A 14-year follow-up study of chest pain patients including stress hormones and mental stress at index event.

BACKGROUND: Knowledge of long-term outcome in chest pain patients is limited. We reinvestigated patients who 14 years earlier had visited the emergency department due to chest pain, and were discharged without hospitalization. Extensive examinations were made at that time on 484 patients including full medical history, exercise test, a battery of stress questions and stress hormone sampling. METHODS: From a previously conducted chest pain study patients still alive after 14 years were approached. Hospitalization or deaths with a diagnosis of ischemic heart disease or cerebrovascular disease were used as end point. RESULTS: During the follow-up period 24 patients had died with a diagnosis of ischemic heart or cerebrovascular disease, and 50 patients had been given such a diagnosis at hospital discharge. Age (OR 1.12, CI 1.06-1.19), previous history of angina pectoris (OR 9.69, CI 2.06-71.61), pathological ECG at emergency department visit (OR 3.27, CI 1.23-8.67), hypertension (OR 5.03, CI 1.90-13.76), smoking (OR 3.04, CI 1.26-7.63) and lipid lowering medication (OR 14.9, CI 1.60-152.77) were all associated with future ischemic heart or cerebrovascular events. Noradrenalin levels were higher in the event group than in the non-event group, mean (SD) 2.44 (1.02) nmol/L versus 1.90 (0.75) nmol/L. When noradrenalin was included in the regression model high maximal exercise capacity was protective of an event (OR 0.986, CI 0.975-0.997). CONCLUSION: In chest pain patients previous history of angina pectoris, hypertension, smoking, pathological ECG at primary examination, and age were the main risk factors associated with future cardiovascular or cerebrovascular events.

Symptoms of chest pain and dyspnoea during a period of 15 years after coronary artery bypass grafting.

AIM: To describe changes in chest pain and dyspnoea during a period of 15 years after coronary artery bypass grafting (CABG) and to define factors at the time of operation that were associated with the occurrence of these symptoms after 15 years. DESIGN: Prospective observational study in western Sweden. SUBJECTS: All patients who underwent first-time CABG, without simultaneous valve surgery, between 1 June 1988 and 1 June 1991. There were no exclusion criteria. FOLLOW-UP: All patients were followed up prospectively for 15 years. The evaluation of symptoms took place through postal questionnaires prior to and 5, 10 and 15 years after the operation. RESULTS: Totally, 2000 patients were included in the survey and 904 (45%) of them survived to 15 years. Among these 904 survivors, the percentage of patients with chest pain increased from 44% to 50% between the 5- and 15-year follow-up (p=0.004). The percentage of patients who reported symptoms of dyspnoea increased from 60% after 5 years to 74% after 15 years (p<0.001). Factors at the time of surgery that independently tended to predict chest pain after 15 years were higher age (p=0.04) and prolonged duration of symptoms prior to surgery (p=0.04). Predictors of dyspnoea after 15 years were higher age (p<0.0001), the use of inotropic drugs at the time of surgery (p=0.001), a history of diabetes (p=0.01) and obesity (p=0.01). CONCLUSION: After CABG, relief from chest pain and dyspnoea is generally maintained over a long period of time. Eventually, however, functional-limiting symptoms tend to recur and about half the patients report symptoms of chest pain, while three-quarters report dyspnoea after 15 years. Even if no clear predictor of chest pain was found at the time of surgery, age, the use of inotropic drugs, diabetes and obesity predicted dyspnoea.

Treatment and outcome in acute myocardial infarction in a community in relation to gender.

