Long-term follow-up after a controlled randomized post-myocardial infarction rehabilitation programme: effects on morbidity and mortality.

Prognosis during 4.5 years of follow-up after myocardial infarction (MI) in 2 groups of patients 25 to 65 years of age was related to physical rehabilitation and usual risk factors. We randomized 167 patients to a rehabilitation (R) group and a control (C) group (84 and 83 patients respectively). At the end of the training period, the R group had a significantly higher work capacity, a higher double product reached during the stress test and lower triglycerides. During the 55 months of follow-up after the physical training or the equivalent spontaneous activity, we observed the prevalence of risk factors and of cardiac events such as angina, new MI, unstable angina, coronary bypass grafting and cardiac death. Survival rate was 92.6% in the R group and 93.7% in the C group. There was no relationship between serum cholesterol levels, tobacco smoking, and blood pressure and mortality and morbidity after the infarction. R patients were more symptom-free (44% against 30%), and had almost the same number of episodes of unstable angina and of cardiac death. 6.1% of the R group and 11.2% of the C group developed a new myocardial infarction. As in previous randomized studies we did not reach statistical significance for long-term benefit, perhaps because of the low sample size. However, our study confirmed a favorable tendency in terms of symptoms and the self confidence of the R patients.

The prognostic significance of clinical history, exercise testing and ambulatory electrocardiography in patients with uncomplicated myocardial infarction.

The prognostic value of early clinical history, exercise testing and ambulatory electrocardiography was assessed in 263 men (mean age 50 years) recovering from an uncomplicated myocardial infarction (MI). During a mean follow-up period of 31 months, 11 patients died of cardiac causes, 22 developed a non fatal recurrent MI, 16 unstable angina (UA) and 16 underwent coronary artery bypass surgery. The appearance at the exercise stress test of an ischemic S-T segment depression of 0.2 mV or greater (P less than 0.001) as well as the achievement of a work load of 360 Kg-m/m' or less (P less than 0.01) and of a rate-pressure product of 200 Units or less (P less than 0.01), were found to be predictive of the future development of UA, but neither of cardiac death nor of non fatal recurrent MI. The ischemic response was also seen to be predictive of cardiac death (P less than 0.05). S-T segment depression of 0.1 mV or greater, angina and ventricular ectopic activity during the stress test and clinical history were not of predictive value. Complex ventricular ectopic activity (multiform extrasystoles, couplets and ventricular tachycardia) recorded during 24 hour ambulatory electrocardiogram was seen to be predictive of death and non fatal MI. Whereas some parameters such as the ejection fraction and the extension of coronary artery disease are generally accepted as good predictors for cardiac events, others, such as those derived from exercise testing, history and ambulatory electrocardiography may change their predictive value from one survey to another. These discrepancies are due to differences in patient characteristics, in methodology and in medical management.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute effects of chewable nifedipine on hemodynamic responses to upright exercise in patients with prior myocardial infarction and effort angina.

To evaluate the hemodynamic effects of nifedipine on anginal patients during exercise in the upright position, a placebo (P) and 20 mg of nifedipine were administered in a double-blind random sequence to ten patients presenting with exertional angina and a healed myocardial infarction. All patients had previously undergone coronary angiography. The effects of nifedipine in the upright position at rest, at the anginal threshold, and at the maximal level of exercise were studied. Nifedipine decreased systemic vascular resistances in upright position and increased the cardiac index. It reduced the severity of angina and allowed a higher physical work capacity without anginal symptoms. The most important beneficial effect of nifedipine appears to be the reduction in afterload, but an improvement of left ventricular function cannot be ruled out.

[Influence of sleep, wakefulness and some daily activities on ventricular ectopic activity in recent myocardial infarction (author's transl)]. / Influenza del ciclo sonno-veglia e di alcune attivita' giornaliere sull'attivita' ectopica ventricolare nell'infarto miocardico recente.

87 24-hour electrocardiographic monitoring sessions were conducted in 71 ambulatory patients (pts) in the early post-hospital phase after acute myocardial infarction. 29 (41%) had anterior, 42 (59%) inferoposterior myocardial infarction, 44 (62%) had angina or asymptomatic ischemia, 7 (10%) were in cardiac failure (II-III class NYHA). The occurrence of ventricular ectopic activity (VEA) during sleep hours was compared to the awake state; VEA during sexual and other activities of the awake state was studied. Excluding pts free of VEA during 24-hour monitoring the number of ventricular mature beats was lowered in 71% of sessions and augmented in 12% during sleep hours (p less than 0.001). Maximal grade of VEA was observed during wakefulness in 62% of session and in 9% during sleep (p less than 0.001); in 9% there was no difference, in 20% no VEA occurred. Total VEA, bi-tri-quadrigeminism and repetitive extrasystoles were significantly reduced during sleep: p less than 0.001, p less than 0.05 and p less than 0.01 respectively. This pattern was independent from site of infarction, presence of ischemia, cardiac failure (II-III class NYHA). A discrete correlation was observed between total VEA and heart rate; a poor correlation was seen between total VEA, multiform and repetitive extrasystoles. During wakefulness VEA was mainly related to physical exertion and emotional stress. Sleep and relax periods of the day showed VEA similar to sleeping hours of the night. Sexual activity did not significantly elicit more VEA than other activities of the awake state. Repetitive forms, observed in 8% of the population, were probably related to the rapid increase of sympathetic tone. The absence of repetitive VEA, potentially dangerous, during sleep hours (except the first) not due to antiarrhythmic drugs suggests to increase the dosage of these medications during the awake state in the majority of these pts.

