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Awad-Elkarim AA, Bagger JP, Albers CJ, Skinner JS, Adams PC, Hall RJC. A prospective study of long term prognosis in young myocardial infarction survivors: the prognostic value of angiography and exercise testing. Heart 2003; 89:843-7. [PMID: 12860853 PMCID: PMC1767794 DOI: 10.1136/heart.89.8.843] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To define the ability of early exercise testing and coronary angiography to predict prognosis in young survivors of myocardial infarction (MI). METHODS 255 consecutive patients (210 men) aged 55 years or less (mean 48 years) admitted to hospital (1981-85) were eligible. Of these, 150 patients (130 men) who were able to exercise early after MI and underwent coronary angiography within six months constituted the study group and were followed up for up to 15 years. Survival data up to 18 years was obtained for the whole cohort. RESULTS Survival at a median of 16 years was 52% for the whole cohort, 62% for the study group, and 48% for the excluded group. From nine years onwards survival deteriorated significantly in the study group compared with an age matched background population. Fifteen years after MI, 121 patients (81%) in the study group had had at least one event (death, MI, revascularisation, cardiac readmission, stroke) leaving 29 (19%) event-free. The number of diseased vessels was the major determinant of time to first event (p = 0.001) and event-free survival (p = 0.04). Exercise duration was also important in the prediction of time to first event (p = 0.003). Death was influenced by a history of prior MI. CONCLUSION The favourable initial survival was followed by significant deterioration after nine years. This late attrition is an important treatment target. Furthermore, this study supports risk stratification early after MI combining angiography with non-invasive tools.
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Affiliation(s)
- A A Awad-Elkarim
- Cardiothoracic Directorate, Faculty of Medicine, Imperial College School of Science, Technology and Medicine, Hammersmith Hospital, London, UK.
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Abstract
In recent years, the characteristics of patients who suffer acute myocardial infarction without complications during hospitalization have changed. In addition, the range of non-invasive studies available for evaluating left ventricular systolic function, residual myocardial ischemia, and myocardial viability in these patients has improved. Left ventricular systolic function and residual ischemia should be evaluated in all patients before release. The non-invasive technique used (exercise test, echocardiography, nuclear cardiology, magnetic resonance imaging) depends on availability, experience, and results at each institution. Coronary arteriography should be performed in patients with significant ischemia or severe left ventricular systolic dysfunction in non-invasive studies. In these cases coronary angiography must be performed to determine if coronary arteries are suitable for revascularization before performing a test of myocardial viability.
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Affiliation(s)
- Jaume Candell Riera
- Servei de Cardiologia. Hospital General Universitari Vall d'Hebron. Barcelona. España.
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Shaw LJ, Peterson ED, Kesler K, Hasselblad V, Califf RM. A metaanalysis of predischarge risk stratification after acute myocardial infarction with stress electrocardiographic, myocardial perfusion, and ventricular function imaging. Am J Cardiol 1996; 78:1327-37. [PMID: 8970402 DOI: 10.1016/s0002-9149(96)00653-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We assessed the relation of abnormal predischarge non-invasive test results to outcomes in postmyocardial infarction patients. We included series published from 1980 to 1995 containing only myocardial infarction patients, enrolling most patients after 1980, testing within 6 weeks of infarction, having follow-up rates > 80%, and having 2 x 2 frequency outcome rates for test results, that were the latest of multiple reports. Sensitivity, specificity, and predictive values were calculated for test results for 1-year outcomes (cardiac death, cardiac death or reinfarction). Univariable and summary odds were calculated for test results. Reports (n = 54) included a total of 19,874 patients and were primarily retrospective (76%) and small series (35% of reports included < 5 deaths). One-year mortality ranged from 2.5% for pharmacologic stress echocardiography to 9.3% for exercise radionuclide angiography. Positive predictive values for most noninvasive risk markers were < 0.10 for cardiac death and < 0.20 for death or reinfarction. Electrocardiographic, symptomatic, and scintigraphic risk markers of ischemia (ST-segment depression, angina, a reversible defect) were less sensitive (< or = 44%) for identifying morbid and fatal outcomes than markers of left ventricular dysfunction or heart failure (exercise duration, impaired systolic blood pressure response, and peak left ventricular ejection fraction). The positive predictive value of predischarge noninvasive testing is low. Markers of left ventricular dysfunction appear to be better predictors than markers of ischemia. Limitations of the literature-small samples and widely varying event rates-impede our ability to discern the accuracy of pre-discharge noninvasive testing. More rigorous, controlled trials are required to elucidate the relative value of these tests for risk stratification.
