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PubMed2001

Age and the utilization of cardiac catheterization following uncomplicated first acute myocardial infarction treated with thrombolytic therapy (The Second National Registry of Myocardial Infarction [NRMI-2]).

Considerable data indicates that patients <50 years of age have lower morbidity and mortality after acute myocardial infarction (AMI) than older patients. It has been demonstrated that use of routine cardiac catheterization and revascularization in younger patients with AMI and successful thrombolysis does not confer benefit compared with a more conservative approach. Despite this, it has been our impression that cardiac catheterization is frequently employed in younger patients with AMI. Patients with uncomplicated initial AMI treated with thrombolytic therapy in the Second National Registry of Myocardial Infarction (NRMI-2) between June 1994 and April 1998 were identified. Patients were categorized into 4 age strata for purposes of analysis. A total of 61,232 cases met our inclusion criteria. Cardiac catheterization was performed during hospitalization in 78% of patients after an uncomplicated initial AMI. Age was inversely associated with receipt of cardiac catheterization: 85% of those < or =49 years old underwent catheterization compared with 63% of those > or =70 years old. Regression analysis revealed that use of catheterization was 2.9 times greater (95% confidence intervals 2.7 to 3.2) in patients < or =49 years old compared with those > or =70 years old. Geographic location and payor status also strongly influenced utilization of this procedure. In conclusion, routine coronary angiography after uncomplicated AMI is extensively utilized in all age groups, particularly in those <50 years of age. The efficacy and cost effectiveness of this strategy in these patients has not yet been determined in clinical trials.

Age Factors↗
PubMed2003

Time for contrast material to traverse the epicardial artery and the myocardium in ST-segment elevation acute myocardial infarction versus unstable angina pectoris/non-ST-elevation acute myocardial infarction.

Although the time for contrast material to fill the epicardial artery in the setting of acute coronary syndromes has been studied extensively, the time for contrast material to fill the myocardium has not been evaluated. We compared differences in myocardial contrast material transit among patients with unstable angina pectoris/non-ST-elevation acute myocardial infarction (UAP/NSTEAMI) with patients with ST-elevation acute myocardial infarction (STEAMI). The time it took for contrast material to first appear and to arrive at peak intensity in the myocardium was compared in 224 patients with STEAMI enrolled in the LIMIT-AMI study versus 430 patients with UAP/NSTEAMI enrolled in the TACTICS-TIMI 18 trial. In patients with STEAMI, there was a delay in both the time for contrast material to first enter the myocardium (5,619 +/- 1,789 vs 4,663 +/- 1,626 ms, p <0.0001) and the time from entrance to peak blush intensity (2,387 +/- 1,359 vs 1,959 +/- 1,244 ms, p = 0.003) compared with patients with UAP/NSTEAMI. STEAMI remained significantly associated with impaired entrance of contrast material into the myocardium (p <0.0001) in a multivariate model controlling for known correlates of impaired epicardial flow (presence of thrombus, percent diameter stenosis, left anterior descending artery location, and contrast material inflow in the epicardial artery [corrected TIMI frame count]). The time for contrast material to enter the myocardium is impaired to a greater degree in STEAMI compared with UAP/NSTEAMI, even after adjusting for other variables known to delay flow in the epicardial artery. These data provide insight into potential mechanistic differences between these 2 clinical syndromes.

Angina, Unstable↗
PubMed2003

Relation of mortality of primary angioplasty during acute myocardial infarction to door-to-Thrombolysis In Myocardial Infarction (TIMI) time.

