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Formation of a left ventricular aneurysm and intraventricular thrombus represents one of the dreaded sequelae of coronary artery disease and acute myocardial infarction. The present emphasis is to reduce the incidence by reduction of cholesterol and fats, elimination of smoking, improved detection and control of hypertension and diabetes mellitus. Earlier diagnosis is available with stress testing and other noninvasive techniques. Cardiac catheterization allows detection of occlusive lesions. The CASS and other studies increasingly prove that percutaneous angioplasty and coronary artery bypass surgery improve life expectancy and implicitly should reduce the incidence of acute myocardial infarction. In the setting of the latter, thrombolytic agents may reduce the amount of myocardial injury. Despite these measures, formation of left ventricular aneurysms remains a common occurrence. Diagnosis and management are critical issues to the cardiac surgeon.
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PMID:Left ventricular aneurysm and intraventricular thrombi. Investigation and surgical correlations. 187 80

The authors investigated the association of serum copper concentration with the risk of acute myocardial infarction in 1,666 randomly selected men aged 42, 48, 54, or 60 years who had no symptomatic ischemic heart disease at entry. Baseline examinations in the Kuopio Ischaemic Heart Disease Risk Factor Study in Eastern Finland were done during 1984 to 1988. In Cox multivariate survival models adjusting for age, examination year, ischemic electrocardiogram in exercise, maximal oxygen uptake, diabetes, family history of ischemic heart disease, cigarette-years, mean systolic blood pressure, serum high density lipoprotein (HDL) cholesterol subfraction HDL2 and low density lipoprotein (LDL) cholesterol concentrations and blood leukocyte count, serum copper concentration in the two highest tertiles (1.02-1.16 mg/liter and 1.17 mg/liter or more) associated with 3.5-fold (95% confidence interval (Cl) 1.3-9.4, p less than 0.05) and 4.0-fold (95 percent Cl 1.5-10.8, p less than 0.01) risk of acute myocardial infarction. These data indicate that high copper status, reflected by elevated serum copper concentration, is an independent risk factor for ischemic heart disease.
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PMID:Serum copper and the risk of acute myocardial infarction: a prospective population study in men in eastern Finland. 159 83

Significant delays in seeking definitive treatment for the signs and symptoms of acute myocardial infarction increase morbidity and mortality. In most studies, delay times average more than 4 hours. The following variables are associated with increased delay: a medical history of angina, diabetes mellitus, or hypertension; older age; black race; seeking advice from a family member or a physician; symptom onset on a weekday; and attempts at self-treatment. Variables associated with reduced delay times are the following: pain recognized as cardiac in origin, hemodynamic instability, severe chest pain, younger age, and consultation with a coworker. Surprisingly, patients who have already experienced a myocardial infarction are just as likely to delay as patients who have not had this experience. These findings provide direction for developing and testing patient and family interventions, establishing community education programs, and reducing patient delay in response to the signs and symptoms of acute myocardial infarction.
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PMID:Treatment-seeking behavior among those with signs and symptoms of acute myocardial infarction. 189 41

Coronary bypass surgery was performed prior to hospital discharge in 303 (22%) of 1387 consecutive patients enrolled in the TAMI 1 to 3 and 5 trials of intravenous thrombolytic therapy for acute myocardial infarction. Bypass surgery was of emergency nature (less than 24 hours from treatment with intravenous thrombolytic therapy) in 36 (2.6%) and was deferred (greater than 24 hours) in 267 (19.3%) patients. The indications for bypass surgery included failed angioplasty (12%); left main or equivalent coronary disease (9%); complex or multivessel coronary disease (62%); recurrent postinfarction angina (13%); and refractory pump dysfunction, mitral regurgitation, ventricular septal rupture or abnormal predischarge functional test (1% each). Although patients having bypass surgery were older (59.5 +/- 9.8 versus 56.0 +/- 10.2 years, (p less than 0.0001), had more extensive coronary artery disease (46% with three-vessel disease versus 11%, (p less than 0.0001), had more frequent diabetes mellitus (19% versus 15%, (p = 0.048), had more prior infarctions (p less than 0.0001), had more severe initial depression in global left ventricular ejection fraction (48.0 +/- 11.9% versus 51.8 +/- 11.9%, p = 0.0002), and regional infarct zone (-2.7 +/- 0.94 versus -2.5 +/- 1.1 SD/chord, p = 0.02) and noninfarct zone function (-0.36 +/- 1.8 versus 0.43 +/- 1.6 SD/chord, p less than 0.0001) than patients not having coronary bypass surgery, no difference in the incidence of death in hospital (7% surgical versus 6% nonsurgical) or death at long-term follow-up of hospital survivors (7% surgical versus 6% nonsurgical) was noted between groups. Surgical patients demonstrated a greater degree of recovery in left ventricular ejection fraction (3.4 +/- 9.8% versus 0.16 +/- 8.5%, p = 0.036) and infarct zone regional function (0.71 +/- 1.1 versus 0.34 +/- 0.99 SD/chord, p = 0.001) when immediate (90 minutes following initiation of thrombolytic therapy) and predischarge (7 to 14 days after treatment) contrast left ventriculograms were compared than did patients who received only intravenous thrombolytic therapy with or without coronary angioplasty. These data suggest a beneficial influence of coronary bypass surgery on left ventricular function and possibly on the clinical outcome of patients initially treated with intravenous thrombolytic therapy for acute myocardial infarction.
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PMID:Coronary bypass surgery improves global and regional left ventricular function following thrombolytic therapy for acute myocardial infarction. TAMI Study Group. 190 87

