Chronic obstructive pulmonary disease in patients admitted with heart failure.

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is an important differential diagnosis in patients with heart failure (HF). The primary aims were to determine the prevalence of COPD and to test the accuracy of self-reported COPD in patients admitted with HF. Secondary aims were to study a possible relationship between right and left ventricular function and pulmonary function. DESIGN: Prospective substudy. SETTING: Systematic screening at 11 centres. SUBJECTS: Consecutive patients (n = 532) admitted with HF requiring medical treatment with diuretics and an episode with symptoms corresponding to New York Heart Association class III-IV within a month prior to admission. INTERVENTIONS: Forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC) were measured by spirometry and ventricular function by echocardiography. The diagnosis of COPD and HF were made according to established criteria. RESULTS: The prevalence of COPD was 35%. Only 43% of the patients with COPD had self-reported COPD and one-third of patients with self-reported COPD did not have COPD based on spirometry. The prevalence of COPD in patients with preserved left ventricular ejection fraction (i.e. LVEF >or=45%) was significantly higher than in patients with impaired LVEF (41% vs. 31%, P = 0.03). FEV(1) and FVC were negatively correlated with right ventricular end-diastolic diameter and tricuspid annular plane systolic excursion and FVC positively correlated with systolic gradient across the tricuspid valve. CONCLUSION: Chronic obstructive pulmonary disease is frequent in patients admitted with HF and self-reported COPD only identifies a minority. The prevalence of COPD was high in both patients with systolic and nonsystolic HF.

The prognostic importance of creatinine clearance after acute myocardial infarction.

AIMS: The purpose of this study was to assess renal dysfunction as an independent predictor of mortality after acute myocardial infarction. METHODS: The study population was 6252 patients with a myocardial infarction admitted alive from 1990 to 1992. The mortality status was obtained after at least 6 years. RESULTS: Cox proportional-hazards model demonstrated that the unadjusted risk ratio associated with a calculated creatinine clearance < or =40 ml x min(-1) compared to a clearance above 85 ml x min(-1) was 7.1 (95% confidence interval 6.2-8.0). Adjustment for multiple available covariates reduced this risk to 2.0 (1.6-2.4). The unadjusted risk ratio associated with clearance from 41 to 55 ml x min(-1) and from 71 to 85 ml x min(-1) was 3.7 (3.3-4.2) and 1.5 (1.3-1.7) respectively, but after adjustment for all available variables these risks were reduced to 1.4 (1.2-1.6) and 1.1 (0.9-1.3) respectively. CONCLUSION: Renal dysfunction is an important risk factor after acute myocardial infarction. When the risk is adjusted for available competing risk factors only severely reduced renal function is associated with an important and independent risk of mortality after acute myocardial infarction. The risk of a moderate reduction in renal function is almost fully explained by an association with other conditions.

Short and long term prognostic importance of regional dyskinesia versus akinesia in acute myocardial infarction.

BACKGROUND: The prognostic importance of dyskinesia after acute myocardial infarction is unknown, and recommendations have been made that dyskinesia be included in calculations of wall motion index (WMI). OBJECTIVE: To determine whether it is necessary to distinguish between dyskinesia and akinesia when WMI is estimated for prognostic purposes following acute myocardial infarction. DESIGN: Multicentre prospective study. PATIENTS: 6676 consecutive patients, screened one to six days after acute myocardial infarction in 27 Danish hospitals. INTERVENTIONS: WMI was measured in 6232 patients, applying the nine segment model, scoring 3 for hyperkinesia, 2 for normokinesia, 1 for hypokinesia, 0 for akinesia, and -1 for dyskinesia. Calculation of WMI either included information on dyskinesia or excluded this information by giving dyskinesia the same score as akinesia. MAIN OUTCOME MEASURES: Long term outcome (up to seven years) with respect to mortality. RESULTS: Dyskinesia occurred in 673 patients (10.8%). In multivariate analysis, WMI was an important prognostic factor, with a relative risk of 2.4 (95% confidence interval (CI), 2.2 to 2.7), while dyskinesia had no independent long term prognostic importance (relative risk 1.00; 95% CI, 0.89 to 1.12). For 30 day mortality dyskinesia had a relative risk of 1.23 (95% CI, 1.00 to 1.53) (p = 0.045). CONCLUSIONS: Echocardiographic evaluation of left ventricular systolic function shortly after an acute myocardial infarct gives important prognostic information, but the presence of dyskinesia only has prognostic importance for the first 30 days.

