Impaired fasting glucose in combination with silent myocardial ischaemia is associated with poor prognosis in healthy individuals.

AIM: As both impaired fasting glucose and silent myocardial ischaemia are risk factors for cardiovascular disease and death, we hypothesized that these risk factors in combination would identify those subjects at the highest risk of adverse events. METHODS: Healthy individuals without diabetes (n=596, 55-75 years) were examined for silent myocardial infarction (≥ 1 mm ST-interval during ≥ 1 min) by ambulant 48-h continuous electrocardiogram monitoring and impaired fasting glucose (fasting plasma glucose 5.6-6.9 mmol/l). RESULTS: After 6.3 years, 77 subjects met the endpoint of myocardial infarction and/or death. The prevalence of silent myocardial ischaemia at inclusion was 12.3% in subjects with impaired fasting glucose and 11.7% in subjects with normal fasting glucose, P=0.69. Subjects with impaired fasting glucose/silent myocardial ischaemia more often met the endpoint (36%) than subjects with impaired fasting glucose/no silent myocardial ischaemia (15%), subjects with normal fasting glucose/silent myocardial ischaemia (12%), and subjects with normal fasting glucose/no silent myocardial ischaemia (10%), respectively, (P<0.001). In a Cox model including these four study groups of interest, gender, age, smoking habits, blood pressure and total cholesterol, only subjects with impaired fasting glucose/silent myocardial ischaemia exhibited an increased risk of death or myocardial infarction (hazard ratio 2.5, P=0.016). CONCLUSION: The combination of impaired fasting glucose and silent myocardial ischaemia was associated with the poorest prognosis in middle-aged and older subjects without previously known glucose metabolic aberration and heart disease.

C-reactive protein, heart rate variability and prognosis in community subjects with no apparent heart disease.

OBJECTIVES: Increased C-reactive protein (CRP) and reduced heart rate variability (HRV) both indicate poor prognosis. An inverse association between HRV and CRP has been reported, suggesting an interaction between inflammatory and autonomic systems. However, the prognostic impact of this interaction has not been studied. We thus investigated the prognostic impact of CRP, HRV and their combinations. DESIGN: Population-based study. SUBJECTS: A total of 638 middle-aged and elderly subjects with no apparent heart disease from community. METHODS: All were studied by clinical and laboratory examinations, and 24-h Holter monitoring. Four time domain measures of HRV were studied. All were prospectively followed for up to 5 years. RESULTS: Mean age was 64 years (55-75). During the follow-up, 46 total deaths and 11 cases of definite acute myocardial infarction were observed. Both CRP and three of four HRV measures were significantly associated with increased rate of death or myocardial infarction. In a Cox model with CRP >or=2.5 microg mL(-1), standard deviation for the mean value of the time between normal complexes

[Prognosis after late versus early nonfatal myocardial infarction]. / Prognosen efter sent versus tidligt ikkedødeligt myokardiereinfarkt. DAVIT Study Group.

Many recent studies have identified nonfatal recurrent myocardial infarction (RNMI) as the most significant predictor for later outcome. Almost all of these studies have been based on the studies of RNMI in the first year after the index infarction. The prognosis after late RNMI has not been studied properly. In 3,867 nonselected patients below 76 years of age with an acute myocardial infarction we studied the prognosis after a first RNMI depending on the year of its occurrence after the index infarction. Mortality was estimated by the method of Kaplan-Meier and the differences were evaluated by means of the Tarone-Ware test. Four hundred and ninety-three (13.6%) patients had a first RNMI in the first, 151 (5.4%) in the second, 105 (4.2%) in the third, and 71 (3.8%) in the fourth year after the index infarction (group 1-4). One-year mortality rate after RNMI was 23.7% in the first group, 24.1% in the second, 17.5% in the third, and 22.8 in the fourth group. When all the groups were compared with each other no significant difference was found between the mortality rates (p = 0.12) or Standardised Mortality Rates. We concluded that late and early RNMIs have almost the same grave prognosis.

[Diagnosis of acute myocardial infarction in Denmark]. / Diagnostik af akut myokardieinfarkt i Danmark.

The introduction of new biochemical markers for myocardial damage in the recent years and different application of these methods in different centres may have an impact on the diagnostic criteria for acute myocardial infarction (AMI). By means of a questionnaire we studied the diagnostic criteria for AMI in relation to the use of different biochemical markers among 78 Danish hospitals. There were large variations with regard to the choice of cardiac markers and diagnostic values for different markers. CK-B is the cardiac marker mostly used followed by CK-MB. Troponin-T test was used by about 20% of the centres. Many centres are planning to use CK-MB and Troponin-T test. A common national and international policy for diagnosis of AMI in relation to different cardiac markers should reduce these improper differences.

Verapamil and risk of cancer in patients with coronary artery disease. DAVIT Study Group. Danish Verapamil Infarction Trial.

The risk of cancer in users of verapamil was assessed in a long-term follow-up of 1,775 patients who were randomized to verapamil or matching placebo in the Danish Verapamil Infarction Trial-II in the years 1985 to 1987. During 10,474 patient-years, no increased risk of cancer was observed for the verapamil-treated men or women compared with the age- and sex-matched background population.