For primary angioplasty of acute myocardial infarction (AMI), the relation of treatment benefit and time has been debated. The present study aimed to evaluate, in a single-center cohort of patients with ST-segment elevation AMI, which time intervals were carefully and consistently measured, and the relations among ischemic time, in-hospital delays, and in-hospital survival. We included 499 patients (mean age 59 years; 80% men) who underwent successful primary percutaneous transluminal coronary angioplasty (PTCA) for AMI admitted < or =6 hours after symptom onset. The population was divided into tertiles with respect to time between onset of symptoms and admission, onset of symptoms to Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow, and time from admission to TIMI grade 3 flow. Univariate analysis followed by multiple logistic regression was performed using the variables linked to mortality in the univariate analysis to assess the relation between predictor variables and in-hospital mortality. The in-hospital mortality rate was 3.2%. There was no significant relation between the various tertiles of time intervals and in-hospital mortality. After linear logistic regression, only age (odds ratio [OR] 1.79 per 10 years), female gender (OR 3.56), and door-to-TIMI 3 time (OR 1.27 per 15 minutes) were independently correlated with in-hospital mortality.

Abciximab↗
PubMed1996

Comparison of presentation, treatment, and outcome of acute myocardial infarction in men versus women (the Myocardial Infarction Triage and Intervention Registry)

This study compared the presentation (symptoms and signs), treatment, and outcome of 1,097 consecutive patients (851 men and 246 women) from the Myocardial Infarction Triage and Intervention (MITI) Project Registry with confirmed acute myocardial infarction (AMI), all of whom were initially evaluated in the prehospital setting, met clinical criteria for possible thrombolysis, and were followed throughout their hospital course. Women were older than men and had a higher prevalence of known cardiovascular risk factors, including systemic hypertension and congestive heart failure. The presentation of AMI with respect to symptoms, delay, and hemodynamic and electrocardiographic findings was for the most part indistinguishable between mean and women. Women appeared "undertreated" early in the course of AMI and were half as likely as men to undergo acute catheterization, angioplasty, thrombolysis, or coronary bypass surgery (odds ratio 0.5 [0.3 to 0.7]). The risk for hospital mortality in women was almost twice that for men (odds ratio 1.95 [1.01 to 3.8]). Hospital mortality after AMI was also independently predicted by older age, early evidence of hemodynamic instability, and an intraventricular conduction abnormality on the initial electrocardiogram. Although similar in its presentation, AMI in women is not as aggressively treated, and results in a less favorable outcome than in men. Gender as well as nongender-specific risk factors are important in assessing risk and the likelihood of early intervention after AMI.

Aged↗
PubMed1996

Effects of the early administration of zofenopril on onset and progression of congestive heart failure in patients with anterior wall acute myocardial infarction. The SMILE Study Investigators. Survival of Myocardial Infarction Long-term Evaluation.

Chronic congestive heart failure (CHF) is a common disease responsible for a high mortality and morbidity whose clinical course can be improved by angiotensin-converting-enzyme (ACE) inhibition. However, limited data are available on the effects of ACE inhibitors on the onset and progression of CHF in patients with acute myocardial infarction (AMI). The present study was performed as a substudy of the Survival of Myocardial Infarction Long-term Evaluation trial and involved 1,146 patients with anterior wall AMI not undergoing thrombolysis with the exclusion of patients with prior history or clinical signs of CHF on admission. Patients were randomly allocated to treatment with zofenopril (7.5 to 30 mg twice daily) or placebo for a cumulative period of 6 weeks. The prevalence of CHF, either mild to moderate or severe, has been the main objective and has been evaluated 6 weeks and 1 year after AMI. The overall prevalence of CHF was not reduced by zofenopril after both 6 weeks and 12 months. Conversely the prevalence of severe CHF (1.6% vs 2.6%: risk reduction 55.5%; 95% confidence interval 9 to 63; p = 0.0325) and the combined occurrence of death or severe CHF (4.8% vs 8.2%: risk reduction 59%; 95% confidence interval 11 to 71; p = 0.024) were reduced after 6 weeks of treatment with zofenopril. Moreover, the percentage of patients experiencing a deterioration to severe CHF after 1 year was significantly reduced with zofenopril (11.0% vs 24.3%; p = 0.001). In conclusion, the early administration of zofenopril to patients with AMI attenuates the progression of the clinical symptoms of CHF and its clinical consequences, suggesting that ACE inhibitors should be regarded as a suitable strategy for the prevention and treatment of CHF in patients with AMI.

