Effects of early use of atenolol or captopril on infarct size and ventricular volume: A double-blind comparison in patients with anterior acute myocardial infarction.

BACKGROUND: beta-Blockers and ACE inhibitors reduce early mortality when either one is started in the first hours after myocardial infarction (MI). Considering the close correlation between morphological changes and prognosis, we aimed to investigate whether the benefit of both beta-blockers and ACE inhibitors might reside in a similar protective effect on infarct size or ventricular volume. METHODS AND RESULTS: In a randomized, double-blind comparison between early treatment with captopril or atenolol in 121 patients with acute anterior MI, both drugs showed a similar reduction in mean blood pressure. However, only the atenolol-treated patients showed a significant early reduction in heart rate. Infarct size, obtained from the perfusion defect in resting single photon emission imaging, was higher in captopril-treated patients than in atenolol-treated patients: 29.8+/-12% versus 20.8+/-12% (P:<0.01) by polar map and 28.3+/-13% versus 20.0+/-13% (P:<0.01) by tomography. Changes from baseline to 1 week and to 3 months in ventricular end-diastolic volume, assessed by echocardiography, were as follows: 58+/-14 versus 64+/-19 (P<0.05) and 65+/-21 mL/m(2) (P<0.05), respectively, with captopril, and 58+/-18 versus 64+/-18 (P<0.05) and 69+/-30 mL/m(2) (P<0.05), respectively, with atenolol. Neither group showed significant changes in end-systolic volume. Among patients with perfusion defect >18% (n=51), those treated with atenolol showed a significant increase of end-systolic and end-diastolic ventricular volumes, whereas captopril-treated patients did not. CONCLUSIONS: Although early treatment with atenolol or captopril results in similar overall short- and medium-term preservation of ventricular function and volumes, in patients with larger infarctions, a beta-blocker alone does not adequately protect myocardium from ventricular dilatation.

Incidence, clinical characteristics, and prognostic significance of right bundle-branch block in acute myocardial infarction: a study in the thrombolytic era.

BACKGROUND: Whereas the significance of right bundle-branch block (RBBB) in acute myocardial infarction was extensively studied in the prethrombolytic era, a possible change in the overall incidence and meaning of RBBB as a consequence of thrombolytic therapy is not well known. METHODS AND RESULTS: A multicenter, prospective study of 1238 patients consecutively diagnosed with acute myocardial infarction and admitted to three coronary care units was conducted. ECGs during the acute phase and clinical events until discharge and 1-year follow-up were monitored. In the 135 (10.9%) patients in whom RBBB was found, there were 51 (37.8%) new cases, 46 (34.1%) old cases, and 38 (28.1%) cases with an indeterminate time of origin. New RBBB was permanent in 26 and transient in 25 patients. RBBB was isolated in 76 (56%) and bifascicular in the remaining 59 (44%) patients. The following complications were more frequently associated with RBBB than non-RBBB patients: heart failure, 24% versus 46% (P<.001); use of pacemaker because of atrioventricular block, 3.6% versus 11% (P<.001); and 1-year mortality, 17.6% versus 40.7% (P<.001). Early mortality was significantly higher for new RBBB (43.1%, P<.001) than for old (15.5%) and indeterminate (15.3%) RBBB. These figures for 1-year mortality were 58.8% (P<.001), 35.5 (P<.01), and 23% (NS), respectively. Permanent and transient RBBB had different mortality rates: early mortality, 76% versus 8%, and 1-year mortality, 84% versus 32% (P<.001 for both). For isolated RBBB versus bifascicular block, early mortality was 14.4% versus 40.6%, and 1-year mortality was 30.2% versus 54.2% (P<.05 for both). Multivariate analysis showed an independent prognostic value of RBBB for early and 1-year mortality. CONCLUSIONS: The overall meaning of RBBB in acute myocardial infarction has not changed in the thrombolytic era, although a higher rate of new and transient RBBB and a lower rate of bifascicular block may represent a beneficial effect of thrombolytic therapy.

[The prognostic significance of complete atrioventricular block in patients with acute inferior myocardial infarct. A study in the era thrombolytics]. / Significación pronóstica del bloqueo auriculoventricular completo en pacientes con infarto agudo de miocardio inferior. Un estudio en la era trombolítica.