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Affiliation(s)
- L J Shaw
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina 27705-4667, USA
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Skinner JS, Albers CJ, Goudevenos J, Fraser C, Odemuyiwa O, Hall RJ, Adams PC. Prospective study of patients aged 55 years or less with acute myocardial infarction between 1981 and 1985: outcome 7 years and beyond. Heart 1995; 74:604-10. [PMID: 8541163 PMCID: PMC484113 DOI: 10.1136/hrt.74.6.604] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE To determine the long-term prognosis of patients after a myocardial infarction (MI) at a young age. DESIGN Prospective cohort study of patients aged 55 years or less suffering a myocardial infarction. SETTING A single coronary care unit admitting patients from the community. PATIENTS 255 consecutive patients (210 men) aged 55 years or less admitted between 1981 and 1985 after acute MI. Twenty four patients died in hospital or within 3 months of infarction and 11 were lost to further follow up after discharge. Of the remaining patients, 150 (mean (SD) age 48 (5.7) years) able to exercise 3 weeks after infarction and who agreed to undergo coronary angiography were recruited to a study group and seen 18 months, and 3, 5, and 7 years after MI. In addition, a cross sectional analysis of survival was made to a median of 120 months. Seventy 3 month survivors (mean (SD) age 48 (5.8) years) were not recruited to the study group but were traced for late survival through their general practitioners and family health service associations to a median of 130 months. MAIN OUTCOME MEASURES Survival in young patients after MI and the survival of 3 month survivors stratified by their ability to exercise and agreement to undergo angiography. The rate of coronary artery surgery (CAGB) and reinfarction during the first 7 years after index MI in patients recruited to the study group. RESULTS Sixteen patients (6%) died in hospital and eight (3%) within 3 months of the index infarction. The 7 and 11 year survival rates in the whole cohort of 255 patients were 80% and 66% respectively using life table methods. Survival 7 years after MI, in patients recruited to the study group was better than in those not recruited (93% v 79%, P = 0.001), but thereafter mortality in the study group accelerated and there was no significant difference in survival 11 years after infarction (76% v 67%, P = 0.05). There was a trend towards higher mortality in patients with multivessel disease and severely impaired left ventricular function. During the first 7 years after MI, 38 of 150 patients in the study group underwent CABG and 19 suffered reinfarction, which was fatal in three. CONCLUSION The medium-term prognosis of young survivors of MI is good, particularly in patients recruited to the study group. After 7 years there is an increase in mortality and the long-term prognosis is less favourable. This should be taken into account when planning future management and follow up of young patients after MI.
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Affiliation(s)
- J S Skinner
- Department of Cardiology, Royal Victoria Infirmary, Newcastle upon Tyne
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5
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Lundin P, Jensen J, Rehnqvist N, Eriksson SV. Ischemia monitoring with on-line vectorcardiography compared with results from a predischarge exercise test in patients with acute ischemic heart disease. J Electrocardiol 1995; 28:277-85. [PMID: 8551170 DOI: 10.1016/s0022-0736(05)80045-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Information from 24-hour monitoring with on-line vectorcardiography, starting immediately after admission, was compared with results from a predischarge exercise test 3-13 days after admission. A total of 169 patients with acute myocardial infarction and 73 patients with unstable angina pectoris were investigated. Patients were followed for 487 +/- 135 days. During the follow-up period, 19 patients (8%) died from cardiac causes and 34 (14%) were hospitalized for a myocardial infarction. The QRS vector difference (QRS-VD), ST change vector magnitude (STC-VM), ST vector magnitude (ST-VM), and ST vector leads X, Y, Z were monitored. Patients with ST depression on the exercise test showed higher occurrence of transient, supposedly ischemic, episodes of QRS-VD, STC-VM, and ST-VM than patients without ST depression. The sensitivity and specificity of identifying patients with ST depression at the exercise test were respectively, 71 and 47% for QRS-VD episodes, 58 and 56% for ST-VM episodes, and 55 and 65% for STC-VM episodes. The maximum ST depression at the exercise test was related to the maximum ST depression in vector lead X (r = .44, P < .001) and the number of STC-VM (r = .40, P < .001), ST-VM (r = .37, P < .001), and QRS-VD (r = .33, P < .001) episodes on the VCG. In multivariate analysis, maximum ST depression in vector lead X and STC-VM episodes were the best determinants for ST depression at the exercise test. In a Cox regression model, the optimal combination of exercise test data in patients who died from cardiac causes exhibited a global chi-square value of 20.0. The combination of these data and the number of STC-VM episodes increased the global chi-square value to 30.6. This study indicates that in patients with acute ischemic heart disease, early continuous vectorcardiographic monitoring may predict the results from a predischarge exercise test and also contributes independent prognostic information beyond that of exercise test data.
