Acute myocardial infarction in the elderly: differences by age.

OBJECTIVES: We evaluated the clinical characteristics and outcomes of elderly patients hospitalized with acute myocardial infarction (AMI) to describe differences by age. BACKGROUND: Elderly patients with AMI are perceived as a homogeneous population, though the extent by which clinical characteristics vary among elderly patients has not been well described. METHODS: Data from 163,140 hospital admissions of Medicare beneficiaries age > or =65 years between 1994 and 1996 with AMI at U.S. hospitals were evaluated for differences in clinical characteristics and mortality across five age-based strata (in years): 65 to 69, 70 to 74, 75 to 79, 80 to 84 and > or =85. RESULTS: Older age was associated with a greater proportion of patients with functional limitations, heart failure, prior coronary disease and renal insufficiency and a lower proportion of male and diabetic patients. Of note, the proportion of patients presenting with chest pain within 6 h of symptom onset, and with ST-segment elevation, was lower in each successive age group. Thirty-day mortality rates were higher in older age groups (65 to 69: 10.9%, 70 to 74: 14.1%, 75 to 79: 18.5%, 80 to 84: 23.2%, > or =85: 31.2%, p = 0.001 for trend). The effect of age persisted but was attenuated after adjustment for differences in patient characteristics; similar trends were observed for one-year mortality. CONCLUSIONS: Our data indicate significant age-associated differences in clinical characteristics in elderly patients with AMI, which account for some of the age-associated differences in mortality. The practice of grouping older patients together as a single age group may obscure important age-associated differences.

Transesophageal Doppler color flow mapping assessment of atrial septal defect.

Transesophageal Doppler color flow imaging was performed in 19 adult patients (mean age 35 years) with an atrial septal defect demonstrated by cardiac catheterization or at surgery, or both. The transesophageal study correctly identified and classified 19 of 19 shunts in contrast to 16 of 18 shunts identified by the transthoracic approach. The area of the atrial septal defect was calculated by assuming it to be circular and taking the maximal Doppler color flow jet width at the defect site as its diameter. The pulsed Doppler sample volume was placed parallel to the shunt flow direction at the defect site to obtain the mean velocity and flow duration. From these values, the shunt volume was calculated as a product of the defect area, mean velocity, flow duration and heart rate. The calculated shunt flow volume obtained by transesophageal study showed a good correlation with shunt flow volume (r = 0.91, p less than 0.001) and pulmonary to systemic blood flow ratio (r = 0.84, p less than 0.001) obtained at cardiac catheterization. The size of the defect by transesophageal Doppler color flow mapping correlated fairly well with the size estimated at surgery (r = 0.73, p = 0.004). It is concluded that transesophageal Doppler color flow imaging is useful in the detection and classification of atrial septal defects and in the assessment of shunt volumes.

The treatment of elderly diabetic patients with acute myocardial infarction: insight from Michigan's Cooperative Cardiovascular Project.

BACKGROUND: Diabetic patients with acute myocardial infarction (AMI) have higher morbidity and mortality rates than nondiabetic patients with AMI. Thus, reliable adherence to quality care is necessary in these patients to improve outcomes. We analyzed data from the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in Michigan, addressing quality of care in diabetic patients with AMI. METHOD: All acute-care hospitals in Michigan had 8 consecutive months of baseline CCP data abstracted from medical records of all Medicare patients who were discharged with a principal diagnosis of AMI. Owing to the staggered 8-month periods, abstraction occurred for patients who were discharged between April 1, 1994, and July 31, 1995. RESULTS: Diabetic patients accounted for 33% of 8455 patients with AMI. Diabetic patients were primarily younger, female, and nonwhite. They had a greater frequency of non-Q-wave AMI and presented less often within 6 hours of their infarction. Comorbid conditions, such as hypertension, prior AMI, prior stroke, and/or prior revascularization, were more frequent in diabetic than in nondiabetic patients. Congestive heart failure occurred more frequently in diabetic patients. Length of stay (7.9 vs 7.0 days; P<.001), in-hospital mortality rates (16% vs 13%; P<.001), and rates for mortality within 30 days (21% vs 17%; P<.001) were higher in diabetic patients. CONCLUSIONS: Despite greater frequencies of comorbid conditions, poorer outcomes, and greater resource use, there is poor overall adherence to most quality indicators in diabetic patients with AMI. Better methods for systematizing proven prevention and treatment strategies in the care of patients with AMI are needed in this unique high-risk cohort.

