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PubMed2004

"Homicide by heart attack" revisited.

The sudden death of a person caused by an arrhythmia that is induced by physical and/or emotional stress provoked by the criminal activity of another person is sometimes referred to as "homicide by heart attack." Published criteria for such an event relate to situations where no physical contact occurs between the perpetrator and the victim. Situations involving physical contact, but with absence of lethal injuries, are frequently treated is a similar fashion by forensic pathologists. Herein, we propose a set of modified criteria, which include cases where physical contact has occurred. Five examples of so-called "homicide by heart attack" are presented, including a 40-year-old man who was struck in the head with a wooden statue, a 74-year-old man who was punched in the jaw by a robber, a 66-year-old woman who was started awake by a home-intruder, a 67-year-old woman who struggled with a would-be purse-snatcher in a parking lot, and a 52-year-old man who was in a physical altercation with a younger man. In each instance, autopsy revealed the presence of severe, underlying heart disease, as well as absence of lethal injuries. In each case, investigative information was such that the emotional and/or physical stress associated with the criminal activity of another individual was deemed contributory to the death. The presumed mechanism of death in each case was a cardiac dysrhythmia related to underlying heart disease, but initiated by the emotional and/or physical stress.

Adult↗
PubMed1982

The natural history of acute heart attacks. Cape general practitioner series.

One hundred and twenty-nine Cape Town general practitioner participated in an emergency coronary care project in which one of the main aims was to survey the natural history of acute heart attacks in their practices over a 14-month period. Although the 1-month community mortality rate (28% of 445 patients of all ages and 23% of 356 patients under the age of 70 years) compared favourably with those of other series, the proportion of patients dying before hospitalization was similar to that of other series (approximately two-thirds). Of the 140 deaths in patients of all ages over a 3-month period, 71 (51%) took place before hospitalization or emergency treatment (pretreatment phase); 85 (60,7%) were due to probable or recorded arrhythmias and 47 (33,6%) to pump failure. Of the 71 deaths in the pretreatment phase, 67 (94%) were caused by a probable arrhythmia. Forty-four of the 69 deaths that occurred after treatment and up to 3 months after the onset of symptoms were due to pump failure. Thus, it is concluded that the commonest post-treatment cause of death is pump failure. Conversely, deaths due probable arrhythmias are most common in the absence of medical intervention, when failure deaths are arae. Of the 140 who died, 37% (52 patients) died within 1 hour of the onset of symptoms and 51% (72 patients) within 4 hours after the onset of symptoms. When therapeutic intervention occurred even within the first 2 hours of symptoms, deaths due to probable arrhythmias could be avoided, with only 3 occurring in 188 treated patients. This natural history survey of acute heart attacks is the first of its kind in South Africa.

Acute Disease↗
PubMed2001

Operational aspects of terminating the doxazosin arm of The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized, practice-based trial sponsored by the National Heart, Lung, and Blood Institute (NHLBI). The double-blind, active-controlled component of ALLHAT was designed to determine whether the rate of the primary outcome-a composite of fatal coronary heart disease and nonfatal myocardial infarction-differs between diuretic (chlorthalidone) treatment and each of three other classes of antihypertensive drugs: a calcium antagonist (amlodipine), an angiotensin-converting enzyme inhibitor (lisinopril), and an alpha-adrenergic blocker (doxazosin) in high-risk hypertensive persons ages 55 years and older. In addition, 10,377 ALLHAT participants with mild to moderate hypercholesterolemia were also enrolled in a randomized, open-label trial designed to determine whether lowering serum LDL cholesterol with an HMG CoA reductase inhibitor (pravastatin) will reduce all-cause mortality as compared to a control group receiving "usual care." In January 2000, an independent data review committee recommended discontinuing the doxazosin treatment arm. The NHLBI director promptly accepted the recommendation. This article discusses the steps involved in the orderly closeout of one arm of ALLHAT and the dissemination of trial results. These steps included provisional preparations; the actual decision process; establishing a timetable; forming a transition committee; preparing materials and instructions; informing 65 trial officers and coordinators, 628 active clinics and satellite locations, 313 institutional review boards, over 42,000 patients, and the general public; reporting detailed trial results; and monitoring the closeout process. Control Clin Trials 2001;22:29-41

Adverse Drug Reaction Reporting Systems↗
PubMed1999

Prehospital delay in patients hospitalized with heart attack symptoms in the United States: the REACT trial. Rapid Early Action for Coronary Treatment (REACT) Study Group.