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Affiliation(s)
- P Lundin
- Department of Medicine, Danderyd Hospital, Stockholm, Sweden
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6
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Olona M, Candell-Riera J, Permanyer-Miralda G, Castell J, Barrabés JA, Domingo E, Rosselló J, Vaqué J, Soler-Soler J. Strategies for prognostic assessment of uncomplicated first myocardial infarction: 5-year follow-up study. J Am Coll Cardiol 1995; 25:815-22. [PMID: 7884082 DOI: 10.1016/0735-1097(94)00503-i] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES Our aim was to use noninvasive studies early after infarction to assess medium-term prognosis in patients with a first uncomplicated myocardial infarction. BACKGROUND Although the use of early postinfarction assessment to gauge short-term prognosis in myocardial infarction is well established, there have been few comprehensive evaluations of noninvasive methods for assessing medium- and long-term prognosis. METHODS We prospectively studied 115 consecutive patients < 65 years old with a first acute uncomplicated myocardial infarction to evaluate the prognostic role of predischarge cardiac studies. These included submaximal exercise testing, thallium-201 scintigraphy, radionuclide exercise ventriculography, two-dimensional echocardiography, ambulatory electrocardiographic (Holter) monitoring and cardiac catheterization. All patients without complications were followed up > or = 5 years. RESULTS During the follow-up period, 78 patients (68%) developed complications, which were severe in 37 (32%). Exercise thallium-201 scintigraphy yielded the highest percentage (77%) for correctly classified patients. It also had the highest predictive value for complications (97%) and severe complications (92%) when it was used in association with exercise testing and radionuclide ventriculography. The addition of cardiac catheterization did not improve on the predictive power of noninvasive studies. Four decision trees (exercise testing + echocardiography, exercise testing + radionuclide ventriculography, thallium-201 + echocardiography, thallium-201 + radionuclide ventriculography) allowed stratification of all patients in a high, intermediate or low risk category. The combination of thallium-201 scintigraphy and radionuclide ventriculography yielded the best results (90% predictive value for complications if the outcome of both tests was positive), but there were no significant differences with the other models. CONCLUSIONS Any combination of a test detecting residual ischemia or functional capacity, or both (exercise testing or thallium-201 scintigraphy), and a test assessing ventricular function (echocardiography or radionuclide ventriculography) results in useful prognostic information in patients with an uncomplicated first acute myocardial infarction.