INTRODUCTION AND OBJECTIVES: Complete atrioventricular block (CAVB) during inferior acute myocardial infarction (AMI), characterizes a high-risk subgroup of patients. This study was designed to determine the incidence and meaning of CAVB associated with inferior AMI and their peculiarities in relation to thrombolytic therapy. METHODS: Prospective and multicenter, involving 605 patients consecutively admitted with inferior AMI. We studied clinical characteristics and complications occurring during hospitalization and one-year follow-up were monitored. RESULTS: CAVB was found in 57 (9.4%) patients and was more frequently associated with: right ventricular involvement (35% vs 10%; p < 0.001), higher indexes of infaret size: ST elevated ECG leads (4.67 +/- 1.67 vs 4.1 +/- 1.4; p < 0.01) and peak of creatinkinase (2,219 +/- 1,543 vs 1,589 +/- 1,203; p < 0.01). Patients with CAVB had a higher incidence of cardiogenic shock (14% vs 5%; p < 0.05) and in-hospital mortality (21% vs 8.7%). CAVB had an independent value for predicting in-hospital mortality (odds ratio 2.7, 95% confidence interval, 1.3-5.5). CAVB appeared more frequently in the first hour of evolution (91% vs 41%; p < 0.01); its duration was shorter than 6 hours in a higher ratio (80% vs 5%; p < 0.01), and in- hospital mortality was lower (8.5 vs 40.9%; p < 0.05), in patients receiving thrombolytic treatment compared with patients without this treatment. CONCLUSIONS: CAVB is a relatively frequent complication of inferior AMI and is often associated with larger infarcts, high incidence of complications and mortality. Earlier appearance, shorter duration and fewer in-hospital mortalities seem to characterize those CAVBs occurring in patients treated with thrombolytics.

[Intracranial hemorrhage following thrombolytic therapy in acute myocardial infarct]. / Hemorragia intracraneal tras la terapéutica trombolítica en el infarto agudo de miocardio.

INTRODUCTION: Intracranial hemorrhage in acute myocardial infarction, under thrombolytic therapeutic, ranges from 0.3 to 3% in different trials. We carried out a study to stabilised the incidence of this complication in ours patients, as well as to analyze its characteristics and asses the presence the predictive factors. METHODS: We retrospectively reviewed 997 consecutive patients with acute myocardial infarction treated with thrombolytic agents. We used two different protocols in two consecutive periods of time. Protocols differ in the age of the patients, the thrombolytic agent and its interval of applications. We analyze the intracranial hemorrhage incidence rate in each period, as well as its relations with the age of the patients, the sex and the thrombolytic agent used. We also analyze the possible predictive risk factors: cerebral-vascular disease, hypertension, diabetes, etc. RESULTS: The overall rate of intracranial hemorrhage was 1.6%, higher in the patients of the second period (0.9% vs 1.9%, p = NS). The age over 70 years don't show a significant increase of this incidence (1.7% vs 1.5%). The APSAC group have shown a greater rate of hemorrhage (4%) than streptokinase (0.8%) and rTPA (1.2%). Cerebral-vascular disease and hypertension background were the two factors more frequently related to hemorrhage. The mortality rate was 68.7%. CONCLUSION: The intracranial hemorrhage is a severe complication of thrombolytic therapy with a relative low incidence, but in our experience, higher than described in multicenter studies. There are several factors related that we would to take into account when is applied this therapy.

[Tetanus in the Murcia region: the clinico-epidemiological characteristics of 150 cases]. / Tétanos en la Región de Murcia: características clínico-epidemiológicas de 150 casos.

150 tetanus cases registered on the region of Murcia have been retrospectively analyzed, they have been collected from the patients admitted at a Intensive Care Unit during a period of 18 years; the clinical together with the epidemiological features, as well as their variations, have been studied through out the years. The impact of a vaccination program in adults which was performed in our region during 1981 has been also evaluated in relationship with the incidence of disease and the economical cost of it. Incidence remained homogeneous until 1982, from that date on a sudden decrease on the number of cases was observed, related with the vaccination program [Period previous to the vaccination program: mean 10 cases/year, versus 5 cases/year since it was started (p < 0.001)]. Regarding the epidemiological characteristics, it is remarkable the shift of the disease toward a more advanced age of onset together with a predominance on females beginning in 1978, but without reaching statically significance. More frequent route of infection is nowadays the intramuscular suppurative injection. Besides this fact the severity of the cases have been increasing (from 59% to 71%, p < 0.005), which has determined that the global mortality of the disease remains almost the same (38%). Mortality has no relationship with age, but is related with being a female (p < 0.05), with intramuscular injection as route of infection (p < 0.025), with the clinical stage (p < 0.001) and with a short incubation period (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Thrombolytic therapy in acute myocardial infarct. New performance protocols. Their influence on mortality and the incidence of complications]. / Terapéutica trombolítica en el infarto agudo de miocardio. Nuevos protocolos de actuación. Su influencia en la mortalidad e incidencia de complicaciones.

