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1.
Eur Heart J ; 23(21): 1678-83, 2002 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-12398825

RESUMO

BACKGROUND: While right ventricular myocardial infarction is associated with increased in-hospital morbidity and mortality, prognostic risk factors for in-hospital and long-term mortality are poorly defined. OBJECTIVES: To evaluate the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) risk score analysis in patients with right ventricular myocardial infarction (RVI). DESIGN: Retrospective analysis of a community population. SETTING: Mayo Clinic Coronary Care Unit. PATIENTS: One hundred and two patients with RVI from 580 consecutive patients from Rochester, Minnesota admitted to the Coronary Care Unit with acute inferior or lateral wall myocardial infarction from January 1988 through March 1998. MEASUREMENT: Combined TIMI risk score analysis with in-hospital and long-term mortality. RESULTS: In-hospital morbidity (RVI: 54.9% vs non-RVI: 22.2%; P<0.001) and mortality (RVI: 21.6% vs non-RVI: 6.9%;P <0.001) were increased in patients with RVI. The TIMI risk score predicted risk (per one point increase in TIMI score) for in-hospital mortality (OR 1.23, 95% CI 1.02-1.51, P=0.037) and long-term mortality (OR 1.57, 95% CI 1.25-1.96, P<0.001). Patients with RVI whose TIMI risk score was >or=4 had significantly worse long-term survival compared to those patients with RVI and TIMI score <4 (P=0.006). CONCLUSIONS: In-hospital morbidity and mortality, and long-term mortality are increased by right ventricular infarction and can be accurately predicted by the initial TIMI risk score.


Assuntos
Infarto do Miocárdio/tratamento farmacológico , Terapia Trombolítica/métodos , Idoso , Feminino , Mortalidade Hospitalar , Hospitalização , Humanos , Masculino , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Análise de Sobrevida
2.
Mayo Clin Proc ; 76(10): 1011-20, 2001 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-11605685

RESUMO

Acute coronary syndromes (ACS) are complications of atherosclerotic vascular disease that are triggered by the sudden rupture of an atheroma. Atherosclerotic plaque stability is determined by multiple factors, of which immune and inflammatory pathways are critical. Unstable plaque is characterized by an infiltrate of T cells and macrophages, thereby resembling a delayed hypersensitivity reaction. On activation, T cells secrete cytokines that regulate the activity of macrophages, or the T cells may differentiate into effector cells with tissue-damaging potential. Constitutive stimulation of T cells and macrophages in ACS is not limited to the vascular lesion but also involves peripheral immune cells, suggesting fundamental abnormalities in homeostatic mechanisms that control the assembly, turnover, and diversity of the immune system as a whole. This review gives particular attention to the emergence of a specialized T-cell subset, natural killer T cells, in patients with ACS. Natural killer T cells have proinflammatory properties and the capability of directly contributing to vascular injury.


Assuntos
Doença das Coronárias/imunologia , Células Matadoras Naturais/imunologia , Doença Aguda , Angina Instável/imunologia , Arteriosclerose/complicações , Arteriosclerose/imunologia , Artrite Reumatoide/imunologia , Antígenos CD28/imunologia , Antígenos CD4/imunologia , Doença das Coronárias/etiologia , Citocinas/imunologia , Transdução de Sinais , Síndrome
3.
Am Heart J ; 142(5): 768-74, 2001 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-11685161

RESUMO

BACKGROUND: The role of early coronary angiography in the evaluation of patients with unstable angina has been controversial. This study was designed to determine the effect of early coronary angiography on long-term survival in patients with unstable angina. METHODS: We reviewed the Olmsted County Acute Chest Pain Database, a population-based epidemiologic registry that includes all patients residing within Olmsted County who were seen for emergency department evaluation of acute chest pain from 1985 to 1992. Patients with symptoms consistent with myocardial ischemia qualifying as unstable angina were classified as undergoing early (

Assuntos
Angina Pectoris/diagnóstico por imagem , Angina Pectoris/mortalidade , Angiografia Coronária , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Análise de Sobrevida
4.
Fam Pract ; 18(5): 537-9, 2001 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-11604379