BACKGROUND: The use of thrombolytic therapy for patients with myocardial infarction has been limited by patient delay in seeking care. We sought to characterize prehospital delay in patients hospitalized for evaluation of heart attack symptoms. METHODS AND RESULTS: The Rapid Early Action for Coronary Treatment (REACT) is a multicenter, randomized community trial designed to reduce patient delay. At baseline, data were abstracted from the medical records of 3783 patients hospitalized for evaluation of heart attack symptoms in 20 communities. The median prehospital delay was 2.0 hours; 25% of patients delayed longer than 5.2 hours. In a multivariable analysis, delay time was longer among non-Hispanic blacks than among non-Hispanic whites, longer at older ages, longer among Medicaid-only recipients and shorter among Medicare recipients than among privately insured patients, and shorter among patients who used an ambulance. CONCLUSIONS: The observed pattern of differences is consistent with the contention that demographic, cultural, and/or socioeconomic barriers exist that impede rapid care seeking.

Adult↗
PubMed1983

Effect of propranolol in reducing mortality in older myocardial infarction patients. The Beta-Blocker Heart Attack Trial experience.

The results from the Beta-Blocker Heart Attack Trial for patients ages 60-69 years indicate a significant beneficial effect of propranolol and an overall reduction in mortality of 33%. This beneficial effect appears to begin early and continues through 3 years of follow-up. Examination of patient complaints and medical reasons for withdrawing study medication indicates that side effects resulting from propranolol use were infrequent in both the younger and older age groups, and there were no major differences between the two groups. Given these results, and considering the large number of hospital-diagnosed myocardial infarctions that occur each year in persons older than 60 years of age, it appears that the use of propranolol, where not contraindicated, could delay mortality in a substantial number of older postinfarction patients.

Adult↗
PubMed1999

Heart attacks and lower-limb function in master endurance athletes.

PURPOSE: Whether very vigorous physical activity bestows on the participant more health benefits or more adverse effects is unclear: we investigated whether men participating in competitive endurance sports in middle and old age are at increased risk of heart attacks as well as of lower-limb osteoarthritis and disability. METHODS: In our cohort study with an 11-yr follow-up, we studied 269 male orienteering runners (mean age 48.6 yr at baseline; range 37-61), who in 1984 were placed among the 60 best in their master orienteer age-class in Finland, and 188 male nonsmoking controls (mean age 50.4 yr; range 39-61) classified as healthy at 20 yr of age and without overt ischemic heart disease up until 1985. We followed mortality and studied the prevalence of questionnaire-reported physician-diagnosed diseases and disabilities at the end of the follow-up in late 1995. RESULTS: Two (0.7%) of the 269 runners and 10 (5.3%) of the 188 controls had suffered myocardial infarctions during the follow-up, the age-adjusted odds ratio (95% confidence interval) being 0.15 (0.03-0.67) in runners compared with controls (P = 0.0059). At follow-up, orienteering runners reported knee osteoarthritis and knee pain more often than did the controls, whereas the occurrence of hip osteoarthritis and hip pain did not differ. Disability due to hip or knee pain after the same everyday activities tended to be less in the runners. CONCLUSION: In top-level master endurance athletes having a long-term training background and participating in competitive endurance sports, the risk both of heart attack and of lower-limb disability is low.

Adult↗
PubMed2006

St. Francis Health System overhauls heart attack care process.

For scoring in the top 20% of hospitals for acute myocardial infarction (AMI), Bon Secours' St. Francis Hospital, in Greenville, SC, received a $54,000 bonus check last November from a Medicare pay-for-performance demonstration project. By implementing several process improvements, including improving its door to balloon time--the time it takes for a heart attack patient to enter the emergency department and then having an angioplasty in the cardiac cath lab--St. Francis' composite quality scores improved to 98% from 90% for AMI, or heart attack.

Acute Disease↗
PubMed1978

Cutting back after a heart attack: an overview.

Increasingly, health workers are concerned with the alteration of complex and deeply embedded behaviors; essential to these tasks is an understanding of the other's situation as he or she views it. This study took the perspective of the patient, inductively generating a conceptual formulation to explain and understand life after a heart attack. The basic problem of minimizing losses under conditions of uncertainty and unknown parameters of action is confronted. Resolution is achieved through "cutting back," which has three major stages: (1) immobilization, characterized by explaining and estimating the damage; (2) resumption, in which patients figure the complex calculus of the new situation to determine what they must cut back, what they should cut back, and what they will and will not cut back; and (3) new normal, when the major work is that of adjusting to the permanent changes wrought by the heart attack experience which affect identity. Exploratory diagnosis of complex health education problems through a "grounded theory" approach is demonstrated by the study.