The new protocols of actuation in acute myocardial infarction thrombolysis have increased the number of patients treated, and have changed their characteristics. To assess the influence that this event has had in the complications incidence and mortality rate, we revise 704 infarcts treated with thrombolytic in a coronary unit, during 8 years. We separate two groups: 1) Patients treated since november 1983 to december 1988 following the established protocol at the beginning of this therapeutic (n = 328). 2) Patients treated since this date to july 1991, with a new protocol that include older than 70 years patients, moore than 6 hours of therapeutics delay and use of another thrombolytics, moreover streptokinase (n = 376). These changes have increased the number of thrombolysis in the second group (24.6 vs 49.1%; p < 0.001). Nevertheless being a higher group of risk we have found neither a significant mortality increase (6.40 vs 7.71%; p = NS), nor complications related to the thrombolysis: The incidence of major hemorrhages were 2.13 vs 1.06% (p = NS), cerebral hemorrhages 0.91 vs 1.6% (p = NS), hypotension related to the thrombolytics 15.55 vs 5.85% (p < 0.001). Neither has had significant difference in the incidence of reinfarcts (6.42 vs 5%; p = NS). In conclusion, the great number of thrombolysis realized nowadays, due to the actuation protocols changes, have increased significantly, neither the complications related with this therapeutic, nor the mortality rate, nor the reinfarcts number.

Effects of early use of captopril on haemodynamics and short-term ventricular remodelling in acute anterior myocardial infarction.

To determine whether ventricular short-term enlargement following acute myocardial infarction is related to increased left filling pressures and whether early treatment with captopril alters this process we studied 68 patients with a first acute myocardial infarction. Forty patients with a pulmonary capillary pressure equal or above 17 mmHg were randomized to treatment with conventional therapy plus captopril (n 20) or placebo (n 20), in a double blind fashion. The remaining 28 patients (non-dysfunction group) were treated conventionally. During the first 72 h, afterload showed a prompt decrease in the captopril group as compared to placebo. Changes from baseline to 14 days in end-diastolic and end-systolic left ventricular volume indexes determined by radionuclide ventriculography were: non-dysfunction, 85.6 (+/- 21) vs 88 (+/- 20) and 44 (+/- 17) vs 44 (+/- 17) ml.m-2; captopril (n 20), 96.6 (+/- 18) vs 99 (+/- 19) and 66 (+/- 22) vs 65 (+/- 22) ml.m-2; placebo (n 20), 96 (+/- 25) vs 113 (+/- 19) (P < 0.001) and 63 (+/- 18) vs 74 (+/- 22) ml.m-2 (P < 0.01). This study indicates that short-term ventricular enlargement is related to the degree of ventricular dysfunction and that captopril may improve this process.

[Evaluation of clinical heart insufficiency in patients with acute myocardial infarct treated with intravenous streptokinase]. / Valoración de la insuficiencia cardíaca clínica en pacientes con infarto agudo de miocardio tratados con estreptocinasa intravenosa.

We assessed the incidence of clinical heart failure in patients with acute myocardial infarction admitted to a coronary care unit and treated with intravenous streptokinase. We compared 2 groups of patients: 1) treated group: patients with acute myocardial infarction admitted to the unit in the last 3 years and treated with intravenous streptokinase, following a protocol established previously. 2) CONTROL GROUP: patients with the same characteristics and selection criteria as for the treated group, admitted to the unit during the previous 2 years and conventionally treated, without thrombolytic therapy. We assessed, in both groups, the incidence of heart failure at the time of admission, at discharge and the total incidence in the unit, following the Killip and Kimball criteria. The total incidence of heart failure was higher in the control group than in the treated group (43.8 vs 19.1%, p less than 0.001). This difference was even greater when the comparison was made with the reperfused patients (43.8% vs 18%, p less than 0.001). Heart failure incidence at the time the patients were discharged from de unit was also higher in the control group (21.2% vs 4.3%, p less than 0.001). When we considered severe heart failure (III-IV Killip Group) we also observed a significant difference between both groups. In conclusion, the incidence and the severity of clinical heart failure were lower in patients treated with streptokinase than in those treated conventionally.