RESUMO

BACKGROUND: Community education programmes focused on raising public awareness of the symptomatology of acute coronary syndromes have had mixed results. OBJECTIVES: The Wabasha Heart Attack Team project, a unique multidisciplinary public education effort in Minnesota, sought to educate area citizens about signs and symptoms of acute myocardial infarction (MI). METHODS: After an intensive 1-month education period, we compared presentations for emergency evaluation of chest pain during the study period with baseline data from the same seasonal period of the preceding year. RESULTS: Visits to the Emergency Room for symptomatic heart disease increased significantly during the study period (56 patients versus 46 patients during the baseline period), as did the percentage of patients presenting with acute MI (18% versus 12%, P < 0.05). Use of emergency medical services for pre-hospital evaluation was significantly increased (41% versus 27%, P < 0.05). CONCLUSION: A community education campaign can significantly increase use of pre-hospital emergency medical service resources and may increase the number of patients presenting with acute chest pain symptoms, including MI.


Assuntos
Angina Pectoris/diagnóstico , Educação em Saúde , Infarto do Miocárdio/diagnóstico , Idoso , Feminino , Educação em Saúde/métodos , Humanos , Masculino
5.
Clin Cardiol ; 24(8): 542-7, 2001 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-11501605

RESUMO

BACKGROUND: The American Heart Association has classified obesity as a major modifiable risk factor for coronary artery disease, but its relationship with age at presentation with acute myocardial infarction (AMI) is poorly documented. HYPOTHESIS: The study was undertaken to evaluate the impact of obesity on age at presentation, and on in-hospital morbidity and mortality in patients with AMI. METHODS: Our analysis includes a consecutive series of 906 Olmsted County patients (mean age 67.7 years, 51% male) admitted with AMI to the Mayo Clinic Coronary Care Unit (CCU). The patients were entered into the Mayo CCU Database, a prospective registry of data pertaining to patients admitted to the Mayo Clinic CCU with AMI. Age at AMI occurrence and in-hospital morbidity and mortality were noted. RESULTS: Obese patients (body mass index [BMI] >30) with AMI were significantly younger than patients with AMI in the overweight (BMI 25-30) and normal-weight (BMI < 30) groups (62.3+/-13.1 vs. 66.9+/-13.2 and 72.9+/-13.4, respectively. p < 0.001). Obesity and overweight status were associated with male gender, diabetes mellitus, hypercholesterolemia, and smoking history; however, after multivariate adjustment for these risk factors, excess weight and premature AMI remained significantly associated. Compared with normal-weight patients, overweight patients presenting with AMI were 3.6 years younger (p < 0.001, confidence interval [CI] 1.9-5.4) and obese patients 8.2 years younger (p < 0.001, Cl 6.2-10.1). No significant increase in in-hospital morbidity and mortality was seen. CONCLUSION: In this population-based study, overweight and obese status are independently associated with the premature occurrence of AMI, but not with an increased incidence of in-hospital complications.


Assuntos
Infarto do Miocárdio/etiologia , Obesidade/complicações , Idade de Início , Idoso , Índice de Massa Corporal , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Infarto do Miocárdio/epidemiologia , Infarto do Miocárdio/fisiopatologia , Obesidade/epidemiologia , Obesidade/fisiopatologia , Estudos Prospectivos , Fatores de Risco , Estados Unidos/epidemiologia , Função Ventricular Esquerda
6.
Cost Qual ; : 12-20, 25, 2001 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-11482251

RESUMO

OBJECTIVE: We evaluated the association between length of hospital stay (LOS) and clinical factors, treatment intensity, and use of percutaneous coronary revascularization from 1988 to 1997. BACKGROUND: Multiple factors contribute to the observed reduction in LOS for patients with myocardial infarction. METHODS: We studied a series of 849 consecutive patients admitted with acute myocardial infarction to the Mayo Clinic Coronary Care Unit within three time periods: period I (1988-1990), period II (1991-1993), and period III (1994-1997). RESULTS: Median LOS decreased significantly between 1988 and 1997 (9 days to 5 days, 36% reduction, p < 0.0001), with significant reductions (p < 0.001) associated with certain therapies: primary reperfusion (6 days vs 7 days), b-blockers (6 days vs 8 days), and aspirin (6 days vs 8 days). Hospitalizations were lengthened by coronary artery bypass grafting (12 vs 6 days) and by serious complications (10 vs 6 days). The era of the admission (period I vs II vs III) is a significant, powerful predictor of LOS, even after adjustment for other key variables. CONCLUSION: The 36% reduction in LOS for acute myocardial infarction between 1988 and 1997 is related both to therapeutic modalities and temporal trends. Further study is needed to clarify whether the trend for decreasing LOS persists and influences outcome and health care quality variables.