Age-distribution, risk factors and mortality in smokers and non-smokers with acute myocardial infarction: a review. TRACE study group. Danish Trandolapril Cardiac Evaluation.

Smoking is a risk factor for acute myocardial infarction; paradoxically, many studies have shown a lower post-infarct mortality among smokers. There are some important differences between smokers and non-smokers, which might explain the observed difference in mortality: smokers have less multivessel disease and atherosclerosis but are more thrombogenic; thrombolytic therapy seems to be more effective among smokers; smoking might result in an increased out-of-hospital mortality rate, by being more arrhythmogenic; and smokers are on average a decade younger than non-smokers at the time of infarction, and have less concomitant disease. Adjusting for these differences in regression analyses shows that smoking is not an independent risk factor for mortality after acute myocardial infarction. The difference in age and risk factors are responsible for the lower mortality among smokers.

The prognostic importance of smoking status at the time of acute myocardial infarction in 6676 patients. TRACE Study Group.

Smoking is an important risk factor for atherosclerotic heart disease, but several studies have shown smoking to be associated with a favourable prognosis in patients who have suffered an acute myocardial infarction (AMI). We studied a large group of consecutive patients admitted alive to hospital with an infarction in order to further study the prognostic importance of smoking status at the time of myocardial infarction. The study cohort comprised 6676 patients with an enzyme-confirmed myocardial infarction admitted to 27 Danish hospitals over a 26-month period between 1990 and 1992. Smoking status was determined at the time of hospitalisation and complete follow-up was obtained in October 1996. Smokers were on average 10 years younger, had fewer concomitant cardiac risk factors, and were more likely to be male and to receive thrombolytic therapy more frequently than non-smokers. In univariate analysis, smoking was associated with reduced 30-day and long-term mortality (risk ratio at 30 days 0.55, P < 0.001, risk ratio long-term 0.59, P < 0.001). When age only was included in a multivariate analysis, smoking was no longer of importance in short- or long-term mortality (risk ratio 0.92, P = 0.4 at 30 days and long-term risk ratio 0.98, P = 0.7). Inclusion of further variables did not change this picture. In conclusion, smoking contributes to the occurrence of AMI at a younger age. The more favourable prognosis in smokers at the time of AMI is a result of more favourable baseline characteristics, especially their lower age.

Long-term prognostic importance of hyperkinesia following acute myocardial infarction. TRACE Study Group. TRAndolapril Cardiac Evaluation.

The long-term prognostic importance of hyperkinesia is unknown following an acute myocardial infarction (AMI). The American Society of Echocardiography recommends that hyperkinesia should not be included in calculation of wall motion index (WMI). The objective of the present study was to determine if hyperkinesia should be included in WMI when it is estimated for prognostic purposes following an AMI. Six thousand, six hundred seventy-six consecutive patients were screened 1 to 6 days after AMI in 27 Danish hospitals. WMI was measured in 6,232 patients applying the 9-segment model and the following scoring system: 3 for hyperkinesia, 2 for normokinesia, 1 for hypokinesia, 0 for akinesia, and -1 for dyskinesia. All patients were followed with respect to mortality for at least 3 years. WMI was calculated in 2 different ways: 1 including hyperkinetic segments (hyperkinetic-WMI) and the other excluding nonhyperkinetic segments (nonhyperkinetic-WMI) by converting the hyperkinetic segments to normokinetic segments. Hyperkinesia occurred in 736 patients (11.8%). WMI was an important prognostic factor (relative risk 2.49; p = 0.0001) for long-term mortality together with heart failure, history of hypertension, angina, or diabetes, previous AMI, age, thrombolytic therapy, arrhythmias, and bundle branch block. In a multivariate analysis including nonhyperkinetic-WMI, hyperkinesia was associated with a relative risk of 0.84, which was statistically significant (confidence intervals 0.74 to 0.96; p = 0.01). When hyperkinesia was included, both in WMI (hyperkinetic-WMI) and as an independent variable, no additional prognostic information (relative risk 0.93; p = 0.26) was obtained. An echocardiographic evaluation shortly after an AMI gave important prognostic information, especially if the information concerning hyperkinesia was included. If WMI is used for prognostic purposes, hyperkinesia should be included in calculation of the index.

Impact of immediate and delayed myocardial scintigraphy on therapeutic decisions in suspected acute myocardial infarction.