The relation between alcohol and nonfatal acute myocardial infarction (AMI) was examined in a case-control study of 89 male patients and 271 control subjects in Fukuoka, Japan. Patients admitted for the first AMI at 2 hospitals in Fukuoka City were aged 40 to 69 years, and control subjects were recruited based on the telephone directory of the city. Information on alcohol drinking and potential coronary risk factors was obtained by using a self-administered questionnaire, and past drinkers were separated from lifelong abstainers in the analysis. After adjustment for age, occupation, cigarette smoking, strenuous exercise, body mass index, hypertension, diabetes mellitus and parental heart disease, the risk of AMI was progressively less with increasing levels of alcohol consumption. With those who never drank as a referent, adjusted odds ratios for current drinkers consuming less than 30, 30 to 59, and greater than or equal to 60 ml/day of alcohol were 1.11 (95% confidence interval 0.51 to 2.42), 0.31 (0.11 to 0.83), and 0.13 (0.05 to 0.36), respectively. These findings add to the body of data showing that alcohol drinkers are less likely to have AMI.
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PMID:Alcohol intake and nonfatal acute myocardial infarction in Japan. 192 12

Elderly patients with acute myocardial infarction (AMI) have a higher subsequent mortality than younger ones, yet the reasons for this adverse prognosis are poorly understood. We compared the clinical course and the prognosis of 163 patients aged 40 to 69 years with 112 patients older than 70 years. During hospitalization period 15.9% of younger and 37.5% of older patients died; at 1 year follow-up the cardiac mortality rate was 8.7% in younger and 12.9% in older patients. In elderly patients a greater prevalence of female gender, diabetes mellitus, anterior myocardial infarction, atrial fibrillation and a greater incidence of heart failure and shock were observed. Multivariate stepwise analysis identified shock and heart rate greater than or equal to 90 bpm at the time of admission as the most important prognostic variables for in-hospital mortality in both groups; heart failure (Killip class II and III) was significant in younger patients, while non Q wave myocardial infarction correlated with a better prognosis in elderly. In elderly patients who survived AMI, predischarge Holter monitoring showed higher frequency and complexity of ventricular arrhythmias, and radionuclide angiography lower left ventricular ejection fraction (E.F.) values. In these patients no difference was found in E.F. values despite myocardial infarction sites. At 1 year follow-up E.F. less than 40% and ventricular arrhythmias (3-4 Moss grading system) were significantly related to prognosis in younger patients, while E.F. less than 40% and clinical signs of heart failure in elderly. Therefore, low E.F. and heart failure account for a worse prognosis in elderly patients, while ventricular arrhythmias in younger ones. The results of this study support aggressive management even in elderly patients following AMI to preserve left ventricular function. In elderly patients a large use of antiarrhythmic drugs is not recommended because of low prognostic value of ventricular arrhythmias.
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PMID:[Influence of age on the short- and medium-term prognosis in patients with acute myocardial infarct]. 193 43

The purpose of this study was to assess the influence of aging on the surgical results. The subjects which were 70-year or older included 13 cases of acute myocardial infarction with mechanical failure (AMI), 36 of elective aortocoronary bypass (CABG) and 33 of valvular heart disease (VHD). The control group younger than 70 included 32 cases of CABG and 32 of VHD. The complication rate of hypertension or diabetes mellitus in the older group was not significantly higher than in younger group. The characteristics of the preoperative status in the older group, however, seemed to be renal and hepatic hypofunction and anemia. The amount of intraoperative bleeding in older group was larger than in younger group. The periods of ICU stay, respiratory assist and postoperative hospitalization in older group were significantly longer than in younger group. The operative mortality rate of AMI was 61.5%, of CABG 8.3% and of VHD 12.1%. The operative mortality rate of emergent or urgent operation was 47.6% and of elective one 8.2%. The 4-year survival rate of CABG was 82% and the 6-year survival rate of VHD was 85%. Sixty four survivors (95.5%) improved to I-II of NYHA classification and of only 3 survivors (4.5%) remained in NYHA III class. The operative and long term results of elective surgery in older patients were comparable to those in younger ones. Therefore aging, itself, should not be a limiting factor in 70-year or older patients with good mental activity.
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PMID:[Results and problems of open heart surgery in patients seventy years of age and older]. 194 70