Assuntos
Angioplastia Coronária com Balão/estatística & dados numéricos , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Infarto do Miocárdio/terapia , Terapia Trombolítica/estatística & dados numéricos , Idoso , Feminino , Mortalidade Hospitalar , Hospitais de Prática de Grupo/estatística & dados numéricos , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Análise Multivariada , Infarto do Miocárdio/complicações , Infarto do Miocárdio/mortalidade , Avaliação de Processos e Resultados em Cuidados de Saúde
7.
Am J Cardiol ; 88(5): 482-7, 2001 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-11524054

RESUMO

Maximal benefits of coronary reperfusion after acute myocardial infarction (AMI) with ST-segment elevation may be attenuated by neutrophil-mediated reperfusion injury. Inflammatory mediators released from potentially viable myocytes cause activation of neutrophils, which traverse the endothelium and enter the myocardium. This process involves interaction between the neutrophil-expressed CD11/CD18 and endothelial-expressed intercellular adhesion molecule-1 (ICAM-1). Preclinical studies have shown that monoclonal antibodies (MAb) to CD18 can limit infarct size and preserve left ventricular function. We sought to determine the initial clinical safety and tolerability of Hu23F2G (LeukArrest), a humanized MAb to CD11/CD18, in patients with AMI who underwent percutaneous transluminal coronary angioplasty (PTCA). Sixty patients with AMI were randomized to low- (0.3 mg/kg) or high-dose (1.0 mg/kg) Hu23F2G or to placebo immediately before PTCA. We found no clinically significant differences in vital signs, physical examination, laboratory evaluation, or need for subsequent cardiac interventions. In Hu23F2G treatment groups, serum concentration of Hu23F2G increased rapidly to 3,234 +/- 1,298 microg/L (low-dose group) and 15,558 +/- 4409 microg/L (high-dose group) between 5 and 60 minutes, then declined over 72 hours to near-baseline values. Myocardial single-photon emission computed tomographic imaging 120 to 260 hours after PTCA showed no statistically significant differences in final left ventricular defect size. Hu23F2G was well tolerated, with no increase in adverse events, including infections. Thus, Hu23F2G appears safe and well tolerated in patients undergoing PTCA for AMI.


Assuntos
Angioplastia Coronária com Balão/métodos , Anticorpos Monoclonais/administração & dosagem , Infarto do Miocárdio/terapia , Fármacos Neuroprotetores/administração & dosagem , Idoso , Anticorpos Monoclonais Humanizados , Distribuição de Qui-Quadrado , Terapia Combinada , Angiografia Coronária , Relação Dose-Resposta a Droga , Método Duplo-Cego , Esquema de Medicação , Eletrocardiografia , Feminino , Seguimentos , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Projetos Piloto , Probabilidade , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Estatísticas não Paramétricas , Taxa de Sobrevida , Tomografia Computadorizada de Emissão de Fóton Único , Resultado do Tratamento
8.
Am J Cardiol ; 88(5): 541-6, 2001 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-11524065

