in urban or rural areas affected the practitioners' attitude to the management of severely ill patients but not to the management of patients with uncomplicated attacks.

Attitude of Health Personnel↗
PubMed1993

Accuracy of recall of hip fracture, heart attack, and cancer: a comparison of postal survey data and medical records.

Accuracy of recall of hip fracture, heart attack, and cancer was evaluated by comparing data obtained from postal surveys and medical records of participants in the Leisure World Disease Prevention Study. The study cohort comprised 13,897 residents of Leisure World Laguna Hills who responded to a questionnaire first mailed in 1981. Follow-up questionnaires requesting information on recent disease history were mailed in 1983 and 1985 to all living cohort members and were returned by 9,734 (86%) and 8,884 (82%) persons, respectively. The proportion of false-positive answers was about 40% for acute myocardial infarction, but less than 10% for hip fracture and cancer. Many of those who gave a false-positive answer on the questionnaire had a condition that the lay population might easily confuse with the condition of interest (e.g., heart attack vs. other cardiovascular disease). Among persons with the disease of interest recorded in the medical record, the percentage who failed to report their events on the questionnaires was highest for those who had an acute myocardial infarction, followed by those who had cancer and those who had hip fracture. The highest rates of confirmation of cancer were for cancers of the breast, bladder, prostate, and uterus. For closely related sites (e.g., colon and rectum), the reliability of reports decreased. The amount of information obtained varied according to the wording of the questionnaire and the specificity of the questions asked. Improved accuracy of recall was observed when the occurrence of specific diseases was asked in addition to a general question about recent hospitalizations.

California↗
PubMed1997

Recognizing a heart attack: the process of determining illness.

OBJECTIVE: To examine the process by which patients with acute myocardial infarction recognize illness and the need for medical treatment. DESIGN: Descriptive, exploratory, qualitative. SETTING: The coronary care and progressive care units of two midwestern medical centers. SUBJECTS: Thirty men and women with a diagnosis of acute myocardial infarction. METHODS: Open-ended interviews were conducted on the fourth or fifth day of hospitalization. All interviews were recorded on audiotape and transcribed. Data were analyzed by using grounded theory methods. RESULTS: Findings of the study indicated that determining illness and the need for medical attention was often a difficult process involving phases. The first phase involved attending to or ignoring bodily sensations as they come and go or additional sensations develop. Some subjects moved precipitously to seeking treatment; others took days to attend to bodily sensations. The second phase involved comparing sensations with those from a previously experienced illness or with the subject's concept of sensations likely to accompany common ailments such as indigestion or flu or more serious illnesses such as ulcer, gallbladder disease, or heart attack. The quality of sensations experienced had an important influence on assigning probable cause and deciding that medical attention is warranted. CONCLUSIONS: The disruptive nature of signs and symptoms and how closely signs and symptoms matched the subject's prototype for a heart attack greatly influenced the determination that illness was present and healthcare was needed. These findings have implications for educating the public about the complex and variable manifestations of a heart attack.

Adult↗
PubMed2006

Clinical events in high-risk hypertensive patients randomly assigned to calcium channel blocker versus angiotensin-converting enzyme inhibitor in the antihypertensive and lipid-lowering treatment to prevent heart attack trial.

The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial (ALLHAT) provides a unique opportunity to compare the long-term relative safety and efficacy of angiotensin-converting enzyme inhibitor and calcium channel blocker-initiated therapy in older hypertensive individuals. Patients were randomized to amlodipine (n=9048) or lisinopril (n=9054). The primary outcome was combined fatal coronary heart disease or nonfatal myocardial infarction, analyzed by intention-to-treat. Secondary outcomes included all-cause mortality, stroke, combined cardiovascular disease (CVD), end-stage renal disease (ESRD), cancer, and gastrointestinal bleeding. Mean follow-up was 4.9 years. Blood pressure control was similar in nonblacks, but not in blacks. No significant differences were found between treatment groups for the primary outcome, all-cause mortality, ESRD, or cancer. Stroke rates were higher on lisinopril in blacks (RR=1.51, 95% CI 1.22 to 1.86) but not in nonblacks (RR=1.07, 95% CI 0.89 to 1.28), and in women (RR=1.45, 95% CI 1.17 to 1.79), but not in men (RR=1.10, 95% CI 0.92 to 1.31). Rates of combined CVD were higher (RR=1.06, 95% CI 1.00 to 1.12) because of higher rates for strokes, peripheral arterial disease, and angina, which were partly offset by lower rates for heart failure (RR=0.87, 95% CI 0.78 to 0.96) on lisinopril compared with amlodipine. Gastrointestinal bleeds and angioedema were higher on lisinopril. Patients with and without baseline coronary heart disease showed similar outcome patterns. We conclude that in hypertensive patients, the risks for coronary events are similar, but for stroke, combined CVD, gastrointestinal bleeding, and angioedema are higher and for heart failure are lower for lisinopril-based compared with amlodipine-based therapy. Some, but not all, of these differences may be explained by less effective blood pressure control in the lisinopril arm.

Amlodipine↗
PubMed1985

Beta-Blocker Heart Attack Trial: impact of propranolol therapy on ventricular arrhythmias.

The natural history of and the effect of propranolol on ventricular arrhythmias post-myocardial infarction were analyzed using data from the Beta-Blocker Heart Attack Trial (BHAT). The Beta-Blocker Heart Attack Trial was a multicenter, randomized, double-blind, placebo-controlled trial among 3,837 patients entered from 5 to 21 days after hospitalization for acute myocardial infarction. At baseline, prior to randomization, 3,290 (85.7%) patients underwent 24-hr ambulatory ECG monitoring which was repeated in approximately 25% of a randomly selected subset of the study population at 6 weeks. Ventricular arrhythmias were divided into eight different categories which defined the prevalence of ventricular arrhythmias in terms of frequency and/or complexity. Ventricular arrhythmias at baseline were associated with age, past history of myocardial infarction, and use of diuretics and digitalis. Paired data (baseline and 6-week) were available for 428 patients on propranolol and 412 on placebo. Propranolol markedly blunted the two- to threefold increase in ventricular arrhythmias that occurred from baseline to 6 weeks in the placebo group. Propranolol decreased the proportion of patients having ventricular arrhythmias during waking hours compared with sleep. These data show that propranolol has an antiarrhythmic effect and suggest that an antiarrhythmic mechanism may in part be responsible for the observed reduction in sudden cardiac death mortality in BHAT.

Adult↗
PubMed1984

"Containing" an infarct: preventing the heart attack in the first place.

The number one health problem and killer of adults in the United States is the heart attack. Since the development of cardiopulmonary resuscitation (CPR) 30 years ago, hospitals have addressed this problem by setting up coronary care units. As a result, approximately 100,000 lives are saved each year, yet an estimated 600,000 people still die each year from heart attack before they reach the hospital. To break this barrier, it is increasingly important to teach, not only CPR throughout the community, but also the early warning signs. In Maryland, a resolution by the State Board of Education and a proclamation by the Governor have jointly designated the high schools as the focal point for teaching. Patients with chest pain must be taught to enter the system early while they still have undamaged myocardium and thus a better chance to respond to modern therapy.

Adult↗