To assess the impact of patient age on the use of diagnostic testing in the management of acute myocardial infarction, the authors reviewed the hospital charts of 4,109 patients hospitalized for validated acute myocardial infarction in the Worcester, Massachusetts, metropolitan area during selected years between 1975 and 1986. Older patients were more likely to be female and to have a prior history of angina, hypertension, and diabetes mellitus (p less than 0.001). Acute myocardial infarctions among older patients were more likely to be recurrent, anterior in location, non-Q wave, smaller as reflected by peak creatine kinase levels, and complicated by congestive heart failure, cardiogenic shock, and atrial fibrillation (p less than 0.001). In-hospital mortality was directly related to increasing patient age (p less than 0.001). Patterns of utilization of the following diagnostic tests were examined: Holter monitoring, radionuclide ventriculography, echocardiography, exercise testing, pulmonary artery catheterization, and coronary arteriography. After adjustment for differences in demographic and clinical characteristics and in-hospital mortality, patients aged 65 years and older were significantly less likely to undergo exercise testing than were patients less than age 55. Patients older than age 75 were significantly less likely to undergo radionuclide ventriculography, pulmonary artery catheterization, and coronary arteriography than were younger patients. Sex-specific analyses did not produce results substantially different from those for the overall study population. The results of this community-wide study suggest that among patients hospitalized for acute myocardial infarction, chronologic age may be an independent determinant of utilization patterns of diagnostic testing. These findings suggest the need for a prospective evaluation of this issue, with an additional emphasis placed on the contributions of functional status and noncardiovascular illness to decision-making in the clinical management of acute myocardial infarction patients.
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PMID:Diagnostic testing in acute myocardial infarction: does patient age influence utilization patterns? The Worcester Heart Attack Study. 195 Dec 92

To test the hypothesis that long-term beta- or calcium-antagonist therapy begun before the time of myocardial infarction and coronary reperfusion might improve patient in-hospital survival compared with reperfusion alone, 424 consecutive patients successfully reperfused with coronary angioplasty within 12 hours of infarct symptom onset were carefully and retrospectively characterized. Forty-seven patients (11%) were taking beta antagonists and 74 patients (17%) were taking calcium antagonists at the time of infarction. Patients receiving beta antagonists had a more frequent history of hypertension (p less than or equal to 0.001) and prior infarction (p less than or equal to 0.01) than those not so treated and patients receiving calcium antagonists had a more frequent history of prior infarction, prior angina, hypertension and diabetes (all p less than or equal to 0.001) than their nontreated counterparts. Stepwise logistic regression analysis found significant independent correlations between in-hospital death and the following variables: recurrent ischemia (p less than or equal to 0.001); proximal left anterior descending coronary infarct (p less than or equal to 0.001); 3-vessel disease (p = 0.002); patient age (p = 0.004); and initial total occlusion of the infarct artery (p = 0.022). After adjustment for these factors, beta antagonist use (mortality = 0 vs 8% without treatment) was still significantly correlated with improved survival (p = 0.048), whereas calcium-antagonist therapy made no difference in survival. Heart rate and left ventricular end-diastolic pressure upon presentation were significantly lower in patients treated with beta antagonists. Thus, beta-antagonists therapy, but probably not calcium-antagonist therapy, taken before reperfusion for acute myocardial infarction, may improve early survival compared to reperfusion alone. Larger studies will be required to confirm or refute these observations.
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PMID:Possible survival benefit from concomitant beta-but not calcium-antagonist therapy during reperfusion for acute myocardial infarction. 197 88

I have outlined the approach to therapy of supraventricular tachyarrhythmias practiced by a cardiologist who is not performing special studies in the cardiac electrophysiology laboratory. This review includes the list of common and rare supraventricular arrhythmias, application of diagnostic noninvasive procedures, indications for referral for special electrophysiologic studies, and brief description of drugs and procedures used in the therapy of supraventricular tachyarrhythmias. In addition to general guidelines for treatment of these arrhythmias, I have outlined specific recommendations for patients with acute myocardial infarction, angina pectoris, ventricular dysfunction and congestive heart failure, obstructive cardiomyopathy, hyperthyroidism, AV accessory pathways, chronic obstructive lung disease, diabetes mellitus, hypertension, concomitant ventricular arrhythmias, tachycardia-bradycardia syndrome, and anxiety.
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PMID:What determines the choice of treatment in patients with supraventricular tachycardia? 197 41


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