Adolescent↗
PubMed1996

Effect of reperfusion modality on outcome in nonsmokers and smokers with acute myocardial infarction (a Primary Angioplasty in Myocardial Infarction [PAMI] substudy). PAMI Investigators.

We analyzed the 395 patients randomized into the Primary Angioplasty in Myocardial Infarction (PAMI) trial to receive tissue plasminogen activator (tPA) or to undergo primary percutaneous transluminal coronary angioplasty (PTCA) for acute myocardial infarction (AMI). Of these, 168 were current smokers and 128 had never smoked. Univariate analyses of baseline characteristics and outcome, including death, recurrent AMI, and recurrent ischemia, were done by chi-square analysis. Multivariate stratified analysis was then performed controlling for age and gender, which were found to be confounders of outcome. The combined in-hospital outcomes of death, recurrent AMI, and recurrent ischemia were similar for smokers and nonsmokers (p = 0.12). When stratified according to treatment modality, non-smokers treated with PTCA had a lower frequency of death and nonfatal recurrent AMI (7% vs 18%; p = 0.05), in-hospital ischemia (11% vs 33%; p = 0.004), or the combined event (13% vs 40%; p = 0.001). At 6 months, nonsmokers treated with PTCA continued to have a lower incidence of death or nonfatal recurrent AMI (11% vs 24%; p = 0.07) compared with tPA. Conversely, in smokers, the treatment strategy did not significantly affect hospital outcomes: recurrent ischemia (12% vs 23%; p = 0.07), death and recurrent AMI (6% vs 8%; p = 0.55), or the combined event (15% vs 25%; p = 0.12). The statistical significance of these associations was maintained when multivariate analysis controlling for age and gender was used. Thus, nonsmokers presenting with AMI had a significantly better outcome when treated with primary angioplasty; these differences were not seen in smokers.

Aged↗
PubMed1996

Beta blockers prevent cardiac death following a myocardial infarction: so why are so many infarct survivors discharged without beta blockers?

Too often, infarct survivors are discharged from physician's care and/or hospital stay without beta-blocker therapy. This reflects concerns by physicians regarding precipitation of adverse effects. Ironically, many of the infarct survivors not receiving beta blockers could actually derive the greatest benefits from this treatment.

Adrenergic beta-Antagonists↗
PubMed1997

Usefulness of the admission electrocardiogram for identifying the infarct-related artery in inferior wall acute myocardial infarction.

We analyzed the admission electrocardiogram in 109 patients with inferior wall acute myocardial infarction in an attempt to determine the infarct-related artery (IRA). The presence of ST depression in leads V1 or V2 had a high sensitivity for predicting the left circumflex artery as the IRA. The lack of ST depression in V1 or V2 had a high negative predictive value for excluding the left circumflex artery as the IRA.

Coronary Angiography↗
PubMed1997

Evolution of late potential parameters in thrombolyzed acute myocardial infarction might predict patency of the infarct-related artery.

