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Previous studies have reported conflicting results on gender differences in the management of acute myocardial infarction (AMI) and have not evaluated hospital length of stay or costs. To determine gender-based differences in presentation, management, length of stay, costs, and prognosis after AMI, we studied 561 patients with AMI. Women were older, had systemic hypertension, diabetes mellitus, and a non-Q-wave AMI more frequently, whereas more men smoked cigarettes. Predictors of coronary angiography were: male gender (RR 1.9; 95% CI 1.2 to 3.1), chest pain at presentation (RR 1.8; 95% CI 1.0 to 3.3), recurrent angina (RR 4.1; 95% CI 2.5 to 6.8), admission via the emergency room (RR 0.2; 95% CI 0.1 to 0.3), and younger age. Gender did not predict mortality. Among presenting features, the predictors of length of stay were diabetes, prior coronary bypass and prior coronary angioplasty in men, and age alone in women. Pulmonary edema and need for coronary bypass during the hospital course were predictors of length of stay in men only. Among presenting features, predictors of cost were diabetes in men and congestive heart failure in women. Predictors of cost during hospitalization for men were pulmonary edema, coronary angiography, intraaortic balloon pump use, and coronary bypass; for women, they were peak levels of creatine kinase and coronary bypass. Thus, predictors of length of stay and hospitalization costs differ based on gender. Efforts at cost containment may need to be gender-specific.
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PMID:Do gender-based differences in presentation and management influence predictors of hospitalization costs and length of stay after an acute myocardial infarction? 748 95

Ninety-four consecutive patients (60 men and 34 women; mean age 68.5 +/- 11.5 years) with acute myocardial infarction (MI) were investigated retrospectively, in order to evaluate the prevalence, clinical features, and short-term course of the atypical forms (symptoms other than chest pain). An atypical MI was found in 30 patients, with a prevalence of 32% (95% confidence limits 27-36%). It was most prevalent in women above sixty-five years old (P < 0.05). Abdominal pain, paroxysmal dyspnea, and pulmonary edema were the most frequent symptoms (33%, 17%, 13%, respectively). No differences were observed between typical and atypical MI in regard to risk factors (hypercholesterolemia, arterial hypertension, diabetes mellitus, cigarette smoking) and history of MI, cerebrovascular disease, peripheral vascular disease, or chronic lung disease. Significantly fewer patients with atypical MI had a history of angina pectoris (P < 0.05). No differences were observed in regard to previous medication, except for antiarrhythmic drugs, more often used by atypical patients (P < 0.05). Location and severity of MI (as judged by ECG and peak levels of creatine kinase in the serum) were similar in both subgroups, as were the complications (34% typical and 50% atypical) and death rate (12.5% and 16.7%, respectively). In conclusion, atypical MI is not less severe than typical. This emphasizes the need for a high suspicion index in many different clinical settings, but particularly (although not exclusively) in elderly females, in the presence of abdominal pain or otherwise unexplained paroxysmal dyspnea.
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PMID:Prevalence, clinical features, and acute course of atypical myocardial infarction. 828 84

In the submitted study the authors evaluate the relationship of the clinical course in patients with inferior myocardial infarction (AIM) in relation to the electrocardiographic (ECG) finding in standard and dextro-lateral leads. In a group of 96 patients (mean age 65 +/- 10 years, 66 men and 30 women) according to the ECG 38 had an isolated inferior AIM (group 1), 28 had signs of extension of the inferior AIM to the posterior wall of the left ventricle (group 2) and 30 patients in group 3 had an extension of the inferior AIM to the right ventricle, i.e. an infarction of the right ventricle. All three groups differed significantly as regards the extent of the AIM according to creatine kinase values (7.1 +/- 4.4 and 18.2 +/- 7.2 resp. and 24.8 +/- 11.6 resp.), as regards mortality (0 and 14% and 37% resp.). In group 2, contrary to the other groups, the significantly most frequent complication was pulmonary oedema (36%) and ventricular tachycardia (30%) and in group 3 the significantly most frequent complication was cardiogenic shock (30%) and advanced atrioventricular block (50%). The cause of death in these patients with infarctions of the right ventricle was cardiogenic shock (n = 6), cardiac rupture (n = 3) and electromechanical dissociation (n = 2). A total of 29 (30%) patients with inferior AIM were treated by temporary pacing: in group 1 21%, in group 2 14% and in group 3 57%. The prognosis of these patients was favourable in groups 1 and 2 (1 of 12 patients died) while in group 3 with infarctions of the right ventricle 9 of 17 patients died (p < or = 0.001). The authors found moreover that patients with precordial depression of the ST segment and inferior AIM have, as compared with patients without this depression, significantly higher creatine kinase values (12.5 +/- 5.5 vs. 5.2 +/- 1.3 mu kat; p < or = 0.001) and a higher general incidence of complications. Patients with inferior AIM are thus a non-homogeneous group from which we can differentiate, based on standard ECG examination and by recording right-sided thoracic leads, patients with an increased risk and start specific treatment in time.
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PMID:[Clinical picture of various types of inferior myocardial infarcts. Clinico-electrocardiographic study]. 837 61

