Influence of age on the prognostic importance of left ventricular dysfunction and congestive heart failure on long-term survival after acute myocardial infarction. TRACE Study Group

Development and course of heart failure after a myocardial infarction in younger and older people

Background

Acute myocardial infarction (AMI) is a common cause of heart failure (HF), which can develop soon after AMI and may persist or resolve or develop late. HF after an MI is a major source of mortality. The cumulative incidence, prevalence and resolution of HF after MI in different age groups are poorly described. This study describes the natural history of HF after AMI according to age.

Methods

Patients with AMI during 1998 were identified from hospital records. HF was defined as treatment of symptoms and signs of HF with loop diuretics and was considered to have resolved if loop diuretic therapy could be stopped without recurrence of symptoms. Patients were categorised into those aged < 65 years, 65–75 years, and > 75 years.

Results

Of 896 patients, 311, 297 and 288 were aged < 65, 65–75 and >75 years and of whom 24%, 57% and 82% had died respectively by December 2005. Of these deaths, 24 (8%), 68 (23%) and 107 (37%) occurred during the index admission, many associated with acute HF. A further 37 (12%), 63 (21%) and 82 (29%) developed HF that persisted until discharge, of whom 15, 44 and 62 subsequently died. After discharge, 53 (24%), 55 (40%) and 37 (47%) patients developed HF for the first time, of whom 26%, 62% and 76% subsequently died. Death was preceded by the development of HF in 35 (70%), 93 (91%) and 107 (85%) in aged < 65 years, 65–75 years and >75 years, respectively.

Conclusions

The risk of developing HF and of dying after an MI increases progressively with age. Regardless of age, most deaths after a MI are preceded by the development of HF.

Prognostic factors in patients who have survived myocardial infarction

Patients who have survived myocardial infarction (MI), compared to the general population, have an increased risk of reinfarction, myocardial revascularization, and death. In this study we investigated the prognostic significance of the predictors of the risk for adverse coronary events in 118 patients, both male and female, with a confirmed diagnosis of MI in the last 3 years. The predictors of reinfarction, revascularization and death in patients who survived MI were: poor adherence to hypolipemics (hazard ratio [HR] 3.06, p=0.006), physical inactivity (HR 2.22, p=0.056), the number of variable risk factors (HR 1.29, p=0.025), and age (HR 1.06, p=0.007). After the inclusion of the invariable risk factors in the model of multivariant analysis, the following factors were singled out as significant predictors of the risk: gender (HR 3.86, p=0.0015), physical inactivity (HR 2.38, p=0.007), change in the level of triglycerides (HR 1.49, p=0.040), change in the number of variable risk factors (HR 1.41, p=0.0007), and age (HR 1.05, p=0.009). A 3-year follow-up of the patients who survived the first MI and who were enrolled in this study of secondary prevention demonstrated that physical inactivity, the number of variable risk factors and age significantly contributed to an increased risk of reinfarction, revascularization, and death.

Clinical significance of brain natriuretic peptide in patients with postmyocardial infarction

BACKGROUND

Risk stratification after acute myocardial infarction (AMI) includes the evaluation of left ventricular (LV) function. Natriuretic peptides, and particularly brain natriuretic peptide (BNP), emerged as a potential marker of ventricular function and prognosis after AMI.

HYPOTHESIS

Brain natriuretic peptide levels are related to ventricular function, either systolic or isolated diastolic, and can give prognostic information in patients surviving AMI.

METHODS

In all, 101 patients were enrolled. An echocardiographic (M-mode, two-dimensional, and pulsed Doppler) evaluation was performed and blood samples for BNP measurement were obtained. Clinical events were recorded during 12 months of follow-up.

RESULTS

A negative correlation between BNP and LV ejection fraction was observed (r = -0.38; p < 0.001). The BNP levels were higher among patients with LV systolic dysfunction than in patients with isolated diastolic dysfunction (339.1 +/- 249.9 vs. 168.0 +/- 110.5 pg/ml, p = 0.001). The latter had higher levels of BNP than those with normal LV function (68.3 +/- 72.6 pg/ml, p < 0.001). The BNP accuracy to detect LV systolic dysfunction was good (area under the ROC curve [AUC] = 0.83) and increased when isolated diastolic dysfunction was also considered (AUC = 0.87). Brain natriuretic peptide had a very good accuracy in the prediction of death (AUC = 0.95) and the development of heart failure (AUC = 0.90).

CONCLUSION

These results extend previous evidence relating BNP to systolic function after AMI. Furthermore, a relationship between BNP levels and diastolic function was found. Brain natriuretic peptide had a very good performance in detecting the occurrence of an adverse event. We conclude that BNP can detect high-risk patients and help select patients for more aggressive approaches.