Adaptation, Psychological↗
PubMed2002

Relationship of antihypertensive treatment regimens and change in blood pressure to risk for heart failure in hypertensive patients randomly assigned to doxazosin or chlorthalidone: further analyses from the Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial.

BACKGROUND: The Antihypertensive and Lipid-Lowering treatment to prevent Heart Attack Trial reported that treatment initiated with doxazosin compared with chlorthalidone doubled the risk for heart failure in high-risk hypertensive patients (relative risk, 2.04 [95% CI, 1.79 to 2.32]). Patients assigned to doxazosin therapy had a mean in-trial systolic/diastolic blood pressure 3/0 mm Hg higher than that in patients assigned to chlorthalidone. Sixty-eight percent (6167 of 9061) of the former patients and 59% (9081 of 15 256) of the latter patients were given additional medications to achieve a target blood pressure of less than 140/90 mm Hg. OBJECTIVE: To ascertain the influence of open-label antihypertensive drugs and subsequent blood pressure on relative risk for heart failure. DESIGN: Randomized, double-blind, active-controlled clinical trial. SETTING: 623 sites in the United States and Canada. PATIENTS: Hypertensive patients 55 years of age or older with at least one additional risk factor for cardiovascular disease. INTERVENTION: Chlorthalidone (12.5 to 25 mg/d) or doxazosin (2 to 8 mg/d) for a planned follow-up of 4 to 8 years. MEASUREMENTS: Data on blood pressure, medication, and incident heart failure (treated outside hospital, hospitalized, or fatal) from February 1994 through December 1999. RESULTS: After the treatment groups were categorized as having no exposure to open-label medications (monotherapy) or exposure to open-label therapy, the relative risk for heart failure with doxazosin versus chlorthalidone was 3.10 (CI, 2.51 to 3.82) and 1.42 (CI, 1.20 to 1.69), respectively. After adjustment for follow-up systolic/diastolic blood pressure, the overall relative risk was 2.00 (CI, 1.72 to 2.32). CONCLUSION: In high-risk patients with hypertension, the higher risk for heart failure while taking doxazosin compared with chlorthalidone is attenuated but not eliminated by adding other antihypertensive drugs. The small observed difference in systolic blood pressure does not explain this increased risk.

Antihypertensive Agents↗
PubMed2002

Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual care: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT-LLT).

CONTEXT: Studies have demonstrated that statins administered to individuals with risk factors for coronary heart disease (CHD) reduce CHD events. However, many of these studies were too small to assess all-cause mortality or outcomes in important subgroups. OBJECTIVE: To determine whether pravastatin compared with usual care reduces all-cause mortality in older, moderately hypercholesterolemic, hypertensive participants with at least 1 additional CHD risk factor. DESIGN AND SETTING: Multicenter (513 primarily community-based North American clinical centers), randomized, nonblinded trial conducted from 1994 through March 2002 in a subset of participants from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT). PARTICIPANTS: Ambulatory persons (n = 10 355), aged 55 years or older, with low-density lipoprotein cholesterol (LDL-C) of 120 to 189 mg/dL (100 to 129 mg/dL if known CHD) and triglycerides lower than 350 mg/dL, were randomized to pravastatin (n = 5170) or to usual care (n = 5185). Baseline mean total cholesterol was 224 mg/dL; LDL-C, 146 mg/dL; high-density lipoprotein cholesterol, 48 mg/dL; and triglycerides, 152 mg/dL. Mean age was 66 years, 49% were women, 38% black and 23% Hispanic, 14% had a history of CHD, and 35% had type 2 diabetes. INTERVENTION: Pravastatin, 40 mg/d, vs usual care. MAIN OUTCOME MEASURES: The primary outcome was all-cause mortality, with follow-up for up to 8 years. Secondary outcomes included nonfatal myocardial infarction or fatal CHD (CHD events) combined, cause-specific mortality, and cancer. RESULTS: Mean follow-up was 4.8 years. During the trial, 32% of usual care participants with and 29% without CHD started taking lipid-lowering drugs. At year 4, total cholesterol levels were reduced by 17% with pravastatin vs 8% with usual care; among the random sample who had LDL-C levels assessed, levels were reduced by 28% with pravastatin vs 11% with usual care. All-cause mortality was similar for the 2 groups (relative risk [RR], 0.99; 95% confidence interval [CI], 0.89-1.11; P =.88), with 6-year mortality rates of 14.9% for pravastatin vs 15.3% with usual care. CHD event rates were not significantly different between the groups (RR, 0.91; 95% CI, 0.79-1.04; P =.16), with 6-year CHD event rates of 9.3% for pravastatin and 10.4% for usual care. CONCLUSIONS: Pravastatin did not reduce either all-cause mortality or CHD significantly when compared with usual care in older participants with well-controlled hypertension and moderately elevated LDL-C. The results may be due to the modest differential in total cholesterol (9.6%) and LDL-C (16.7%) between pravastatin and usual care compared with prior statin trials supporting cardiovascular disease prevention.