The subject of this report is a 57-year-old obese, hypertensive woman who had been well until the onset of severe chest pain and hypotension. She had to be defibrillated four times on her way to the hospital. The diagnosis of acute inferior-posterior infarction was made by electrocardiogram (ECG) and there was a markedly elevated serum creatine kinase (CK) (including the MB fraction). The patient had a very low cardiac output and ejection fraction. A lung scan revealed possible pulmonary embolism for which she was anticoagulated. She remained hypotensive and hypoxemic and, on Day 17 of her hospital stay, she had a bout of severe dyspnea. A new systolic murmur was heard and the clinical diagnosis of ruptured papillary muscle was made and confirmed by echocardiography, and later at autopsy. All three coronary arteries were severely atherosclerotic and, in addition, the right coronary artery was completely closed by a thrombus. This case clearly illustrates the major pathological changes in the heart that correlate with the clinical findings in patients with a myocardial infarct that is complicated by left ventricular papillary muscle rupture. The pathophysiological effects of this condition, as illustrated in this case report, include the following:1. The posterior papillary muscle wa s almost completely separated from its base, with only a thin strip of muscle intact. The mistral valve thus was insufficient (a "flail valve''); this markedly reduced the ejection fraction of the left ventricle, increased its end-diastolic volume and pressure, produced a damming of blood in the pulmonary circulation, and this resulted in the pulmonary edema seen on the chest x-ray.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Acute myocardial infarction with papillary muscle rupture. 841 63

Ten cases of acute renal failure (ARF) were seen in the period from July 1990 to August 1991 in the Nephrology Department of the SIMS Hospital, Srinagar. All were males in the age group of 18-28 years and in apparent good health when apprehended by the police. There was alleged history of physical torture of different types. All had been beaten on the buttocks, back and limbs; in addition, 2 cases had been given repeated electric shocks and 1 case put to 'sit-and-stand' exercise for about 3 h. The interval between the first day of torture till they came to our observation varied from 4 to 11 days. The main clinical features at the time of presentation were generalized aches and weakness (10), oligoanuria (9), vomiting (8), hypertension (6), acidosis (10), facial puffiness and pedal edema (6), fever and shivering (3), pulmonary edema (2), stupor (4), and hyperkalemia (5). All the cases had an established ARF (serum creatinine 668-1,997 mumol/l and serum urea 21.8-71.8 mmol/l) when first seen. Muscle enzymes, creatine phosphokinase, lactic dehydrogenase and serum glutamic oxaloacetic transaminase were all significantly raised indicating rhabdomyolysis. All showed evidence of myoglobin casts in urine. Nine had oliguric and 1 had nonoliguric ARF. All except the 1 case with nonoliguric ARF were managed with peritoneal dialysis and/or hemodialysis. All recovered. Early recognition of ARF is important since the main attention in such cases is directed towards the surgical aspect.
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PMID:Acute renal failure following physical torture. 845 79

From January 1984 to May 1994, 17 of 239 children under 15 years old stung by Tityus serrulatus (15.1%) or Tityus bahiensis (84.9%) presented severe envenoming. Of these 17 patients (1-11 years old; median = 2 yr) 14 were stung by T. serrulatus and three by T. bahiensis. All of them received scorpion antivenom i.v. at times ranging from 45 min. to 5 h after the accident (median = 2 h). On admission, the main clinical manifestations and laboratory and electrocardiographic changes were: vomiting (17), diaphoresis (15), tachycardia (14), prostration (10), tachypnea (8), arterial hypertension (7), arterial hypotension (5), tremors (5), hypothermia (4), hyperglycemia (17), leukocytosis (16/16), hypokalemia (13/17), increased CK-MB enzyme activity (> 6% of the total CK, 11/12), hyperamylasemia (11/14), sinusal tachycardia (16/17) and a myocardial infarction-like pattern (11/17). Six patients stung by T. serrulatus had depressed left ventricular systolic function assessed by means of echocardiography. Of these, five presented pulmonary edema and four had shock. A child aged two-years old presented severe respiratory failure and died 65 h after being stung by T. serrulatus. Severe envenomations caused by T. serrulatus were 26.2 times more frequent than those caused by T. bahiensis (p < 0.001).
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PMID:A comparative study of severe scorpion envenomation in children caused by Tityus bahiensis and Tityus serrulatus. 859 62