Left ventricular systolic dysfunction and the risk of ischemic stroke in a multiethnic population

BACKGROUND AND PURPOSE

Left ventricular dysfunction (LVD) is associated with cardiovascular mortality. Its association with ischemic stroke has been mainly documented after myocardial infarction. The stroke risk associated with LVD, especially of mild degree, in the general population is unclear. The purpose of this study was to evaluate the relationship between LVD and ischemic stroke in a multiethnic cohort.

METHODS

LV systolic function was assessed by transthoracic 2-dimensional echocardiography in a subset of subjects from the Northern Manhattan Study (NOMAS), 270 patients with first ischemic stroke and 288 age-, gender- and race-matched community controls. LV ejection fraction was measured by a simplified cylinder-hemiellipsoid formula, and categorized as normal (>50%), mildly (41% to 50%), moderately (31% to 40%) or severely (< or =30%) decreased. The association between impaired ejection fraction and ischemic stroke was evaluated by logistic regression analysis after adjustment for established stroke risk factors.

RESULTS

LVD of any degree was more frequent in stroke patients (24.1%) than in controls (4.9%; P<0.0001), as was moderate/severe LVD (13.3% versus 2.4%; P<0.001). A decreased ejection fraction was associated with ischemic stroke even after adjusting for other stroke risk factors. The adjusted odds ratio for any degree of LVD was 3.92 (95% CI, 1.93 to 7.97). The adjusted odds ratio for mild LVD was 3.96 (95% CI, 1.56 to 10.01) and for moderate/severe LVD 3.88 (95% CI, 1.45 to 10.39). The association between LVD of any degree and stroke was present in all age, gender and race-ethnicity subgroups.

CONCLUSIONS

LVD, even of mild degree, is independently associated with an increased risk of ischemic stroke. The assessment of LV function should be considered in the assessment of the stroke risk.

Therapies to prevent heart failure post-myocardial infarction

Heart failure (HF) is a common complication of myocardial infarction (MI) that carries a poor prognosis when present. HF and/or left ventricular systolic dysfunction (LVSD) occur in approximately 40% of patients who suffer acute MI. The estimated mortality of patients developing HF or LVSD post-MI is 20% to 30%, with that risk varying based on the presence of HF upon initial assessment versus occurring later during the MI hospitalization. Clinical factors and comorbidities associated with post-MI HF include age, diabetes, hypertension, female gender, infarct size, and tachycardia. Factors associated with decreased survival in patients with post-MI HF include Killip class, age, low blood pressure, tachycardia, male gender, and anterior location of MI. Despite extensive data identifying this patient population as high risk, patients with post-MI HF or LVSD are significantly less likely to receive evidence-based medications or revascularization procedures than those without HF. Despite the high prevalence of HF after MI, few studies have examined therapies to prevent it. This review summarizes studies that reported the incidence, risk factors, and outcomes of patients with post-MI HF or LVSD. Additionally, we discuss therapies to prevent post-MI HF and treatment of patients with post-MI HF and/or LVSD.

Sympathetic Drive in Anterior and Inferior Uncomplicated Acute Myocardial Infarction

Background— The sympathetic activation that follows acute myocardial infarction (AMI) has been associated with increased morbidity and mortality. Because the prognosis after anterior AMI (ant-AMI) is worse than that after inferior AMI (inf-AMI), we planned to determine whether the magnitude of sympathetic hyperactivity differs between the two.

Methods and Results— Thirty-nine patients with uncomplicated AMI, comprising 2 matched groups of 17 patients with ant-AMI, and 22 patients with inf-AMI were examined. Measurements were obtained 2 to 4 days after AMI and compared with 20 normal subjects (NC) who were matched in terms of age and body weight to the AMI groups. Resting muscle sympathetic nerve activity was quantified from multiunit bursts (MSNA) and from single units (s-MSNA). Both groups of AMI patients were matched with regard to hemodynamic variables, left ventricular function, and infarct size. Both groups had greater (at least P <0.01) sympathetic nerve activity than NC (60±4.3 bursts/100 cardiac beats and 68±4.9 impulses/100 cardiac beats), but the magnitude of sympathetic nerve hyperactivity in ant-AMI (81±4.0 bursts/100 cardiac beats and 91±4.9 impulses/100 cardiac beats) was similar ( P >0.05) to that in inf-AMI (80±3.2 bursts/100 cardiac beats and 90±4.0 impulses/100 cardiac beats)

Conclusions— Both ant-AMI and inf-AMI resulted primarily in a similar magnitude of sympathetic nerve hyperactivity. These findings suggest that the worse prognosis after ant-AMI compared with after inf-AMI would not be related primarily to the degree of sympathetic hyperactivity.