Aged↗
PubMed1984

Prediction of emotional and social outcome after a heart attack.

Data from two prospectively studied series of patients recovering from heart attacks (n = 129 and 100) were analysed to determine the extent to which early findings can predict later psychological and social outcome. Some aspects of early and late outcome can be predicted with modest accuracy by multiple regression analysis of information obtained during the acute hospital admission. More accurate, and therefore clinically more useful, prediction of late outcome is possible in early convalescence. It is suggested that systematic clinical assessment during admission and a few weeks after return home could detect most patients in need of extra specialist rehabilitation.

Convalescence↗
PubMed1975

Carbon monoxide and heart attacks.

A study of the relationship between carbon monoxide exposure and heart attacks was conducted in Baltimore. There was no evidence of clustering of either myocardial infarction or sudden ASHD on a specific day, nor was there correlation between the number of cases per day and ambient CO levels. Postmortem HbCO levels were slightly higher in ASHD sudden deaths than in sudden deaths due to other causes. Any differences were probably primarily due to cigarette smoking. Cigarette smokers who died suddenly due to ASHD had substantially higher postmortem HbCO levels than nonsmokers. Practically all of the elevated HbCO levels could be related to cigarette smoking or specific environmental exposure. There were no differences between HbCO levels in ASHD sudden death patients and in living controls. There was also no relationship between cardiac pathologic findings and postmortem HbCO levels among patients dying suddenly of ASH.

Adult↗
PubMed1983

Family coping with the crisis of heart attack.

Forty families of patients who had suffered from their first heart attack were studied during the hospitalization and after discharge. Areas of family functioning examined were maintenance of the emotional health of family members, financial management, household management, and dealing with children and their needs. Impacts of this family crisis varied among these areas as well as over time. Families employed different sets of coping strategies in different areas of their life. Implications of these findings for social work intervention in such crises are discussed.

Crisis Intervention↗
PubMed2003

Perspectives from the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial--Lipid Lowering Trial and the Anglo-Scandinavian Cardiac Outcomes Trial--Lipid Lowering Arm.

PURPOSE OF REVIEW: The design, process and outcomes are compared between two large clinical trials of LDL cholesterol reduction with statin treatment in patients with known high blood pressure. This new information is placed in the context of previous clinical trials of cholesterol reduction, which have provided analyses of sub-groups with high blood pressure. RECENT FINDINGS: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial failed to find a significant reduction of total mortality (primary endpoint), cardiovascular mortality or major cardiovascular events. This differed sharply from the Anglo-Scandinavian Cardiac Outcomes Trial, Lipid Lowering Arm, which was stopped before the planned termination due to a marked reduction (36%) in coronary death or myocardial infarction (primary endpoint). This trial also found significant reductions in stroke (27%) and separately, all major vascular events (21%). The two studies were similar in that they each contained over 10 000 participants with documented high blood pressure requiring drug therapy and they both used a fixed dose of a single statin. Pravastatin (40 mg/day) was used in the former and atorvastatin 10 mg/day in the latter. The major difference was that the control group in the Anglo-Scandinavian trial was treated with placebo with a double blind design whereas antihypertensive and lipid-lowering trial was open label with controls receiving usual care. SUMMARY: The benefit of achieving and maintaining significant LDL cholesterol reduction in patients with high blood pressure was convincingly demonstrated in the Anglo-Scandinavian trial. The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial failed to achieve similar success due to use of a less effective drug and loss of the differential effect with increasing statin treatment in the usual care control group.

Aged↗
PubMed2004

Hampering a heartbreaker. Antibiotic might stem injury from heart attack.

A TV ad urges people who think they're having a heart attack to pop an aspirin before rushing to the emergency room. They might be even better off taking antibiotics, according to a new study. The work shows that an antibiotic stems a previously untreatable form of heart damage not by killing bugs but by suppressing cellular enzymes.

Animals↗
PubMed1982

Increased physical activity: a protective factor against heart attacks in Puerto Rico.