Early myocardial scintigraphic imaging has become technically feasible in patients admitted to hospital with suspected acute myocardial infarction. After prompt injection of 99mTc-sestamibi, subsequent scintigraphic imaging of perfused myocardium can be performed. During a 5-month period, 237 patients were admitted to the coronary care unit of a district hospital on suspicion of acute ischaemic syndrome, and injection of 99mTc-sestamibi for the performance of myocardial scintigraphy was carried out in 134 patients, on average 2 h after onset of symptoms. The investigation was repeated in 126 patients, on average 18 h after the injection. Three planar views were taken in the coronary care unit with a mobile gamma camera. The prevalence of acute myocardial infarction was 53%. The predictive value at the first scintigraphic imaging for a positive or negative test for myocardial infarction 54% and 56%, respectively. Even exclusion of patients with a previous infarction did not increase the diagnostic validity. The predictive value of a negative test, 77%, at the second scintigraphy was still insufficient to make immediate therapeutic decisions. Myocardial scintigraphy performed early, on suspicion of acute myocardial infarction, cannot therefore be used routinely as a diagnostic test prior to intervention in unselected patients because some 90% of this patient group have myocardial perfusion defects.

[Cardiac risk in surgery. A review and guidelines for risk evaluation and reduction of cardiac risk in general surgery]. / Kardial risiko ved operation. En oversigt og vejledende retningslinier for vurdering og reduktion af kardial risiko ved almenkirurgiske indgreb.

Cardiac complications occur with an incidence of 2-6% and are a main cause (15-20%) of mortality after non-cardiac surgery. Cardiac risk should be determined and reduced by treatment preoperatively and by an intraoperative and postoperative care that has been adjusted to the increased risk. This review provides recommendations concerning risk evaluation and management.

[Does the patient obtain close contact with the hospital physician when a physician/nurse team is established?]. / Opnår patienten fast tilknytning til hospitalslaegen ved etablering af et laege-/sygeplejerske-team?

The contact between patients and doctors was examined having established smaller doctor/nurse teams to take care of the same seven to eight patients during the weekdays of their stay at hospital. Ten weekdays after their admission to hospital 63% of the patients had not had contact with any other doctor(s) than their personal doctor(s), and 70% of the patients had seen only two different doctors. During the same period the doctors saw their patients three times on an average. We conclude that organizing the hospital doctors in small teams is a way to obtain good continuity in the contact between the patient and the hospital doctor.

[Is it possible to establish a constant physician/nurse team at an emergency department of internal medicine?]. / Kan etablering af fast laege-/sygeplejerske-team gennemføres på en akut almen intern medicinsk afdeling?

In order to obtain better continuity in the contact between the patient and doctors/nurses during hospitalization in a medical department, small teams of nurses and doctors were established, so that the patients were attached to their personal doctor and nurse. In nearly three-fourth of the weekdays the patients saw their personal doctor and nurse. We conclude, that within the Danish public health care system and according to the contractual agreements it is possible to establish small doctor/nurse teams and by this to obtain a high continuity during daytime.

Performance characteristics of creatine kinase-MB isoenzyme measured with an immunoenzymometric and an immunoinhibition assay in acute myocardial infarction with and without thrombolytic therapy.

In a time study we compared the analytical and clinical performance of the Tandem Icon QSR CK-MB enzyme-immunoassay (Hybritech) (creatine kinase-MB) and a creatine kinase-MB immunoinhibition method (Boehringer Mannheim GmbH) (creatine kinase-B). Two hundred and ninety-nine serum samples from 38 patients suspected of acute myocardial infarction were collected at regular intervals during 48 hours. Twenty-nine patients were diagnosed as having acute myocardial infarction, of whom 19 received thrombolytic therapy. Although highly correlated, the large scatter around the regression line at low values indicated a different clinical performance of the two methods. We evaluated and compared test performance at different decision levels by means of frequency distributions and predictive values of positive and negative results. For early diagnosis of acute myocardial infarction (4 hours after onset of pain) the Hybritech creatine kinase-MB method gives acceptable predictive values. In thrombolytic treated acute myocardial infarction patients, the peak creatine kinase-MB and creatine kinase-B concentrations were reached after 13.0 h and 13.6 h after the onset of pain, compared with 19.8 h and 17.8 h for patients without thrombolytic therapy.

Myocardial perfusion at fatal infarction: location and size of scintigraphic defects.

In a consecutive study of myocardial scintigraphy in acute ischemic syndrome, four patients had 99mTc-hexamibi injected intravenously before they developed fatal cardiogenic shock. Planar scintigraphy was performed after death. Slices of the hearts after autopsy were analyzed for scintigraphic and pathoanatomic abnormalities. Location of perfusion defects in planar views of the heart was in good agreement with the scintigraphied, sliced sections. The extent of infarction judged from inspection and formasan staining was much smaller (7%-40% and 6%-43% of the total slice area) than found at scintigraphy, where 83%-92% of the myocardium showed ischemia as defined by a 99mTc-hexamibi uptake below an arbitrary limit on half maximum uptake. Myocardial hypoperfusion might thus aggravate the functional impairment at myocardial infarction and lead to cardiogenic shock.