RESUMO

The Coumadin Aspirin Reinfarction Study demonstrated that combination treatment with fixed dose warfarin (1 or 3 mg) + aspirin 80 mg was not superior to aspirin 160 mg alone after myocardial infarction for reducing nonfatal reinfarction, nonfatal stroke, and cardiovascular death. In this analysis, we examined the importance of aspirin dose in the protection against the secondary end point of ischemic stroke. The comparison arms for this analysis were warfarin 1 mg + aspirin 80 mg versus aspirin 160 mg. In the Coumadin Aspirin Reinfarction Study, 2,028 patients were randomized to aspirin 80 mg plus warfarin 1 mg, and 3,393 were randomized to aspirin 160 mg alone. A predictive model for ischemic stroke was developed using the Cox proportional-hazards model. A reduced Cox proportional-hazards model was developed to test for the effect of aspirin dose on ischemic stroke in predefined subgroups. The incidence of ischemic stroke was lower in patients treated with aspirin 160 mg than in patients treated with aspirin 80 mg + warfarin 1 mg (0.6% vs 1.1%; p = 0.0534). Age, previous stroke or transient ischemic attack, and aspirin dose were independent predictors of ischemic stroke. In addition, the highest risk patients, those with Q-wave myocardial infarction and male patients, appeared to receive greater benefit from aspirin 160 mg than from aspirin 80 mg + warfarin 1 mg. The results of this secondary analysis suggest that aspirin 160 mg is more effective than aspirin 80 mg + warfarin 1 mg in preventing ischemic stroke in post-myocardial infarction patients.


Assuntos
Anticoagulantes/administração & dosagem , Aspirina/administração & dosagem , Infarto do Miocárdio/tratamento farmacológico , Infarto do Miocárdio/mortalidade , Acidente Vascular Cerebral/tratamento farmacológico , Acidente Vascular Cerebral/prevenção & controle , Varfarina/administração & dosagem , Idoso , Relação Dose-Resposta a Droga , Quimioterapia Combinada , Eletrocardiografia , Feminino , Seguimentos , Humanos , Ataque Isquêmico Transitório/tratamento farmacológico , Ataque Isquêmico Transitório/mortalidade , Ataque Isquêmico Transitório/prevenção & controle , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/diagnóstico , Valor Preditivo dos Testes , Modelos de Riscos Proporcionais , Medição de Risco , Prevenção Secundária , Índice de Gravidade de Doença , Acidente Vascular Cerebral/mortalidade , Taxa de Sobrevida , Resultado do Tratamento
9.
Am J Cardiol ; 88(3): 205-9, 2001 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-11472694

RESUMO

Using a community-based population of patients with acute myocardial infarction (AMI), we sought to: (1) determine the prevalence of bundle branch block (BBB) on the presenting electrocardiogram (ECG), (2) compare the clinical characteristics and the treatment administered to patients with and without BBB, and (3) determine the association of BBB with mortality. We analyzed the admission ECGs of 894 consecutive patients with AMI from Olmsted County, Minnesota, seen at our institution from January 1988 to March 1998. Of these, 53 had left BBB (LBBB) (5.9%) and 60 had right BBB (RBBB) (6.7%). Patients with BBB were more likely to be older, have a history of AMI or hypertension, and to be in Killip class >I at presentation. They were less likely to receive primary reperfusion therapy, beta blockers, or heparin, but more likely to receive angiotensin-converting enzyme inhibitors. They had lower mean predischarge ejection fractions (38 +/- 16% vs 50 +/- 15%, p <0.0001). In-hospital mortality was 13.3%, 17.0%, and 9.1% for patients with RBBB, LBBB, and no BBB, respectively (p = 0.11). Respective postdischarge survival at 1, 3, and 5 years was 80%, 60%, and 50% in the RBBB group, 78%, 56%, and 51% in the LBBB group, and 92%, 85%, and 76% in the group without BBB (p <0.0001). Although BBB was not an independent predictor of mortality on multivariate analysis, the presence of transient or persistent BBB with AMI is an easily recognized clinical marker of increased mortality. Our conclusion from this study is that in a community-based population, patients who had LBBB or RBBB at the time of AMI had lower predischarge ejection fractions and higher in-hospital and long-term unadjusted mortality.