The objective was to predict the patency grade of an infarct-related artery by identifying the time course of the changes of the late potential parameters before, during, and shortly after thrombolysis. The study population consisted of 51 patients with acute myocardial infarction (AMI) who received thrombolytic therapy within 3.2 +/- 1.3 hours from the onset of symptoms. Multiple signal-averaged electrocardiograms (SAECGs) were recorded before, during, and shortly after thrombolysis. A total of 489 single-averaged electrocardiographic tracings were evaluated. Late potentials were defined as: QRS duration > 114 ms, low amplitude signals (LASs) > 38 ms, and root mean square (RMS) < 20 microV. Late potentials were found in 37% of patients (21 before and 16 during the first 2 hours of thrombolysis), disappeared in all of patients within 89 +/- 75 minutes (range 25 to 350) but reappeared and persisted in 12% of patients, all with an occluded artery (grade 0). The late potential parameters (QRS, LAS, RMS) showed a gradual improvement which occurred earlier (2 vs 4 hours) and was more marked (0.01 vs 0.05) in cases with a patent artery. This improvement expressed by the late potential parameter index (LnQRS + LnLAS - LnRMS) predicts the patent artery with a sensitivity of 0.94 and specificity of 0.79. The improvement of late potential parameters jointly with close to normal initial values or the late potential parameter index and its changes constituted a satisfactory prediction of the patency grade. Thus, the signal-averaged electrocardiographic technique is capable of predicting the early success or failure of thrombolytic therapy.

Coronary Vessels↗
PubMed1997

Effect of propranolol versus no propranolol on total mortality plus nonfatal myocardial infarction in older patients with prior myocardial infarction, congestive heart failure, and left ventricular ejection fraction > or = 40% treated with diuretics plus angiotensin-converting enzyme inhibitors.

At 32-month follow-up of older patients with prior myocardial infarction, congestive heart failure, and a left ventricular ejection fraction > or = 40% treated with diuretics plus angiotensin-converting enzyme inhibitors, and also with digoxin if atrial fibrillation was present, propranolol caused a 35% significant reduction in total mortality and a 37% significant decrease in total mortality plus nonfatal myocardial infarction compared with no propranolol. At 1-year follow-up, propranolol caused a significantly greater increase in left ventricular ejection fraction (6%) and a significantly greater reduction in left ventricular mass (34 g) than did no propranolol (2% and 20 g, respectively).

Adrenergic beta-Antagonists↗
PubMed1997

Comparison of saruplase and alteplase in acute myocardial infarction. SESAM Study Group. The Study in Europe with Saruplase and Alteplase in Myocardial Infarction.

Four hundred seventy-three patients with acute myocardial infarction (AMI) were treated with either saruplase (80 mg/hour, n = 236) or alteplase (100 mg every 3 hours, n = 237). Comedication included heparin and acetylsalicylic acid. Angiography was performed at 45 and 60 minutes after the start of thrombolytic therapy. When flow was insufficient, angiography was repeated at 90 minutes. Coronary angioplasty was then performed if Thrombolysis In Myocardial Infarction (TIMI) trial 0 to 1 flow was seen. Control angiography was at 24 to 40 hours. Baseline characteristics were similar. Angiography showed comparable and remarkably high early patency rates (TIMI 2 or 3 flow) in both treatment groups: at 45 minutes, 74.6% versus 68.9% (p = 0.22); and at 60 minutes 79.9% versus 75.3% (p = 0.26). Patency rates at 90 minutes before additional interventions were also comparable (79.9% and 81.4%). Angiographic reocclusion rates were not significantly different: 1.2% versus 2.4% (p = 0.68). After rescue angioplasty, angiographic reocclusion rates of 22.0% and 15.0% were observed. Safety data were similar for both groups. Thus, (1) early patency rates were high for saruplase and alteplase treatment, (2) reocclusion rates for both drugs were remarkably low, and (3) complication rates were similar. Thus, saruplase seems to be as safe and effective as alteplase.

Aged↗
PubMed1998

Comparison of double bolus urokinase versus front-loaded alteplase regimen for acute myocardial infarction. Thrombolysis in Myocardial Infarction in Korea (TIMIKO) study group.

This study was performed to compare the double bolus urokinase regimen with the front-loaded alteplase regimen for acute myocardial infarction. Double bolus urokinase is an easy, safe, and effective thrombolytic regimen with comparable results to standard front-loaded alteplase in acute myocardial infarction.

Adolescent↗
PubMed1999

Early infarct artery collateral flow does not improve long-term survival following thrombolytic therapy for acute myocardial infarction.