The incidence and potential risk factors of coronary heart disease were assessed in 2,585 rural and 6,208 urban men, aged 45 to 64 years, participating in the Puerto Rico Heart Health Program, a prospective epidemiologic study of coronary heart disease initiated in 1965. An index of daily physical activity and a metabolic equivalent of heaviest activity were estimated from each individual history. Rural men had higher mean levels of overall activity as well as higher levels of heavy activity than urban men. An 8 1/4 year follow-up study for coronary heart disease other than angina pectoris was analyzed for relationships with physical activity. Significant inverse associations were found for both urban and rural men. Metabolic equivalent of heaviest activity showed similar results. Although the physical activity index was inversely associated with most known coronary risk factors, multivariate analyses indicated that a significant independent inverse relationship existed with the incidence of coronary heart disease. In Puerto Rico, increased physical activity appears to be a separate protective factor against heart attacks.

Activities of Daily Living↗
PubMed2001

Participant recruitment in the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a practice-based, randomized, multicenter clinical trial in 42,419 high-risk hypertensive patients aged 55 years and older; 10,356 of these patients are also in a lipid-lowering trial component. The purpose of the antihypertensive component is to determine whether the occurrence of fatal coronary heart disease and/or nonfatal myocardial infarction differs between patients randomized to diuretic (chlorthalidone) and those randomized to either calcium antagonist (amlodipine), angiotensin-converting enzyme inhibitor (lisinopril), or alpha-adrenergic blocker (doxazosin) therapy. (The doxazosin arm has been discontinued.) The purpose of the lipid-lowering component is to determine whether lowering low-density lipoprotein cholesterol with a 3-hydroxymethyl-glutaryl coenzyme A reductase inhibitor (pravastatin) in moderately hypercholesterolemic patients will reduce all-cause mortality compared to a control group receiving "usual care." ALLHAT recruited patients from a variety of practice settings from February 1994 through January 1998. Sites were paid for randomizations and are paid for completed follow-up visits and documented study events. Communication and monitoring were facilitated by nine regional coordinator teams. It was recognized from the outset that patient recruitment would be a very large task because of the number of participants (> 40,000) needed, the ambitious nature of the goal for recruitment of African-Americans (> 55%), and the knowledge that many investigators had limited experience recruiting participants for clinical trials. Multiple adjustments in the initial ALLHAT overall recruitment plan facilitated achievement of sample size goals for both components of the trial. The experience obtained from this large trial should be valuable for the planning and implementation of successful recruitment in future trials.

Aged↗
PubMed2003

Effects of propranolol on recovery of heart rate variability following acute myocardial infarction and relation to outcome in the Beta-Blocker Heart Attack Trial.

This study evaluated the effects of propranolol on recovery of heart rate variability (HRV) after acute myocardial infarction and its relation to outcome in the Beta-blocker Heart Attack Trial (BHAT). Beta blockers improve mortality after acute myocardial infarction, but through an unknown mechanism. Depressed HRV, a measure of autonomic tone, predicts mortality after acute myocardial infarction. Whether beta blockers influence recovery of HRV after acute myocardial infarction, and thereby improve outcome, is unknown. We compared 24-hour HRV parameters at 1 week after acute myocardial infarction and after 6 weeks of treatment with propanolol (n = 88) or placebo (n = 96). The relation between 25-month outcome (death/acute myocardial infarction/congestive heart failure), propranolol treatment, and HRV was further analyzed. After 6 weeks, high-frequency (HF) power (log-normalized), an index of vagal tone, increased more in propranolol-treated patients (4.28 +/- 0.1 to 5.17 +/- 0.09 ms(2)) than in placebo-treated patients (4.26 +/- 0.09 to 4.77 +/- 0.1 ms(2), p <0.05). Sympathovagal balance measured by the low-frequency (LF) to HF ratio increased in placebo-treated patients (3.55 +/- 0.24 to 3.86 +/- 0.24) but decreased in those treated with propranolol (3.76 +/- 0.29 to 3.17 +/- 0.23, p <0.01). Other frequency-domain parameters increased over time but were not affected by propranolol. Propranolol blunted the morning increase in the LF/HF ratio. Recovery of HF, the strongest HRV predictor of outcome, and propranolol therapy independently predicted outcome. In summary, after acute myocardial infarction, propranolol therapy improves recovery of parasympathetic tone, which correlates with improved outcome, and decreases morning sympathetic predominance. These findings may elucidate the mechanisms by which beta blockers decrease mortality and reduce the early morning risk of sudden death after acute myocardial infarction.

Adrenergic beta-Antagonists↗