Nonsteroidal anti-inflammatory drugs after acute myocardial infarction. DAVIT Study Group. Danish Verapamil Infarction Trial.

The effect of nonsteroid anti-inflammatory drugs (NSAIDs) after acute myocardial infarction was studied in a retrospective study of 88 patients who were receiving regular NSAID treatment at randomization in the Danish Verapamil Infarction Trial II. There were no significant differences in mortality or major events between NSAID-treated patients versus controls (1,687); however, in a multivariate analysis a nonsignificant beneficial trend in favor of NSAIDs was observed.

[The use of vena cava filters in Denmark]. / Brugen af vena cava-filtre i Danmark.

By means of a questionnaire we studied the current indications for and the extent of the use of vena cava filters (VCF) in 325 Danish hospital departments. Two hundred and eighty (86%) responded. Only six clinical and four radiological departments (4%) used VCF. Eighteen percent did not find any indications for the use of VCF, 32% were not familiar with the method, and 46% replied that they did not have the relevant patient population. The reported indications for VCF are consistent with the international guidelines. We discussed the scientific background, indications and limitations for the use of VCF and concluded that the current use of VCF in Denmark probably is less than optimal. VCF should be considered in patients with pulmonary embolism or at high risk of pulmonary embolism when anticoagulant therapy is contraindicated.

Temporal pattern of the effect of verapamil on myocardial reinfarction. DAVIT Study Group. Danish Verapamil Infarction Trial.

The purpose of this study was to compare the effects of verapamil on early versus late reinfarction after an index myocardial infarction. A total of 1775 consecutive patients < 76 years of age, with acute myocardial infarction, included in the Danish Verapamil Infarction Trial II, were followed for 18 months. Reinfarctions during the observation period were retrospectively divided into the 50% earliest occurring and the 50% latest occurring (early and late reinfarction, respectively). Cox regression analysis was applied to assess the significance of clinical baseline variables and treatment group (verapamil vs. placebo) on early, late, and total reinfarction. One hundred and ninety-one reinfarctions were registered during the 18-month observation: 96 in the first 5 months (early) and 95 in the last 13 months (late). On univariate analysis verapamil significantly reduced the rate of total reinfarction (P = 0.04, hazard ratio [HR] = 0.77; 95% confidence Interval [CI] 0.58-1.03) and early reinfarction (P = 0.007, HR 0.56; 95% CI 0.37-0.86), but not late reinfarction (P = 0.99, HR = 1.05; 95% CI 0.70-1.56). In a multivariate model, only the rate of early reinfarction was reduced by verapamil (P = 0.012, HR = 0.59, 95% CI 0.39-0.90). Additionally, predictors of early and late reinfarction were quite different in this model. After an index myocardial infarction verapamil reduces the rate of early but not late reinfarction.

Comparison of the prognosis after early versus late recurrent nonfatal myocardial infarction. DAVIT Study Group. Danish Verapamil Infarction Trial.

BACKGROUND: Recurrent nonfatal myocardial infarction (RNMI) is the most significant risk factor for later outcome after an index infarction. However, little is known about the prognosis after RNMIs that occur beyond the first year after the index infarction. METHODS AND RESULTS: In 3867 nonselected patients <76 years old with an acute myocardial infarction, we studied the rate of and prognosis after a first RNMI, depending on the year of its occurrence after the index infarction. Mortality rate was estimated by the method of Kaplan-Meier, and the differences were evaluated by means of the Tarone-Ware test. Four hundred ninety-three (13.6%) patients had a first RNMI in the first, 151 (5.4%) in the second, 105 (4.2%) in the third, and 71 (3.8%) in the fourth year after the index infarction (groups 1 through 4). One-year mortality rate after RNMI was 23.7% in the first group, 24.1% in the second group, 17.5% in the third group, and 22.8 in the fourth group. When all the groups were compared with each other, no significant difference was found between the mortality rates (p = 0.12) or standardized mortality rates. CONCLUSIONS: Late RNMIs have almost the same grave prognosis as do early RNMIs.

[Coronary atherosclerosis or diabetic cardiomyopathy? Pathoanatomic changes of blood vessels, nerves and myocardium in patients with diabetes mellitus]. / Koronar aterosklerose eller diabetisk kardiomyopati? Patoanatomiske forandringer of kar, nerver og myocardium hos patienter med diabetes mellitus.

In patients with diabetes mellitus, heart disease is more common that in the background populations and has a more serious prognosis. The reasons are only partially understood. Whether patients with diabetes mellitus have a more diffuse and pronounced coronary atherosclerosis has been the subject of many investigations with diverging results. However, the larger studies suggest that coronary atherosclerosis is more pronounced and diffuse in diabetics compared with non-diabetic patients. The pathoanatomic picture of the atherosclerotic process seems to be identical in patients with and without diabetes mellitus. A number of structural abnormalities in the intramural vessels and interstitial tissue of the heart have been demonstrated in diabetics. However, similar abnormalities have also been reported in non-diabetic patients. With respect to where "diabetic cardiomyopathy" is a specific entity, the existing data are not confirmative. Whether diabetes mellitus per se induces functional changes in the coronary vascular system leading to myocardial ischaemia and dysfunction is a subject for future investigations.