Heart failure after myocardial infarction: a review

PURPOSE

The effects of survival after myocardial infarction on the prevalence of chronic heart failure have not been well characterized. We reviewed studies of the incidence, mortality, and predictors of heart failure after myocardial infarction, and suggest directions for further research.

METHODS AND RESULTS

We conducted a review of the literature from 1978 to 2000. Of 33 identified articles, 18 (55%) included heart failure as a primary endpoint. The mean in-hospital incidence of heart failure after myocardial infarction differed significantly by study design; it was highest in population-based studies and lowest in clinical trials (37% vs. 18%, P <0.01). Only 10 studies reported the incidence of subsequent heart failure. One-year mortality ranged from 16% to 39% and showed no improvement with time. Patients with in-hospital heart failure after myocardial infarction had a two- to sixfold greater in-hospital mortality and up to a fivefold increased 1-year mortality compared with patients without heart failure. The most consistent risk factors for the development of heart failure after myocardial infarction were advanced age, female sex, diabetes, and an increased heart rate at the time of admission.

CONCLUSIONS

The reported incidence of, and mortality from, heart failure after myocardial infarction varies by study design. Additional research on the etiology and prognosis of late heart failure after myocardial infarction is needed.

[Worsening of heart failure during hospital course in myocardial infarction is a factor of poor prognosis. Apropos of a prospective cohort study of 2,507 patients hospitalized with myocardial infarction: the PRIMA study]

BACKGROUND

Worsening of heart failure in patients with myocardial infarction is seldom studied, elderly patients often are not included, and multivariate analysis is uncommon.

AIMS

The prospective PRIMA study (Prise en charge de l'Infarctus du Myocarde Aigu; management of acute myocardial infarction) sought to determine the incidence of heart failure worsening, its risk factors, and its prognostic importance in patients with myocardial infarction, regardless of age and hospital facilities, in the "real world" in a region in France, using multivariate analysis.

METHODS

Data were prospectively collected in all patients with myocardial infarction admitted in all hospitals in three departments in the Rhône-Alpes region in France between September 1, 1993 and January 31, 1995.

RESULTS

Among 2,507 patients, 33% were in Killip classes II-IV at admission. Four hundred and sixteen patients (17%) had worsening of Killip class during the first five days. In-hospital mortality (overall: 14%) increased dramatically with Killip class at admission (9% in class I; 62% in class IV) and with worsening of Killip class during the first five days (36% vs 8% if no worsening). In multivariate analysis, older age, diabetes mellitus and anterior Q-wave myocardial infarction were significant predictors of Killip class at admission and of its worsening. The significant predictors of in-hospital mortality were older age, Killip class III at admission and worsening of Killip class during the first five days.

CONCLUSION

This large, unselected cohort revealed that among patients with myocardial infarction, heart failure and its worsening are frequent, especially in the elderly, and dramatically worsen the in-hospital mortality.

Ischemic Heart Disease in the Elderly:A Need to Understand the Causes of High Mortality After Acute Myocardial Infarction

The short- and long-term mortality of patients greater than 75 years of age with acute myocardial infarction is still very high. These patients have been excluded from most randomized controlled trials designed to test interventions directed to improve the outcome of acute myocardial infarction. Contrary to young-old patients (65-74 years) in whom the benefit obtained with these interventions is even greater than that observed in younger patients, there is a lack of information concerning the optimal treatment of acute myocardial infarction in the oldest patients. Research specifically directed to assess the optimal reperfusion strategy and coadjuvant therapies in patients greater than 75 years old is critically important. The causes for such high mortality are still poorly understood. Several clinical observations suggest that old patients with acute myocardial infarction have specific pathophysiologic behaviors. As the knowledge of the mechanisms of disease is, in clinical practice, the basis of therapy development, clinical and basic research designed to elucidate the specific pathophysiological mechanisms and causes of the high mortality in the oldest patients with acute myocardial infarction should be regarded as a priority in geriatric cardiovascular research. (c) 2000 by CVRR, Inc.

Early Prognostic Assessment and Treatment of Acute Myocardial Infarction in the Elderly

The progressive aging of the population is associated with an increase in the proportion of very old patients (greater than 75 years) hospitalized with acute myocardial infarction. The lack of evidence regarding the efficacy of most therapeutic interventions for acute myocardial infarction in these patients is leading to a significant degree of uncertainty in the cardiology community with respect to their optimal management. When aggressive treatment (defined as a therapeutic strategy designed to obtain and maintain a patent infarct-related coronary artery at an early moment) of acute myocardial infarction is considered in very old patients, three main questions should be addressed: why should we treat? Whom should we treat? And how should we treat? To answer these questions, the authors reviewed the data available in the literature as well as new data from the PPRIMM75 (Pronóstico del PRimer Infarto de Miocardio en Mayores de 75 aÃ+/-os) Registry, a large, prospective database of patients aged 75 years or older, admitted to a single coronary care unit in Madrid, Spain, for their first acute myocardial infarction during the last decade. (c) 2000 by CVRR, Inc.