Assuntos
Bloqueio de Ramo/mortalidade , Infarto do Miocárdio/mortalidade , Idoso , Bloqueio de Ramo/complicações , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Análise Multivariada , Infarto do Miocárdio/complicações , Razão de Chances , Prognóstico , Reprodutibilidade dos Testes , Sobreviventes
11.
Am J Cardiol ; 87(9): 1045-50, 2001 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-11348600

RESUMO

To investigate the relevance of presenting electrocardiographic (ECG) patterns to short- and long-term mortality in nonreferral patients with acute myocardial infarction (AMI), 6 ECG patterns were analyzed. A consecutive series of 907 patients from Olmsted County, Minnesota, admitted to the Mayo Clinic Cardiac Care Unit from January 1, 1988 to March 31, 1998 for acute myocardial infarction comprised the study population. ECG patterns and distribution in the population were: (1) ST elevation alone (20.8%), (2) ST elevation with ST depression (35.2%), (3) normal or nondiagnostic electrocardiograms (18.5%), (4) ST depression alone (11.8%), (5) T-wave inversion only (10.7%), and (6) new left bundle branch block (LBBB) (3.0%). Seven- and 28-day mortalities varied significantly (p <0.01) among the 6 ECG groups. Respective mortalities were 3.0% and 6.0% for patients with normal or nondiagnostic electrocardiograms, 3.1% and 5.2% for T-wave inversion only, 7.4% and 10.6% for ST elevation alone, 9.4% and 13.1% for ST depression alone, 10.3% and 13.8% for ST elevation with ST depression, and 18.5% and 22.2% for new LBBB. Length of hospital stay (LOS) also varied among the ECG pattern groups (p <0.001) with the longest average LOS being in the new LBBB group (12.5 days). Long-term survival was similar among 5 ECG pattern groups (45% to 55% at 8 years from discharge) with the exception of LBBB (20% at 8 years). Among non-LBBB groups, ST-segment depression with or without ST elevation was associated with increased short-term mortality. Also, in this community-based population, 18.5% of patients had normal or nondiagnostic electrocardiograms.


Assuntos
Eletrocardiografia , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Adulto , Idoso , Distribuição de Qui-Quadrado , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Minnesota , Infarto do Miocárdio/terapia , Valor Preditivo dos Testes , Prognóstico , Estudos Retrospectivos , Estatísticas não Paramétricas , Análise de Sobrevida
12.
Am J Cardiol ; 87(6): 771-4, A7, 2001 Mar 15.
Artigo em Inglês | MEDLINE | ID: mdl-11249901

RESUMO

In a retrospective analysis, 66 patients identified as having received a statin drug within 24 hours of admission for acute myocardial infarction were matched 3:1 with a control group of 198 patients not treated with a statin agent. End points of in-hospital mortality and in-hospital reinfarction were significantly lower in the statin-treated group, pointing to a benefit from very early statin treatment in acute myocardial infarction.


Assuntos
Inibidores de Hidroximetilglutaril-CoA Redutases/administração & dosagem , Hipolipemiantes/administração & dosagem , Infarto do Miocárdio/mortalidade , Idoso , Esquema de Medicação , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Infarto do Miocárdio/terapia , Recidiva , Estudos Retrospectivos , Taxa de Sobrevida , Fatores de Tempo
13.
Circulation ; 103(11): 1509-14, 2001 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-11257077

RESUMO

BACKGROUND: Activation of circulating monocytes in patients with acute coronary syndromes may reflect exposure to bacterial products or stimulation by cytokines such as IFN-gamma. IFN-gamma induces phosphorylation and nuclear translocation of transcription factor STAT-1, which initiates a specific program of gene induction. To explore whether monocyte activation is IFN-gamma driven, patients with unstable (UA) or stable angina (SA) were compared for nuclear translocation of STAT-1 complexes and upregulation of IFN-gamma-inducible genes CD64 and IP-10. METHODS AND RESULTS: Peripheral blood mononuclear cells were stained for expression of CD64 on CD14(+) monocytes and analyzed by PCR for transcription of IP-10. Expression of CD64 was significantly increased in patients with UA. Monocytes from UA patients remained responsive to IFN-gamma in vitro, with accelerated transcriptional competency of CD64. IP-10-specific sequences were spontaneously detectable in 82% of the UA patients and 15% of SA patients (P<0.001). Most importantly, STAT-1 complexes were found in nuclear extracts prepared from freshly isolated monocytes of patients with UA, which provides compelling evidence for IFN-gamma signaling in vivo. CONCLUSIONS: Monocytes from UA patients exhibit a molecular fingerprint of recent IFN-gamma triggering, such as nuclear translocation of STAT-1 complexes and upregulation of IFN-gamma-inducible genes CD64 and IP-10, which suggests that monocytes are activated, at least in part, by IFN-gamma. IFN-gamma may derive from stimulated T lymphocytes, which implicates specific immune responses in the pathogenesis of acute coronary syndromes.