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Affiliation(s)
- M Olona
- Servei de Cardiologia, Hospital General Universitari Vall d'Hebron, Barcelona, Spain
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7
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Lundin P, Eriksson SV, Strandberg LE, Rehnqvist N. Prognostic information from on-line vectorcardiography in acute myocardial infarction. Am J Cardiol 1994; 74:1103-8. [PMID: 7977067 DOI: 10.1016/0002-9149(94)90460-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The present study assesses the prognostic information from continuous on-line vectorcardiography in patients with acute myocardial infarction (AMI). A series of 203 patients with AMI were studied. Vectorcardiographic (VCG) recordings were obtained continuously for 24 hours. Analysis was performed on-line with the commercial system MIDA CoroNet. QRS vector difference (QRS-VD), ST change vector magnitude (STC-VM), and ST vector magnitude (ST-VM) were monitored. Patients were followed for 538 +/- 220 days. During follow-up, 36 patients died from cardiac causes and 38 patients had reinfarction. A significantly higher occurrence of transient VCG changes (QRS-VD, STC-VM, and ST-VM; p < 0.001) was seen in patients who died from cardiac causes or experienced either cardiac death or reinfarction at follow-up. The end value for QRS-VD was higher in patients who died from cardiac causes and correlated with the maximal value for creatine kinase when all patients were considered (r = 0.66; p < 0.001). Significantly lower mortality was seen in patients with VCG trend curves suggestive of coronary reperfusion (p < 0.01). In multivariate analysis, occurrence of transient changes in STC-VM, high QRS-VD end value, and VCG trend curves not suggestive of reperfusion gave additional prognostic information beyond that of age, gender, maximal creatine kinase value, heart size on chest x-ray, occurrence of ventricular fibrillation during hospitalization, and the inability to perform exercise tests. VCG monitoring during the first 24 hours of hospitalization for an AMI is a promising method for early detection of patients with increased risk for subsequent cardiac death or reinfarction.
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Affiliation(s)
- P Lundin
- Department of Medicine, Danderyd Hospital, Stockholm, Sweden
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8
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Wosornu D, Goh KY, Gooptu C, Beattie JM, Murray RG. Does thrombolysis affect the prognostic value of the post-infarct exercise test? Int J Cardiol 1994; 47:13-20. [PMID: 7868280 DOI: 10.1016/0167-5273(94)90128-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
There has been some debate on usefulness of the exercise test in risk stratification after myocardial infarction in the thrombolytic era. This was assessed in 295 patients of whom 184 were treated with thrombolysis. Each had an exercise test using a modified Naughton protocol within 14 days of acute myocardial infarction. The tests were graded as high risk positive (112), low risk positive (83), or negative (100). These gradings predicted use of multiple drug therapy (p = 0.05), severity of coronary artery disease (p < 0.01), and coronary artery bypass grafting (p < 0.01). There was no influence on heart failure, recurrent myocardial infarction or death. This was independent of the use of thrombolytic therapy. The whole group had a good prognosis with a mortality of 2.4% after 56 weeks' follow-up. The exercise test is still a useful screening test after myocardial infarction. In this study, there was a high negative predictive accuracy of 91% for any event. Its use is not altered by thrombolysis. The finding of a lack of influence of the exercise test on major events may be a reflection of the current good prognosis after myocardial infarction and the prompt use of revascularisation.
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Affiliation(s)
- D Wosornu
- Department of Cardiology, Birmingham Heartlands Hospital, UK
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9
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Northridge DB, Hall RJ. Post-myocardial-infarction exercise testing in the thrombolytic era. Lancet 1994; 343:1175-6. [PMID: 7909864 DOI: 10.1016/s0140-6736(94)92396-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- D B Northridge
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
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10
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Stevenson R, Umachandran V, Ranjadayalan K, Wilkinson P, Marchant B, Timmis AD. Reassessment of treadmill stress testing for risk stratification in patients with acute myocardial infarction treated by thrombolysis. Heart 1993; 70:415-20. [PMID: 8260271 PMCID: PMC1025352 DOI: 10.1136/hrt.70.5.415] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVES To evaluate the role of a treadmill stress test for identifying patients at risk of recurrent ischaemic events after acute myocardial infarction treated by thrombolysis. BACKGROUND The natural history of myocardial infarction has changed with the introduction of thrombolytic treatment; there is a lower mortality but a higher incidence of recurrent thrombotic events (reinfarction, unstable angina). The treadmill stress continues to be recommended for risk stratification after acute myocardial infarction even though its value has never been formally reassessed in the thrombolytic era. METHODS Prospective observational study in which 256 consecutive patients who presented with acute myocardial infarction treated by thrombolysis underwent an early treadmill stress test and were followed up for 10 (range 6-12) months. RESULTS Recurrent ischaemic events occurred in 41 patients (unstable angina 15, reinfarction 21, death five) and a further 21 required revascularisation. Both ST depression at a low workload and low exercise tolerance (< 7 metabolic equivalents of the task (METS) were predictive of recurrent events, with respective hazard ratios of 1.93 (95% confidence interval (95% CI) 1.17-3.20; p < 0.01)) and 1.67 (95% CI 1.0-2.78; p < 0.05). These variables identified 50% and 70% of patients who subsequently sustained a recurrent ischaemic event, but the corresponding values for positive predictive accuracy were only 26% and 21%. Thus they are of limited value as a screening measure for identifying patients likely to benefit from invasive investigation and revascularisation. None of the other variables (ST elevation, haemodynamic responses, ventricular extrasystoles, angina) was significantly associated with recurrent ischaemic events. CONCLUSIONS The treadmill stress test is of limited value for identifying patients at risk of recurrent ischaemic events after acute myocardial infarction treated by thrombolysis.