Quality improvement initiative and its impact on the management of patients with acute myocardial infarction.

BACKGROUND: Wide variation exists in acute myocardial infarction (AMI) management, leading to differences in outcomes. OBJECTIVE: To assess the impact of the quality improvement initiative on appropriate management of AMI. DESIGN: Prospective patient identification, retrospective medical record review. PATIENTS: All patients with AMI discharged alive (N = 497) from our institution between April 1, 1995, and February 28, 1997. MAIN OUTCOME MEASURE: The effect of quality improvements directed at the patient, nurse, and physician on the adherence to key quality indicators. RESULTS: The quality improvement initiative correlated with more frequent use of reperfusion therapy (98%), and with aspirin use in the emergency department (95%), in ideal eligible patients. Similarly, adherence to discharge quality indicators, including use of aspirin (97%), beta-blockers (94%), angiotensin-converting enzyme inhibitors (90%), and lipid-lowering agents (67%); avoidance of calcium channel blockers (93%); a low-fat diet (96%); smoking cessation counseling (94%); and outpatient rehabilitation referral (70%) was higher, including in the very old (those aged >/=80 years) and in women. The use of a patient education tool was associated with a higher adherence to most quality indicators compared with patients in whom this was not used: discharge aspirin (99% vs 96%; P =.02), beta-blocker (98% vs 91%; P =.002), angiotensin-converting enzyme inhibitor (95% vs 86%; P =.01), and lipid-lowering agent (71% vs 62%; P =.04) use; outpatient rehabilitation (82% vs 63%; P=.001); and documentation of smoking cessation counseling (98% vs 87%; P =. 001). CONCLUSIONS: Implementation of a quality improvement program was associated with a high adherence to quality-of-care indicators for AMI. Patient-directed feedback before discharge improved adherence to key indicators for AMI beyond that achieved with tools only directed at caregivers.

Preoperative and perioperative use of levosimendan in cardiac surgery: European expert opinion.

In cardiac surgery, postoperative low cardiac output has been shown to correlate with increased rates of organ failure and mortality. Catecholamines have been the standard therapy for many years, although they carry substantial risk for adverse cardiac and systemic effects, and have been reported to be associated with increased mortality. On the other hand, the calcium sensitiser and potassium channel opener levosimendan has been shown to improve cardiac function with no imbalance in oxygen consumption, and to have protective effects in other organs. Numerous clinical trials have indicated favourable cardiac and non-cardiac effects of preoperative and perioperative administration of levosimendan. A panel of 27 experts from 18 countries has now reviewed the literature on the use of levosimendan in on-pump and off-pump coronary artery bypass grafting and in heart valve surgery. This panel discussed the published evidence in these various settings, and agreed to vote on a set of questions related to the cardioprotective effects of levosimendan when administered preoperatively, with the purpose of reaching a consensus on which patients could benefit from the preoperative use of levosimendan and in which kind of procedures, and at which doses and timing should levosimendan be administered. Here, we present a systematic review of the literature to report on the completed and ongoing studies on levosimendan, including the newly commenced LEVO-CTS phase III study (NCT02025621), and on the consensus reached on the recommendations proposed for the use of preoperative levosimendan.

Uses and limitations of transthoracic echocardiography in the assessment of atrial septal defect in the adult.