[Assessment of the surgical risk. Is the time between myocardial infarction and a possible surgical procedure of significance for a surgical risk?]. / Operationsrisikovurdering. Er tiden fra et myokardieninfarkt indtil eventuel operation af betydning for operationsrisikoen?

During a five year period, 320 patients suffered from acute myocardial infarction (AMI) and within the next twelve months became candidates for surgery for either appendicitis (99 patients) or for a hip fracture (221 patients). An evaluation of the mortality at the second event (i.e. appendicitis or hip fracture) in relation to the time between AMI and second event, was done following the intention to treat principle. Appendicitis occurred with the same incidence during all 12 months following AMI. The second event mortality was independent of the time interval from AMI to second event. Age, infarction prior to index infarction and congestive heart failure were prognostically important in relation to second event mortality, but did not affect the constant second event mortality during the first year following AMI. Hip fracture occurred more often during the first months following AMI, where the second event mortality was highest. Congestive heart failure either prior to index infarction or at the index infarction was prognostically important in relation to second event mortality. The relatively high mortality in the first months after AMI could partly be explained by an association between congestive heart failure and hip fracture in the first months after AMI. We conclude that the "operative" mortality in patients with recent AMI is high. The mortality is related to congestive heart failure and not to the time between AMI and surgery.

Microvascular right-to-left pulmonary shunt demonstrated by a radionuclide method.

A 37-yr-old man with angiolymphoid hyperplasia (Kimura's syndrome), who had been treated unsuccessfully for suspected asthma, was investigated due to a decrease in arterial oxygen saturation (86%). Right heart catheterization and angiography of the pulmonary artery failed to demonstrate any right-to-left shunts. However, simultaneous scintigraphy over the lungs, kidneys, and head after injection of 150 MBq technetium-99m-labeled macroaggregated albumin i.v. and inhalation of 150 MBq krypton-81m demonstrated a right-to-left shunt in the lungs probably caused by precapillary pulmonary arteriovenous shunts.

[Long-term survival of patients with angina pectoris admitted with suspected myocardial infarction]. / Langtidsoverlevelsen for patienter indlagt med angina pectoris på mistanke om akut myokardieinfarkt.

The long-term survival in 240 patients with severe angina pectoris was assessed. All of these patients had been admitted on account of suspected acute myocardial infarction but this diagnosis could be excluded. The mean age was 64.5 years, range 37-87 years. The one, five and ten year survivals were 83.9, 58.5 and 37.2%, respectively. During the first year after discharge, the risk of dying was 16% and decreases to 9% during the subsequent nine years. By means of univariat analysis, previous AMI and duration of ischaemic heart disease were shown to be of prognostic importance. The variables during hospitalization which were found to provide prognostic information were those concerning congestive heart failure, ventricular ectopic activity and type of angina pectoris. After inclusion of age and previous manifestations of ischaemic heart disease, only variables describing congestive heart failure and ventricular ectopic activity were found to provide prognostic information, by stepwise multivariate analysis.

Cardiac predictors of death after non-cardiac surgery evaluated by intention to treat.

Cardiac risk factors were studied among patients who were admitted to hospital with appendicitis or a fracture of the proximal femur less than one year after being admitted with myocardial infarction. Of 99 patients with myocardial infarction and appendicitis, 87 underwent appendicectomy; and of 221 with myocardial infarction and hip fracture, 179 were operated on. The patients were studied on an intention to treat basis. The mortality within one month was 9% and 16% respectively. A history of congestive heart failure was the dominating risk factor, while ischaemic heart disease (recent myocardial infarction or angina pectoris) had no independent association with mortality. If the ventricular function is known additional preoperative information about the heart is of negligible value when estimating the mortality of non-cardiac surgery.

Stomatococcus mucilaginosus endocarditis.

A case of non-nosocomial, spontaneously occurring endocarditis caused by growth of Stomatococcus mucilaginosus on a prolapsed mitral valve is reported. Despite the organism's high susceptibility in vitro the patient responded slowly to antibiotic treatment. Colony adherence to agar surface and absent or weak catalase reaction differentiated this gram-positive coccus from coagulase-negative staphylococci and micrococci.