While cholera is not endemic in Taiwan, the number of imported cases is increasing. We report a 59-year-old Taiwanese male who developed severe diarrhea and vomiting, two days after returning from Bali. The patient admitted drinking a beverage with ice purchased from a street vendor. On admission he was weak and dehydrated. The patient suffered from hypovolemic shock and acute renal failure. Elevated creatine phosphokinase indicated rhabdomyolysis. Fluid replacement with Ringer's lactate solution was instituted. Dyspnea and pulmonary edema developed, and hemodialysis was begun to remove excess fluid due to decreased urinary output. Isolation of Vibrio cholerae O1 from stool confirmed the diagnosis of cholera, and doxycyline was begun. The patient's condition stabilized, with increased urinary output, and resolution of diarrhea, vomiting and dyspnea. Cholera, although rare in Taiwan, can be lethal if left untreated. Rapid intervention with fluid replacement is essential to prevent hypovolemic shock and circulatory collapse in severe cases.
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PMID:Cholera associated with acute renal failure and rhabdomyolysis: a case report. 904 70

A case of acute renal failure due to rhabdomyolysis in a patient who used cocaine on a daily basis is presented. In contrast to many prior reports of renal failure occurring with cocaine-associated rhabdomyolysis, our patient did not use intravenous cocaine and did not have any evidence of trauma, seizure, hypotension, hyperthermia, hyperactivity, or coma. His creatine phosphokinase peaked at 448,000 U/liter. He was treated initially with forced diuresis and i.v. furosemide, but he became oliguric, developed pulmonary edema, and required hemodialysis. He recovered fully after 3 weeks of dialysis. The literature is reviewed in an attempt to delineate a rational approach to evaluating cocaine users at risk for rhabdomyolysis.
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PMID:Severe rhabdomyolysis with renal failure after intranasal cocaine use. 940 1

Incidence and clinical significance of cardiopulmonary complications of acute cerebral lesions are still unclear. Neurogenic pulmonary edema (NPE) is characterized as an acute, protein-rich lung edema occurring shortly after cerebral lesions associated with an acute rise of intracranial pressure. NPE is infrequently diagnosed, usually in association with head trauma. Pathophysiological mechanisms include a rise of the pulmonary vascular hydrostatic pressure either due to sympathetic innervation with pulmonary vasoconstriction or increased left-atrial pressure following systemic arterial hypertension or an increase in pulmonary capillary permeability. In contrast to NPE, cardiac complications are frequently observed, most consistently in patients with subarachnoid hemorrhage. Typical ECG changes are repolarization abnormalities, similar to those observed in coronary heart disease, and cardiac arrhythmias. The CK-MB may be slightly elevated; echocardiographic findings show a depressed left-ventricular function. Pathological examination reveals myofibrillar necrosis. Cardiac complications are explained with overactivity of the sympathetic innervation and high levels of circulating catecholamines. For adequate treatment, close cardiac monitoring is required in all patients with acute cerebral lesions.
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PMID:[Neurogenic disorders of heart and lung function in acute cerebral lesions]. 946 37

The long term impact of pre-hospital thrombolysis in acute myocardial infarction on the subsequent development of heart failure symptoms was investigated in 362 consecutive patients. The pre hospital strategy, used in 61 patients, allowed for very early administration of streptokinase, within 1.2+/-0.6 (mean+/-S.D.) hours from pain onset. In contrast, 294 patients treated in hospital received lytic treatment within 2.0+/-0.9 hours. The pre hospital group showed faster reperfusion, as measured by the time to peak creatine kinase and to ST segment recovery, but only a slightly better ventricular function, as compared to hospital treated patients. Heart failure symptoms were significantly reduced in the pre hospital group during hospitalization and at long term follow up: there were less dyspnea, fatigue, orthopnea, nocturnal dyspnea, nocturia, peripheral edema and episodes of pulmonary edema. Angina was reduced as well. We conclude that the initial benefit of prehospital thrombolysis translates into long term reduction of heart failure symptoms, thus improving quality of life.
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PMID:Prevention of congestive heart failure by early, prehospital thrombolysis in acute myocardial infarction: a long-term follow-up study. 970 26


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