Assuntos
Angina Instável/metabolismo , Quimiocinas CXC/biossíntese , Interferon gama/farmacologia , Monócitos/efeitos dos fármacos , Receptores de IgG/metabolismo , Transporte Ativo do Núcleo Celular/efeitos dos fármacos , Idoso , Angina Instável/patologia , Quimiocina CXCL10 , Quimiocinas CXC/genética , Proteínas de Ligação a DNA/metabolismo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Monócitos/metabolismo , Receptores de IgG/biossíntese , Receptores de IgG/genética , Fator de Transcrição STAT1 , Transdução de Sinais , Transativadores/metabolismo , Regulação para Cima/efeitos dos fármacos
14.
Mayo Clin Proc ; 76(12): 1192-8, 2001 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-11761499

RESUMO

OBJECTIVE: To determine the effect of intercessory prayer, a widely practiced complementary therapy, on cardiovascular disease progression after hospital discharge. PATIENTS AND METHODS: In this randomized controlled trial conducted between 1997 and 1999, a total of 799 coronary care unit patients were randomized at hospital discharge to the intercessory prayer group or to the control group. Intercessory prayer, ie, prayer by 1 or more persons on behalf of another, was administered at least once a week for 26 weeks by 5 intercessors per patient. The primary end point after 26 weeks was any of the following: death, cardiac arrest, rehospitalization for cardiovascular disease, coronary revascularization, or an emergency department visit for cardiovascular disease. Patients were divided into a high-risk group based on the presence of any of 5 risk factors (age = or >70 years, diabetes mellitus, prior myocardial infarction, cerebrovascular disease, or peripheral vascular disease) or a low-risk group (absence of risk factors) for subsequent primary events. RESULTS: At 26 weeks, a primary end point had occurred in 25.6% of the intercessory prayer group and 29.3% of the control group (odds ratio [OR], 0.83 [95% confidence interval (CI), 0.60-1.14]; P=.25). Among high-risk patients, 31.0% in the prayer group vs 33.3% in the control group (OR, 0.90 [95% CI, 0.60-1.34]; P=.60) experienced a primary end point. Among low-risk patients, a primary end point occurred in 17.0% in the prayer group vs 24.1% in the control group (OR, 0.65 [95% CI, 0.20-1.36]; P=.12). CONCLUSIONS: As delivered in this study, intercessory prayer had no significant effect on medical outcomes after hospitalization in a coronary care unit.


Assuntos
Doenças Cardiovasculares/mortalidade , Doenças Cardiovasculares/terapia , Terapias Espirituais/normas , Resultado do Tratamento , Fatores Etários , Idoso , Doenças Cardiovasculares/classificação , Doenças Cardiovasculares/complicações , Comorbidade , Unidades de Cuidados Coronarianos , Complicações do Diabetes , Progressão da Doença , Intervalo Livre de Doença , Método Duplo-Cego , Feminino , Seguimentos , Parada Cardíaca/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Revascularização Miocárdica , Readmissão do Paciente/estatística & dados numéricos , Fatores de Risco , Índice de Gravidade de Doença , Fumar/efeitos adversos , Terapias Espirituais/métodos , Terapias Espirituais/psicologia
15.
Clin Cardiol ; 23(10): 751-8, 2000 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-11061053