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Affiliation(s)
- R Stevenson
- Department of Cardiology, London Chest Hospital
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11
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Cross SJ, Lee HS, Kenmure A, Walton S, Jennings K. First myocardial infarction in patients under 60 years old: the role of exercise tests and symptoms in deciding whom to catheterise. Heart 1993; 70:428-32. [PMID: 8260273 PMCID: PMC1025354 DOI: 10.1136/hrt.70.5.428] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
OBJECTIVE To determine the role of exercise tests and assessment of angina in the detection of potentially threatening disease in young patients with infarcts. DESIGN Elective readmission of patients at a mean (SD) of 60 (30) days after acute myocardial infarction for assessment of angina, treadmill exercise tests, and cardiac catheterisation. SETTING Cardiology department of a teaching hospital. PATIENTS 186 consecutive survivors, aged under 60 years and discharged from the coronary care unit after a first myocardial infarction. MAIN OUTCOME MEASURES Coronary arteriography, presence of angina, result of exercise tests, and referral for revascularisation. RESULTS 31% of patients had either two vessel disease (with proximal left anterior descending involvement), three vessel disease, or left main stem disease. 49% of all patients had angina. Of the 173 patients who had an exercise test 34% had 1 mm and 24% had 2 mm of exercise induced ST depression. Thirty percent had no angina and a negative exercise test: after a mean (SD) follow up of 16 (4) months none of this symptom free sub-group had died, had experienced a further myocardial infarction, or had been referred for revascularisation. 79% of patients with either two vessel disease (with proximal left anterior descending involvement), three vessel disease, or left main stem disease had either angina or a 1 mm ST depression during the exercise test. CONCLUSION Patients without cardiac pain after myocardial infarction and without ST changes during an exercise do not need arteriography.
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Affiliation(s)
- S J Cross
- Department of Cardiology, Aberdeen Royal Infirmary, Foresterhill
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12
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Odemuyiwa O, Farrell TG, Malik M, Bashir Y, Millane T, Cripps T, Poloniecki J, Bennett D, Camm AJ. Influence of age on the relation between heart rate variability, left ventricular ejection fraction, frequency of ventricular extrasystoles, and sudden death after myocardial infarction. Heart 1992; 67:387-91. [PMID: 1382505 PMCID: PMC1024860 DOI: 10.1136/hrt.67.5.387] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIMS To examine the influence of age on the prediction of sudden death after acute myocardial infarction based on heart rate variability (HRv), left ventricular ejection fraction (LVEF), and the frequency of ventricular extrasystoles. BACKGROUND Autonomic and left ventricular function and the frequency of ventricular extrasystoles change with age but the influence of age on the prediction of sudden death from these variables has not been examined. METHODS The 477 patients who had been through an early postinfarction risk stratification protocol and followed up for a mean of 790 days were dichotomised at 60 years of age. RESULTS Sudden deaths occurred with similar frequency in both age groups (12 (4.7%) of the 256 patients aged < 60 years and seven (3.2%) of the 221 older patients). Sudden death, however, accounted for 52% of all deaths in the young group but only 18.4% of all deaths in the older group (p < 0.01). An HRv index of < 20 units combined with an average of more than 10 ventricular extrasystoles an hour on Holter monitoring (VE10) had a sensitivity of 50%, a positive predictive accuracy of 33%, and a risk ratio of 18 in the young group (p < 0.001) but was not significantly predictive in older patients. The situation was similar when the combination of an LVEF < 40% with VE10 was considered. This combination had a sensitivity of 44%, positive predictive accuracy of 36.4%, and a risk ratio of 16.1 in young patients (p < 0.001), but was not significantly predictive in older patients. The combination of VE10 with either LVEF < 40% or HRv < 20 units gave a sensitivity of 75%, positive predictive accuracy of 30%, and a risk ratio of 30 in young patients (p < 0.001), but the relation between this combination and sudden death in older patients was not statistically significant. CONCLUSION In postinfarction patients aged < 60 sudden death was a more predominant mode of death and was more reliably predicted from a depressed HRv index, an LVEF < 40%, and VE10 than in older postinfarction patients. These findings may have important implications for post-infarction risk stratification and management.