Beneficial effect of prodromal angina pectoris is lost in elderly patients with acute myocardial infarction

BACKGROUND

Prodromal angina pectoris occurring shortly before the onset of acute myocardial infarction is associated with a favorable outcome by the mechanism of ischemic preconditioning. Recent experiments have reported that the beneficial effect of ischemic preconditioning are reversed in the aged heart.

METHODS

We studied 990 patients who underwent coronary angiography within 12 hours after the onset of acute myocardial infarction. Patients were divided into 2 groups: those aged <70 years (nonelderly patients, n = 722) and those aged >/=70 years (elderly patients, n = 268). Prodromal angina in the 24 hours before infarction was found in 190 of 722 nonelderly patients and in 66 of 268 elderly patients (26% vs 25%, P =.61).

RESULTS

In nonelderly patients, prodromal angina was associated with lower peak creatine kinase levels (2438 +/- 1939 IU/L vs 2837 +/- 2341 IU/L, P =.04), lower in-hospital mortality rates (3.7% vs 8.8%, P =.02), and better 5-year survival rates (P =. 007). On the contrary, in elderly patients there was no significant difference in peak creatine kinase levels (2427 +/- 2142 IU/L vs 2256 +/- 1551 IU/L, P =.51), in-hospital mortality rate (21.2% vs 17. 4%, P =.49), and 5-year survival rates (P =.47). A multivariate analysis showed that prodromal angina in the 24 hours before infarction was associated with 5-year survival rate in nonelderly patients (odds ratio 0.49, P =.009) but not in elderly patients (odds ratio l.12, P =.65).

CONCLUSIONS

In nonelderly patients, prodromal angina in the 24 hours before infarction was associated with a smaller infarct size and better short- and long-term survival, suggesting a relation to ischemic preconditioning. However, such a beneficial effect was not observed in elderly patients.

Neutrophilia and congestive heart failure after acute myocardial infarction

BACKGROUND

Inflammation associated with acute myocardial infarction (AMI) is frequently marked by a peripheral leukocytosis and relative neutrophilia. Whether this process may contribute to the development of postinfarction congestive heart failure (CHF) is not established. The objective of this study was to examine the association between hospital admission peripheral total leukocyte count and the neutrophil percentage and the subsequent development of CHF in patients with AMI. The study was designed as a retrospective cohort study in the setting of a tertiary referral hospital. Participants included 185 patients discharged with a diagnosis of AMI between May 1 and Sept 30, 1996.

METHODS AND RESULTS

Outcome measures included clinical episodes of CHF with confirmatory chest roentgenogram findings and/or echocardiographic evidence of contractile dysfunction. Multivariable logistic regression analyses were performed to examine the relation between the total leukocyte count, neutrophil percentage, and the development of CHF in the first 4 days after AMI while controlling for baseline characteristics and early therapeutic interventions. Thirty-one percent of the cohort had a leukocyte count >11.0 x10(9)/L on admission to the hospital; 65% had a neutrophil percentage >65%, and 61% had a lymphocyte percentage </=25%. CHF developed in 43% of the cohort. Of these, 92. 5% had relative neutrophilia (neutrophil percentage >65%) compared with 45% of those in whom CHF did not develop. Multivariable analysis revealed a highly significant association between relative neutrophilia and the subsequent development of CHF (odds ratio 14.3; 95% confidence interval 5.2 to 39.3).

CONCLUSIONS

Relative neutrophilia on admission to the hospital in patients with AMI is significantly associated with the early development of CHF. This association may help in the identification of individuals at high risk who might benefit from more aggressive interventions to prevent or reduce the risk of CHF.

Variables affecting outcome in critically ill patients

Critical care medicine has evolved as a field of science and clinical care. Despite important contributions to our understanding of the molecular basis of critical illness, we still remain troubled by our lack of insight into why some patients have favorable outcomes from critical illness and others do not. This article explores the hypothesis that at least five important variables may alter the outcome of patients suffering from a variety of critical illnesses. These variables include the premorbid immune or genetic status of the patient, the patient's gender, the circulating cholesterol concentration, the patient's age, and various iatrogenic and nosocomial events. Insights into the importance of these five variables may provide opportunities for physicians and scientists to improve outcome in patients suffering from critical illness. Clearly, altering iatrogenic and nosocomial events is already within the realm of opportunity.