RESUMO

BACKGROUND: The continuing applicability of the Killip classification system to the effective stratification of long-term and short-term outcome in patients with acute myocardial infarction (MI) and its influence on treatment strategy calls for reanalysis in the setting of today's primary reperfusion treatments. HYPOTHESIS: Our study sought to test the hypothesis that Killip classification, established on admission in patients with acute MI, is an effective tool for early prediction of in-hospital mortality and long-term survival. METHODS: A series of 909 consecutive Olmsted County patients admitted with acute MI to St. Marys Hospital, Mayo Clinic, between January 1988 and March 1998 was analyzed. Killip classification was the primary variable. Endpoints were in-hospital death, major in-hospital complications, and post-hospital death. RESULTS: Patients analyzed included 714 classified as Killip I, 170 classified as Killip II/III, and 25 classified as Killip IV. Increases in in-hospital mortality and prevalence of in-hospital complications correspond significantly with advanced Killip class (p < 0.01), with in-hospital mortality 7% in class I, 17.6% in classes II/III, and 36% in class IV patients (p < 0.001). Killip classification was strongly associated with mode of therapy administered within 24 h of admission (p < 0.01). Killip IV patients underwent primary angioplasty most commonly and were less likely to receive medical therapy. CONCLUSIONS: Killip classification remains a strong independent predictor of in-hospital mortality and complications, and of long-term survival. Early primary angioplasty has contributed to a decrease in mortality in Killip IV patients, but effective adjunctive medical therapy is underutilized.


Assuntos
Infarto do Miocárdio/classificação , Infarto do Miocárdio/mortalidade , Idoso , Distribuição de Qui-Quadrado , Demografia , Feminino , Mortalidade Hospitalar , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Minnesota/epidemiologia , Prognóstico , Modelos de Riscos Proporcionais , Recidiva , Medição de Risco , Análise de Sobrevida
16.
Mayo Clin Proc ; 75(11): 1185-91; quiz 1192, 2000 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-11075749

RESUMO

Intravenous fibrinolytic therapy is used widely in the treatment of ST-elevation acute myocardial infarction. Advances in this therapeutic modality during the past 5 years include new third-generation fibrinolytic agents and creative strategies to enhance administration and efficacy of fibrinolytic therapy. Several of the new agents allow for single- or double-bolus injection. A number of ongoing large randomized trials are attempting to determine whether the combination of fibrinolytic therapy with low-molecular-weight heparin or a glycoprotein IIb/IIIa antagonist enhances coronary reperfusion and reduces mortality and late reocclusion. One large prospective trial is investigating the potential benefit of prehospital administration of fibrinolytic therapy. This article summarizes recent safety and efficacy data on fibrinolytic therapy, with particular emphasis on the new third-generation fibrin-specific agents; reviews the preliminary data on facilitated fibrinolysis; and discusses the rationale for prehospital administration of fibrinolytic therapy.


Assuntos
Infarto do Miocárdio/tratamento farmacológico , Terapia Trombolítica , Ensaios Clínicos como Assunto , Contraindicações , Fibrinolíticos/administração & dosagem , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Estreptoquinase/uso terapêutico , Ativador de Plasminogênio Tecidual/administração & dosagem
18.
Cardiology ; 93(4): 205-9, 2000.
Artigo em Inglês | MEDLINE | ID: mdl-11025345

RESUMO

Most attempts to identify qualitative and quantitative techniques for assessing myocardial viability and the likelihood of improved function after revascularization in patients with healed myocardial infarcts have focused on treatment strategies and prognosis. This review examines the true value of the electrocardiographic phenomenon of exercise-induced ST segment elevation (EISTE) in Q wave leads as a diagnostic tool for the assessment of myocardial viability. The prognostic potential and clinical utility of the EISTE phenomenon are inhibited both by the heart's electrophysiologic response to exercise-induced metabolic and hemodynamic changes, and by the ECG's limited facility in assessing myocardial preservation. The use of EISTE as an independent indicator for surgical intervention is proscribed by these limitations. The EISTE phenomenon could serve as a useful tool in the first line of discrimination in patients with healed Q wave myocardial infarction, and may justify further diagnostic work-up in patients under consideration for a revascularization procedure. In the era of sophisticated nuclear and echo techniques, accurate imaging studies should not be replaced by ECG analysis alone in the search for viable tissue, except when financial costs are of major importance.