It is known that acutely developed collaterals can prevent the onset of acute myocardial infarction (AMI) in the presence of a total coronary occlusion. However, there still is controversy concerning long-term follow-up of coronary collateral circulation to the infarct-related artery. In this study we analyze the prognostic role of collateral flow (degrees 0 to 3) as well as anterograde flow (degrees 0 to 3) in patients with AMI treated with thrombolytic therapy. Four hundred twenty-two patients (median age 57 years, 355 men) with AMI were treated with intravenous streptokinase and followed prospectively for up to 8 years. At the end of the study period, patients with collateral coronary flow 3 (n = 30) and those with flow <3 (n = 392) at in-hospital coronary arteriography had survival rates of 66% and 85%, respectively (p <0.12). Meanwhile, patients with coronary anterograde flow 3 (n = 189) and those with flow <3 (n = 233) had survival rates of 89% and 80%, respectively (p <0.04). By censored regression analysis, a negative correlation was found between coronary collateral flow degree and survival (p = 0.0498) and, inversely, a positive correlation was found between coronary anterograde flow degree and survival (p = 0.0053). By Cox multivariate analysis, the following variables showed significant correlations with long-term survival: global left ventricular ejection fraction (p = 0.0003), anterograde flow degree (p = 0.0006), collateral flow degree (negative correlation, p = 0.0179), and medical treatment (negative correlation, p = 0.0464). Thus, patients treated with intravenous streptokinase during AMI and with adequate coronary collateral circulation had a worse prognosis than those who developed adequate anterograde flow, probably because of residual myocardial ischemia. Such patients may benefit from coronary revascularization (angioplasty or surgery) to restore anterograde blood flow and minimize myocardium at risk.

Cardiac Catheterization↗
PubMed1999

Nonsteroidal anti-inflammatory drugs after acute myocardial infarction. DAVIT Study Group. Danish Verapamil Infarction Trial.

The effect of nonsteroid anti-inflammatory drugs (NSAIDs) after acute myocardial infarction was studied in a retrospective study of 88 patients who were receiving regular NSAID treatment at randomization in the Danish Verapamil Infarction Trial II. There were no significant differences in mortality or major events between NSAID-treated patients versus controls (1,687); however, in a multivariate analysis a nonsignificant beneficial trend in favor of NSAIDs was observed.

Aged↗
PubMed1999

Primary coronary infarct artery stenting in acute myocardial infarction.

Completed and ongoing randomized trials have provided results that favor primary infarct-related artery (IRA) stenting as opposed to primary percutaneous transluminal coronary angioplasty, but the applicability of the trial results to all patients with acute myocardial infarction (AMI) has not yet been investigated. This study sought to determine the applicability of an unconditional IRA stenting strategy in nonselected patients with AMI. After successful mechanical recanalization of the IRA, all patients with AMI and a reference diameter > or =2.5 mm were considered eligible for primary IRA stenting without any restriction regarding age or clinical status on presentation. The primary end point of the study was a composite end point defined as death, reinfarction, or repeat target lesion revascularization. Primary IRA stenting was successfully performed in 161 of 190 consecutive patients with AMI (85%), and of 162 (99%) considered suitable for stenting. Patients with nonstented IRA had a reference IRA diameter smaller than patients with a stent (2.71+/-0.48 vs 3.20+/-0.41 mm, p <0.001). Overall, the 6-month mortality was 5%. Mortality was 2% for patients without, and 32% for patients with cardiogenic shock. The incidences of reinfarction and of repeat target lesion revascularization were 1% and 12%, respectively. The 6-month angiographic follow-up showed an IRA patency rate of 94% and a restenosis rate of 26%. The results of this study strengthen the hypothesis that unconditional primary IRA stenting is highly feasible, and may actually improve the outcome of patients with AMI.

Adult↗
PubMed1999

Relation between infarct artery patency at late angiography after acute myocardial infarction and signal-averaged electrocardiography.