[An information survey on the automatic operation of intensive therapy units in Italy]. / Indagine conoscitiva sulla gestione automatica delle sale di terapia intensiva in Italia.

A fact finding study was carried out in 58 resuscitation centres and 78 intensive care units to evaluate the current application of computerised techniques in the monitoring and processing of various parameters relating to hospitalised patients. The enquiry revealed a marked interest in the use of computerised systems, particularly in the electrophysiological and haemodynamic field. Promising results were reported from some centres. Some adverse criticisms and points of discussion still exist. International and national experiences matured so far, however, while primarily directed towards scientific research and technological development, open up significant perspectives for the future, for the rational handling of the data collected, and the extension of current knowledge on matters of physiopathology, electrophysiology, and pharmacokinetics.

[Prognostic and diagnostic value of the exercise test and early coronary anamnesis in patients with myocardial infarct studied in a median term follow-up]. / Valore prognostico e diagnostico della prova da sforzo e dell'anamnesi coronarica precoce in pazienti con infarto miocardico in un follow-up a medio termine.

We performed a maximal or symptom limited exercise stress test (ET) 58 +/- 20 days after acute myocardial infarction (AMI) and looked for the presence of angina (A) 4-5 weeks after AMI in 193 consecutive patients (pts.). The aim of the study was to research from ET and history of early A parameters able to predict further coronary events in the follow-up (FU): new onset of angina, reinfarction or cardiac death. The FU lasted 18.06 months. The drop-out was 7%; so, data was collected on 179 pts.; 95% of our population performed the ET without any therapy. 72 pts. (40%) had an anterior-lateral AMI (I group) and 107 (60%) had an inferior-posterior AMI (II group). Pts. with early A were 35% in the I group (GR) and 52% in the II GR (P less than 0.02). Pts. with a positive ET were 38% in the I Gr and 57% in the II GR (P less than 0.01). The double product (DP) of positive ETs in the I GR was inferior (P less than 0.01) to that of the II GR; the DP of negative ETs in the I GR was inferior (P less than 0.01) to that of II GR. The comparison of the DP of positive and negative ETs showed that the former was inferior either in the I GR (P less than 0.02) or in the II GR (P less than 0.05). The highest value of serum CPK of the acute phase was observed in pts. with ST depression during ET in both groups. In the early phase after AMI, ET and A identified 50% of pits. in the I GR and 74% in the II GR as having further signs of coronary artery disease. These data were confirmed during the FU; the two techniques are then complementary to predict further events in our FU. Incidence rate of early symptoms, ischemic responses to ET, work capacity and DP values obtained during ET differed significantly in the two GRs. Reinfarction rate was 5% in the I GR and 10% in the II GR; mortality rate was similar (4.5%) in both GRs; we dit not identify predictive signs for mortality after 18.06 months from AMI. A negative history of A and a negative ET were predictors of absence of angina, but not of reinfarction nor of coronary death during our FU.

[Plan for installation of an automatic system of analysis of electrocardiograms for a group of hospitals and a regional cardiological record office]. / Progetto di installazione di un sistema automatico di lettura dell'elettrocardiogramma per un gruppo di ospedali e di una anagrafe cardiologica regionale

In view of the present state of the Central ECG Department serving the "San Giovanni" group of hospitals in Turin and in consideration of the ever growing number of ECG's required daily, a reorganization of the department has become necessary. Such a reorganization must be based on the latest facilities offered by electronic engineering, namely by means of automating the entire system. Various manufacturers offer proven equipment and the only problem is one of choosing that most suitable for requirements. Personally, the on line system is considered to be best although many are opposed to it, because it is the only system that makes it possible to answer urgent demands in real time. The material collected by this Centre and by others that must of necessity arise in the Region of Piedmont, should not be dispersed but filed so that it can be employed for further controls and for statistical and epidermiological research. It therefore becomes necessary to set up a large central file at Regional level capable of storing ECG findings and all historical, clinical and laboratory data pertaining to patients who come into contact with the System. On request, it must also be capable of processing stored data and furnishing print-outs of data through video terminals for the purposes of subsequent examinations and continuations of treatment, as well as for clinical or statistical research reasons. Such a file would represent a veritable cardiological register for Piedmont and the first step on the way to the impellent creation of a Sanitary Register of the whole population.