Two-dimensional and color Doppler echocardiography accurately detected the presence of an atrial septal defect (ASD) in 47 of 50 adults (mean age 40 years) confirmed by surgery or cardiac catheterization, or both. It correctly categorized all patients with ostium secundum and ostium primum ASD but misdiagnosed 3 of 5 patients with surgically proven sinus venosus ASD. The shunt flow volume across the ASD was calculated with the standard Doppler equation, and assuming the ASD to be circular correlated with shunt flow volume obtained by cardiac catheterization (r = 0.74). The maximum width of the color flow signals moving across the ASD was taken as its diameter. Mean flow velocity was determined either by placing a pulsed Doppler sample volume parallel to the flow across the ASD as visualized by color Doppler or by color M-mode examination, which allowed determination of flow velocities using a previously validated method that incorporates a computer analysis of pixel color intensity. The pulmonary to systemic blood flow ratio obtained by color-guided conventional Doppler interrogation of the left and right ventricular outflow tracts correlated poorly with cardiac catheterization results (r = 0.38). In patients with associated tricuspid regurgitation, the peak systolic pulmonary artery pressure obtained by color Doppler-guided continuous-wave Doppler correlated well with that obtained at cardiac catheterization (r = 0.89). The maximum color Doppler jet width of the flow across the ASD poorly correlated with ASD size estimated at surgery (r = 0.50).

Relation of systemic sympathetic nervous system activation to echocardiographic left ventricular size and performance and its implications in patients with mitral regurgitation.

We have previously demonstrated that the systemic sympathetic nervous system (SNS) is activated in proportion to an increase in cineventriculographic left ventricular (LV) end-systolic volume and decrease in ejection fraction (EF) in patients with chronic mitral regurgitation (MR). However, the relation between noninvasive echocardiographic measures of LV size and performance and systemic SNS activation and their clinical implications in patients with MR is not known. We studied 17 MR patients with echocardiography, arterial norepinephrine (NE) sampling, and [3H]-NE infusions and arterial blood sampling to determine NE kinetic parameters using a 2-compartment analysis, including extravascular NE release rates (NE2, index of SNS activity) and the metabolic clearance rate from the vascular compartment. The arterial NE values correlated with LV end-systolic dimensions (r = 0.50, p = 0.04), but not with LV end-diastolic dimensions, and EF or fractional shortening measures. The NE2 values correlated with LV end-systolic dimensions (r = 0.53, p = 0.03) and inversely with LVEF (r = -0.45, p = 0.07) and fractional shortening (r = 0.43, p = 0.08) measures, but not with LV end-diastolic dimensions. The metabolic clearance rate values showed an inverse correlation with LV end-diastolic (r = -0.52, p = 0.03) and end-systolic (r = -0.49, p = 0.04) dimensions, but not with LV performance measures. The increase in NE2 values was progressive as the LV endsystolic dimensions increased and more marked at LV end-systolic dimensions > or = 40 mm. Thus, activation of the SNS is related to an increase in echocardiographic LV end-systolic dimensions and a decrease in LV performance measures in chronic MR. Medica, Inc.

Implications of increased left ventricular mass index on in-hospital outcomes in patients undergoing aortic valve surgery.

BACKGROUND: Increased left ventricular mass index has been shown to be associated with higher mortality in epidemiologic studies. However, the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement is unknown. METHODS: We studied 473 consecutive patients undergoing elective aortic valve replacement to assess the influence of left ventricular mass index on outcomes in patients having this procedure. Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index (considered increased if >134 g/m(2) in male patients and >110 g/m(2) in female patients). RESULTS: Left ventricular mass index was increased in 24% of patients undergoing aortic valve replacement. Postprocedural complications (respiratory failure, renal insufficiency, congestive heart failure, and atrial and ventricular arrhythmias), length of stay in the intensive care unit, and in-hospital mortality were increased in patients with increased left ventricular mass index. Multivariable analysis identified prior valve surgery (odds ratio, 4.3; 95% confidence interval, 1.2-15.7; P =.030), left ventricular ejection fraction (odds ratio, 1.07; 95% confidence interval, 1.01-1.14; P =.020), history of hypertension (odds ratio, 8.2; 95% confidence interval, 2.2-30.4; P =.002), history of liver disease (odds ratio, 50.4; 95% confidence interval, 4.2-609.0; P =.002), and increased left ventricular mass index (odds ratio, 38; 95% confidence interval, 9.3-154.1; P <.001) as independent predictors of in-hospital mortality. Furthermore, low output syndrome was identified as the most common mode of death (36%) after aortic valve replacement in patients with increased left ventricular mass index. CONCLUSIONS: Increased left ventricular mass index is associated with increased adverse in-hospital clinical outcomes in patients undergoing aortic valve replacement. Although this finding warrants special modification in perioperative management, further studies are needed to address whether outcomes in asymptomatic patients with aortic valve disease could be improved by earlier aortic valve replacement before a significant increase in left ventricular mass index.