The angiograms of 89 patients were reviewed from the LATE Ancillary Study (randomized trial of recombinant tissue plasminogen activator vs placebo in patients with symptom onset after 6 hours of myocardial infarction) to determine patency of the infarct-related artery (IRA). In the occluded IRA group (n = 35), the incidence of signal-averaged electrocardiographic abnormality (fQRS > 120 ms) was significantly higher (p = 0.04), the filtered QRS duration was significantly longer (p = 0.007), and the V40 was significantly shorter (p = 0.02), compared with the patent IRA group (n = 54).

Adult↗
PubMed2000

ST-segment resolution and infarct-related artery patency and flow after thrombolytic therapy. Thrombolysis in Myocardial Infarction (TIMI) 14 investigators.

Because patients who fail to achieve reperfusion after thrombolytic therapy remain at high risk for morbidity and mortality, noninvasive measures of infarct-related artery (IRA) patency are needed to identify candidates for rescue interventions. We prospectively studied 444 patients from the Thrombolysis In Myocardial Infarction (TIMI) 14 trial with interpretable baseline and 90 minute 12-lead electrocardiograms. The percent resolution of ST-segment deviation from baseline to 90 minutes was compared with 90-minute IRA TIMI flow grade, as determined in an angiographic core laboratory. Patients with complete (> or = 70%) ST resolution (n = 208; 47%) had a patency (TIMI 2 or 3 flow) rate of 94%, a TIMI 3 flow rate of 79%, and a 30-day mortality rate of 1.0%. Patients with partial (30% to 70%) or no (< or = 30%) ST resolution had significantly lower rates of patency (72% and 68%; p < 0.0001 vs complete ST resolution) and TIMI 3 flow (50% and 44%; p < 0.0001 vs complete ST resolution), and higher 30-day mortality (4.2% and 5.9%; p = 0.01 vs complete ST resolution). With use of electrocardiographic criteria alone, approximately 50% of patients can be classified as having a high (94%) probability of IRA patency and a very low risk for mortality. Angiography to determine patency of the IRA may be unnecessary in these patients. In patients without complete (> or = 70%) ST resolution, the IRA is still likely to be patent, and additional information from clinical variables or serum markers may help to identify candidates for coronary angiography. Patients with persistent ST elevation despite a patent IRA are at increased risk for mortality, likely due to extensive microvascular and tissue injury.

Abciximab↗
PubMed1995

Factors influencing the time to administration of thrombolytic therapy with recombinant tissue plasminogen activator (data from the National Registry of Myocardial Infarction). Participants in the National Registry of Myocardial Infarction.

Very early administration of thrombolytic therapy for acute myocardial infarction (AMI) has significantly reduced mortality in eligible patients. The purpose of this study was to evaluate factors which influenced the time from symptom onset to hospital presentation and the time from hospital presentation to the onset of thrombolytic treatment in a large population of patients with AMI. This study included 212,990 patients from 904 hospitals that participated in the National Registry of Myocardial Infarction. The median time from symptom onset to hospital presentation for those treated was 1.5 hours versus 2.7 hours for those not receiving thrombolytic treatment. Older patients and women had increased delay times, as did those who arrived at the hospital during daytime hours. Of the 59,802 (28%) patients who received thrombolytic treatment, 23% were treated < 30 minutes from admission; 63%, < 60 minutes; and 83%, < 90 minutes. Time to treatment increased with age and was longer for women and for patients arriving between midnight and early morning. The most important factor associated with shorter time to treatment was the initiation of thrombolytic treatment in the emergency department rather than in the coronary care unit (47 vs 73 minutes, p < 0.0001). Hospital treatment times are much too long, given that quick identification and treatment of eligible patients are of primary importance in reducing mortality from AMI. To shorten these times, thrombolytic treatment should be initiated in the emergency department, and the effectiveness of hospital programs aimed at reducing time to treatment should be subject to continuing quality improvement surveillance.

Aged↗