Assuntos
Eletrocardiografia/estatística & dados numéricos , Exercício Físico/fisiologia , Infarto do Miocárdio/fisiopatologia , Análise Custo-Benefício , Eletrocardiografia/economia , Teste de Esforço/economia , Teste de Esforço/estatística & dados numéricos , Humanos , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica , Prognóstico , Reprodutibilidade dos Testes
19.
Circulation ; 102(10): 1093-100, 2000 Sep 05.
Artigo em Inglês | MEDLINE | ID: mdl-10973836

RESUMO

BACKGROUND: A multinational, randomized, placebo-controlled trial (Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy, PURSUIT) demonstrated that the platelet glycoprotein IIb/IIIa receptor antagonist eptifibatide reduced the incidence of death or myocardial infarction among patients with acute ischemic syndromes without ST-segment elevation. Because of expected differences in practice patterns, a prospectively planned analysis of outcomes as a function of regions of the world was performed. The current study provides a detailed assessment of eptifibatide among the subgroup of patients enrolled within the United States. METHODS AND RESULTS: Patients presenting with chest pain within the previous 24 hours and ischemic ECG changes or creatine kinase-MB elevation were eligible for enrollment. Of the 10 948 patients randomized worldwide, 4035 were enrolled within the United States. Patients were allocated to placebo or eptifibatide infusion for up to 72 to 96 hours. Other medical therapies and revascularization strategies were at the discretion of the treating physician. Eptifibatide reduced the rate of the primary end point of death or myocardial infarction by 30 days from 15.4% to 11.9% (P=0.003) among patients in the United States. The treatment effect was achieved early and maintained over a period of 6 months (18.9% versus 15.2%; P=0.004). Bleeding events were more common in patients receiving eptifibatide but were predominantly associated with invasive procedures. The magnitude of clinical benefit from eptifibatide was greater among patients in the United States than elsewhere in the world. CONCLUSIONS: Platelet glycoprotein IIb/IIIa receptor blockade with eptifibatide reduces the incidence of death or myocardial infarction among patients treated for acute ischemic syndromes without ST-segment elevation within the United States.


Assuntos
Doença das Coronárias/tratamento farmacológico , Peptídeos/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Doença Aguda , Doença das Coronárias/epidemiologia , Eptifibatida , Hemorragia/complicações , Humanos , Inibidores da Agregação Plaquetária/uso terapêutico , Síndrome , Estados Unidos/epidemiologia
20.
Am J Cardiol ; 86(2): 133-8, 2000 Jul 15.
Artigo em Inglês | MEDLINE | ID: mdl-10913471

RESUMO

This study examined whether nurses could manage coronary risk factors in patients with unstable angina more effectively than physicians practicing usual care. Three hundred twenty-six patients were randomized in the emergency room to a 6-month program of risk factor management by a registered nurse versus participation in usual care. The nurse intervention consisted of a 30-minute counseling visit at 6 to 10 days after the chest pain episode and a second 30-minute session 1 month later. Multiple risk factors were assessed and addressed: smoking, blood lipids, blood pressure, blood glucose, physical inactivity, weight, psychological stress, and social isolation. Compared with usual care, nurse intervention patients significantly reduced both triglycerides (-29 +/- 8 vs 5 +/- 6 mg/dl; p <0.0004) and weight (-0.9 +/- 3.3 vs +0.1 +/- 2.1 kg; p = 0.0071), and had corresponding improvements in self-reported diet compliance and exercise (+34 +/- 106 vs +9 +/- 98 minutes, p = 0.0491). No significant differences between groups were observed in terms of 6-month changes in total, high-density lipoprotein, or low-density lipoprotein cholesterol, blood pressure, fasting blood glucose, percent body fat or waist-hip ratio, or psychological distress scores. The 6-month rate of recurrent events (cardiac death, out-of-hospital cardiac arrest, myocardial infarction) and/or revascularizations (coronary artery bypass surgery or coronary angioplasty) was lower in the nurse intervention group (1% vs 9%; p = 0.002). We conclude that a nurse-delivered risk factor intervention program for patients with chest pain is feasible and more effective than usual care in terms of fostering lifestyle changes that may lower coronary risk.


Assuntos
Angina Instável/terapia , Competência Clínica/estatística & dados numéricos , Enfermagem em Emergência/normas , Idoso , Angina Instável/sangue , Angina Instável/epidemiologia , Aconselhamento , Serviço Hospitalar de Emergência/normas , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Estilo de Vida , Masculino , Corpo Clínico Hospitalar/normas , Pessoa de Meia-Idade , Minnesota/epidemiologia , Fatores de Risco
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