Levels of circulating peptide and steroid hormones in men with lung cancer.

Levels of circulating peptide (FSH, LH, prolactin, ACTH, calcitonin, gastrin and insulin-like growth factor-1 [IGF-1]) and steroid (estradiol, progesterone, DHEA-S and testosterone) hormones were estimated by radioimmunoassay (RIA) and immunoradiometric assay (IRMA) in male patients with lung cancer (n = 37) pre-therapeutically and compared with 25 age matched healthy controls. In this retrospective study, FSH, LH, prolactin, ACTH, calcitonin, gastrin and IGF-1 were significantly higher with concomitant lower levels of DHEA-S and testosterone, while the difference was statistically non-significant for estradiol and progesterone in patients with lung cancer when compared with controls. Early stage patients (Stage II) exhibited higher levels of gastrin as compared to advanced stage patients (Stages III and IV). It is suggested that hormonal imbalance might play an important role in the development and progression in male patients with lung cancer.

Seasonal variation in onset of pulmonary embolism is independent of patients' underlying risk comorbid conditions.

As for many cardiovascular events, pulmonary embolism (PE) is not randomly distributed over time, but shows rhythmic patterns. The purpose of this study was to investigate whether such temporal pattern of occurrence varied in subgroups of patients according to different risk comorbid conditions. All cases of PE observed at the Hospital of Ferrara, Italy, from 1998 to 2001, were considered. After determination of the day of onset, the population was grouped by gender and the most common underlying risk comorbid conditions, e.g., deep vein thrombosis (DVT), neoplasms, cardiomyopathies, traumas/surgical operations, diabetes mellitus, pulmonary diseases, hypertension, cerebrovascular diseases, heart failure, hematologic diseases. For statistical analysis, chi-square test for goodness of fit and partial Fourier series were used. A total of 784 cases (mean age 71 +/- 14 years) were included. Frequency of onset was higher in winter for total population (p = 0.002), men (p = 0.004), DVT (p = 0.001), pulmonary disease (p = 0.008), cardiomyopathies (p = 0.011), and major traumas/surgical operations (p = 0.049). Chronobiologic analysis identified a winter peak for total population (p = 0.008), men (p < 0.001), DVT (p = 0.006), pulmonary diseases (p = 0.017), and hypertension (p = 0.026). This study confirms the winter peak of PE and provides evidence that it is not influenced by the underlying clinical conditions, but probably by endogenous variations.

Gamete intrafallopian transfer: A preliminary experience.

BACKGROUND: After in vitro fertilizationand embryo transfer for tubal infertility, gamete intrafallopian transfer has been introduced for patients with non-tubal infertility. However, the gametes need to be transferred in 2 to 5 minutes and the distance between the operating theatre and tissue culture laboratory delayed its introduction at our hospital. METHODS AND PATIENTS: To overcome this problem we designed a box in which gametes could be stored. Using gametes taken from this box and employing the standard technique, we achieved 5 pregnancies in 39 infertile women. RESULTS: From 41 treatment cycles, 39 women underwent oocyte retrieval. Five pregnancies were achieved of which 4 delivered live births at full term and 1 ended in abortion. Our first gamete intrafallopian transfer baby was born on 6 January 1988. CONCLUSION: The gamete intrafallopian transfer technique can be successfullyadapted for India.

Cardiac risk assessment for noncardiac surgery: current concepts.

Strategies for perioperative risk assessment in patients undergoing noncardiac surgery vary among physicians and are aimed to estimate the risk and minimize complications. We propose simplistic guidelines for assessing and modifying risk for patients undergoing a wide variety of procedures.