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Affiliation(s)
- O Odemuyiwa
- Department of Cardiological Sciences, St George's Hospital, Cranmer Terrace, London
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13
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Rønnevik PK, Følling M, Pedersen D, Rodt SA, von der Lippe G. Increased occurrence of exercise-induced silent ischemia after treatment with aspirin in patients admitted for suspected acute myocardial infarction. Int J Cardiol 1991; 33:413-7. [PMID: 1761336 DOI: 10.1016/0167-5273(91)90071-v] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Patients admitted for suspected acute myocardial infarction within 6 hours (mean 3 hours 42 minutes) after onset of symptoms were randomised to double-blind treatment with low-dose oral aspirin or placebo. Early exercise ischemic responses, exercise capacity and resting left ventricular ejection fraction (radionuclide ventriculography) were estimated in 77 survivors 2-4 weeks later. Exercise performance and ejection fraction in patients with confirmed acute myocardial infarction were equal in the two groups. During exercise, patients treated with aspirin had significantly more silent ischemia (ST depression without chest pain) compared to placebo (28% versus 6%; P = 0.015). The occurrence of positive exercise tests (chest pain or ST-segment depression), however, was similar in the two groups. The results indicate that the administration of aspirin early after acute myocardial infarction increases the occurrence of silent ischemia but has no effect on left ventricular function.
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Affiliation(s)
- P K Rønnevik
- Department of Medicine, University Clinic Haukeland Hospital, Bergen, Norway
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14
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Candell-Riera J, Permanyer-Miralda G, Castell J, Rius-Daví A, Domingo E, Alvarez-Auñón E, Olona M, Rosselló J, Ortega D, Domènech-Torné FM. Uncomplicated first myocardial infarction: strategy for comprehensive prognostic studies. J Am Coll Cardiol 1991; 18:1207-19. [PMID: 1918697 DOI: 10.1016/0735-1097(91)90537-j] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
To evaluate the prognostic role of combined cardiac studies (submaximal exercise test, thallium-201 scintigraphy, radionuclide exercise ventriculography, two-dimensional echocardiography, Holter monitoring and cardiac catheterization) in patients with a first acute myocardial infarction without complications during hospital admission, 115 consecutive patients aged less than 65 years were prospectively evaluated. The studies were carried out before hospital discharge and the patients were then clinically followed up for 12 months. During the follow-up period, 69 patients (60%) developed complications, which were severe in 23 (20%). Half of all complications and 70% of severe complications developed during the 1st follow-up month. Logistic regression analysis disclosed that the combination of studies with the highest predictive power for complications (probability of complications 99%) and severe complications (probability of severe complications 95%) was the association of exercise test + thallium-201 + echocardiogram. Four decision models (exercise test + echocardiography, exercise test + radionuclide ventriculography, thallium-201 scintigraphy + echocardiography, thallium-201 scintigraphy + radionuclide ventriculography) allowed the stratification of all patients in a particular risk category (high, intermediate or low). The best decision model was the association of thallium-201 scintigraphy + radionuclide ventriculography (probability of complications if both tests were positive 84%; probability of absence of severe complications if both tests were negative 88%), but there were no significant differences with the other models. Any association of a test detecting residual ischemia or functional capacity, or both (exercise test or thallium-201) and a test assessing ventricular function (echocardiography or radionuclide ventriculography) results in significant prognostic information in patients with an uncomplicated first acute myocardial infarction. Additional cardiac catheterization does not improve the predictive power of noninvasive studies, which should ideally be performed before hospital discharge because most complications develop during the 1st follow-up month.
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Affiliation(s)
- J Candell-Riera
- Servei de Cardiologia, Hospital General Vall d'Hebron, Barcelona, Spain
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