AIM: To describe treatment and outcome in all patients in a community with acute myocardial infarction (AMI) in relation to gender. METHODS: All patients discharged from hospital between 2001 and 2002 in Göteborg, Sweden, with a diagnosis of AMI underwent a survey to find possible gender differences. All p-values are age adjusted. RESULTS: Among 1423 admissions, women comprised 41% and were older than men (mean 79 versus mean 72 years). Women were admitted to a coronary care unit less frequently than men (49% versus 67%; p=0.005). Women underwent coronary angiography less frequently (21% versus 40%; p=0.02). Percutaneous coronary intervention (PCI) was performed in 10% of the women and 18% of the men (p=0.36). Coronary artery bypass grafting (CABG) was performed in 2% of the women and in 9% of the men (p<0.0001). Female gender was associated with a lower risk of reinfarction during first year after hospital discharge (12% versus 16%; p=0.003). The cumulative three-year mortality was 49% in women and 41% in men. However, when adjusting for age, admittance to CCU, coronary angiography and coronary revascularisation, risk of death during 3 years was lower in women than men (odds ratio 0.72; 95% confidence interval 0.60-0.85; p=0.0001). CONCLUSION: In the community of Göteborg women (mean age 79 years) with AMI are prioritised differently than men (mean age 72 years), prior to admission to a CCU. This results in a less invasive strategy in women, particularly with regard to CABG. When adjusting for difference in age, admittance to CCU and coronary revascularisation female gender was associated with a low risk of death during the subsequent 3 years.

Quality of life 15 years after coronary artery bypass grafting.

OBJECTIVES: To describe changes in quality of life (QoL) during 15 years after coronary artery bypass grafting (CABG) and prediction of impaired QoL after 15 years. METHODS: All patients in western Sweden who underwent primary CABG without simultaneous valve surgery between 1988 and 1991 were included. QoL during a period of 15 years after CABG was evaluated with three instruments: the Nottingham Health Profile, the Psychological General Well-Being Index, and the Physical Activity Score. RESULTS: A total of 2000 patients took part in the survey, (none excluded) of whom 808 were still alive after 15 years and 79% answered the inquiry. Despite an ongoing decline in QoL over the years, an improvement in QoL was maintained in most sub-dimensions at the 15-year follow-up compared with that prior to surgery. Seven factors emerged as predictors of impaired QoL 15 years after CABG. They are as follows: (i) high age, (ii) female sex, (iii) history of diabetes, (iv) obesity, (v) prolonged stay in the intensive care unit, (vi) prolonged treatment on a ventilator, (vii) need for inotropic drugs at the time of surgery; of which the latter three might be secondary to left ventricular dysfunction. CONCLUSION: Despite an ongoing decline in QoL over the years, there was still an improvement in most aspects of QoL 15 years after CABG compared with that before surgery. Intensified early treatment of diabetes, obesity, and left ventricular dysfunction in CABG patients might allow an even better long-term QoL.

Epidemiology of acute myocardial infarction with the emphasis on patients who did not reach the coronary care unit and non-AMI admissions.

OBJECTIVES: To describe the characteristics and outcome of patients with acute myocardial infarction (AMI) in a community, with particular emphasis on those who never reached a Coronary Care Unit (CCU) and those in whom the primary diagnosis was something other than a heart attack. METHODS: Patients hospitalised in the city of Göteborg, Sweden, and discharged (dead or alive) with a diagnosis of AMI. RESULTS: Among 1423 patient admissions the mean overall age was 75 years (81 years and 79 years in the two subsets). Among all patients, 33% had a history of heart failure and 20% had a history of cerebrovascular disease. The figures were even higher in the two subsets which were evaluated. In overall terms, an invasive strategy (coronary angiography) was used in 32% (in 5% and 9% in the two subsets respectively). The overall one-year and three-year mortality rate was 30% and 44% respectively. The three-year mortality rate among patients not admitted to a CCU was 65% and, among patients with no suspicion of a heart attack on admission, it was 68%. CONCLUSION: Even in the 21st century, patients with AMI who reach hospital alive run a high risk of death and nearly half are dead within the first three years. In overall terms, patients are characterised by high age and high co-morbidity. Among patients who do not reach a CCU and among patients with no suspicion of AMI on admission, approximately two thirds are dead within the subsequent three years.