Outcomes with the use of glycoprotein IIb/IIIa inhibitors in non-ST-segment elevation acute coronary syndromes.

OBJECTIVE: To compare the characteristics, management, and outcomes of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) who would have been eligible for inclusion in clinical trials of glycoprotein (GP) IIb/IIIa inhibitors with those of ineligible patients. DESIGN: Multinational, prospective, observational study (GRACE, Global Registry of Acute Coronary Events). SETTING: Patients hospitalised for a suspected acute coronary syndrome and enrolled in GRACE between April 1999 and December 2004. PATIENTS: 29 039 patients with NSTE ACS. MAIN OUTCOME MEASURES: Characteristics and outcomes were compared for trial-eligible (75.0%) and trial-ineligible (25.0%) patients. RESULTS: GP IIb/IIIa inhibitors were administered to 20.0% of eligible and 15.3% of ineligible patients. Compared with eligible patients, ineligible patients who received GP IIb/IIIa inhibitors had significantly higher rates of hospital death (6.8% vs 3.7%) and major bleeding (4.9% vs 2.2%). After adjustment for their higher baseline risk, ineligible patients still experienced higher hospital death rates (adjusted odds ratio (OR) 1.60; 95% confidence interval (CI) 1.01 to 2.39), but not higher bleeding rates, than the eligible group. Use of GP IIb/IIIa inhibitors was associated with a trend towards lower 6-month mortality in eligible (OR 0.86, 95% CI 0.72 to 1.02) and ineligible (OR 0.82, 95% CI 0.65 to 1.05) patients compared with those in whom this therapy was not used. CONCLUSIONS: GP IIb/IIIa inhibitors were markedly underused in the real-world population, irrespective of whether patients were trial-eligible or not. Despite the higher risk of ineligible patients, the benefits of GP IIb/IIIa inhibitors appear to be no less than in eligible patients.

Short- and long-term outcomes following atrial fibrillation in patients with acute coronary syndromes with or without ST-segment elevation.

OBJECTIVE: To assess variables associated with the occurrence of atrial fibrillation (AF) and the relation of AF with short- and long-term outcomes and with other in-hospital complications in patients with acute coronary syndromes (ACS) with and without ST-segment elevation. DESIGN: Pooled database of 120 566 patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation (NSTE) ACS enrolled in 10 clinical trials. Multivariable logistic regression and Cox proportional hazards modelling were used to identify factors associated with AF and its relation with clinical outcomes. SETTING: ACS complicated by AF. PATIENTS: 120,566 patients with STEMI and NSTE-ACS in 10 clinical trials. INTERVENTIONS: None evaluated. MAIN OUTCOME MEASURE: Short- and long-term mortality. RESULTS: Occurrence of AF was 7.5% in the overall population (STEMI 8.0% (n = 84 161); NSTE-ACS = 6.4% (n = 36,405)). Seven-day mortality was higher for patients with AF (5.1%) than for those without (1.6%). After adjusting for confounders, association of AF with 7-day mortality was present in STEMI (hazards ratio (HR) = 1.65; 95% CI 1.44 to 1.90) and NSTE-ACS (HR = 2.30; 95% CI 1.83 to 2.90; p interaction = 0.015). Risk of long-term mortality (day 8 to 1 year) was also higher in STEMI (HR = 2.37; 95% CI 1.79 to 3.15) and NSTE-ACS (HR = 1.67; 95% CI 1.41 to 1.99). AF had a larger impact in NSTE-ACS on risk of short-term mortality (p<0.001), stroke (p<0.001), ischaemic stroke (p<0.001) and moderate or severe bleeding (p<0.001). CONCLUSIONS: AF is more common in patients with STEMI. An association of AF with short- and long-term mortality among patients with STEMI and NSTE-ACS was found. Understanding these findings may lead to better care of patients with this common arrhythmia.

Coronary stent implantation in acute myocardial infarction.

BACKGROUND: The purpose of this study was to provide an overview on stenting in acute myocardial infarction (MI). METHODS AND RESULTS: A search of MEDLINE and the scientific sessions abstracts in peer review journals through May 1998 was carried out to identify any publications on stenting in MI. The settings were retrospective and prospective case series on stenting in MI, nonrandomized and randomized trials comparing primary stenting and primary percutaneous transluminal coronary angioplasty (PTCA) in MI, and stenting in cardiogenic shock complicating MI. Reported outcomes included procedural success, reocclusion, restenosis, and target vessel revascularization rates; incidence of death, MI, recurrent ischemia, major bleeding, and vascular complications; and incidence of cerebrovascular accidents. Procedural success rates were better for stenting than primary PTCA, and postprocedural minimum luminal diameters were larger. This resulted in lower reocclusion and restenosis rates and a lesser need for target vessel revascularization with primary stenting. The incidence of death, MI, and recurrent ischemia was also reduced with primary stenting. Major bleeding and vascular complications were confined to patients receiving anticoagulation as opposed to antiplatelet agents after stenting. Finally, a strategy of bailout stenting for failed PTCA in MI appears to be inferior to a primary stenting strategy. CONCLUSIONS: Stenting in MI is an effective and safe reperfusion strategy with many advantages compared with primary PTCA.

Current concepts in secondary prevention after acute myocardial infarction.

Acute myocardial infarction (MI) is the leading cause of death around the globe. Advances in the field of cardiology have identified several effective treatments that have lead to decrease in mortality from this cause over the past 3 decades. The purpose of this article is to review the existing literature in regards to secondary prevention after acute MI. A search of MEDLINE through August of 1999 was carried out to identify any available publications on secondary prevention after MI. Evidence on the use of both pharmacological and nonpharmacological interventions that was shown to be effective in improving morbidity and mortality was sought. Recommendations for the treatment of patients with acute MI are made based on existing evidence. Betablockers, aspirin and lipid-lowering agents for patients with low density lipoprotein-cholesterol > 130 mg% should be used for all patients following a MI. Angiotensin converting enzyme inhibitors are indicated for patients with congestive heart failure and/or reduced left ventricular ejection fraction and are likely protective in most patients. Calcium channel blockers (Verapamil and Diltiazem) are indicated as second-line therapy for patients who have contraindications or are intolerant to betablockers. The routine prophylactic use of antiarrhythmic drugs to suppress ventricular ectopic beats should be avoided. Recommendations regarding diet, smoking cessation and achievement of ideal body weight should be an integral part of patient management. Referral for outpatient rehabilitation should also be strongly encouraged. Finally, adequate control of blood pressure and diabetes cannot be overemphasized. Adherence to these goals in patients with acute MI will lead to better long-term outcomes and reduction in cardiac death, recurrent MI, stroke, and need for coronary revascularization.

Perioperative cardiac risk assessment for noncardiac surgery.

Patients with coronary artery disease who undergo noncardiac surgery are at risk of cardiac complications. It is, therefore, imperative to assess the risk of noncardiac surgery in these patients in a variety of operative settings. We propose a simplified approach at perioperative risk assessment that ascertains risks based on the need and urgency of surgery, and the type of surgery. Furthermore, we suggest guidelines for perioperative risk assessment based on patient's history and physical exam, their functional capacity and prior procedures. Based on these clinical data, we identify patients into three categories for a cardiac event during noncardiac surgery: high, intermediate and low risk groups. We recommend that all urgent surgeries should be carried out with attempts made at proper perioperative management to reduce the risk of cardiac events. Further, low or intermediate risk patients undergoing minor surgery should be operated without any further cardiac evaluation. Intermediate risk patients, who need an intermediate or major surgery, should undergo a stress test to evaluate for ischemia. If there is evidence of a large ischemic burden and those patients at high risk should undergo cardiac catheterization and appropriate intervention. We also suggest methods of modifying risk in the perioperative period for all patients to reduce perioperative cardiac events with proper monitoring and use of medications including beta blockers. This article provides a detailed review on the current literature supporting the stepwise approach proposed by us.