Platelet function in patients with major depression.

Depression, ischaemic heart disease and cerebrovascular disease are important causes of morbidity and are among the leading contributors to global health burden. These conditions often occur in the same patient, resulting in considerably greater effect on health than combinations of chronic diseases without depression. The frequent occurrence of these conditions in the same patient raises the possibility of a common genetic predisposition, similar risk factors or a pathophysiological link. Serotoninergic and adrenergic signalling play important roles in causing major depression and also in platelet activation and aggregation, which underlies vascular disease. This review discusses the potential pathophysiological link between major depression and conditions in which platelet activation plays an important role and also provides evidence linking the use of the most commonly used antidepressant drugs (i.e. the selective serotonin re-uptake inhibitors) to increased risk of bleeding.

Expression of polycystin-1 enhances endoplasmic reticulum calcium uptake and decreases capacitative calcium entry in ATP-stimulated MDCK cells.

Autosomal dominant polycystic kidney disease (ADPKD) types 1 and 2 arise as a consequence of mutations in the PKD1 or PKD2 genes, encoding polycystins-1 and -2. Because loss of function of either of the polycystins leads to a very similar phenotype and the two proteins are known to interact, polycystins-1 and -2 are probably active in the same pathway. The way in which loss of either polycystin leads to the development of ADPKD remains to be established, but disturbances of cell calcium regulation are likely to play an important role. Here, we demonstrate that polycystin-1, heterologously expressed in Madin-Darby canine kidney cells, had a pronounced effect on intracellular calcium homeostasis. ATP-induced calcium responses in transfection control cells exhibited a double peak and relatively gradual return to baseline. By contrast, cells expressing heterologous polycystin-1 showed a brief, uniphasic peak and an accelerated rate of decay. Heterologously expressed polycystin-1 accelerated endoplasmic reticulum (ER) calcium reuptake and inhibited capacitative calcium entry; we found no effect of the protein on mitochondrial calcium buffering or plasma membrane calcium extrusion. We therefore propose that polycystin-1 accelerated the decay of the cell calcium response to ATP by upregulation of ER calcium reuptake and consequent minimization of the stimulus for capacitative calcium entry. It is possible that cellular dedifferentiation, fluid secretion, and proliferation might therefore arise in ADPKD as a consequence of disturbances in cytoplasmic and ER calcium homeostasis and aberrant capacitative calcium entry.

Depression in patients recovering from a myocardial infarction.

Depression is common among patients recovering from a myocardial infarction (MI). Approximately 1 in 6 patients with MI experience major depression and at least twice as many as that have significant symptoms of depression soon after the event. Post-MI depression is an independent risk factor for increased mortality. Although the mechanism responsible for this association has not yet been defined, depression is clearly associated with poor compliance with risk-reducing recommendations, with abnormalities in autonomic tone that may make patients more susceptible to ventricular arrhythmias, and with increased platelet activation. Coronary revascularization procedures also appear to be used less often in those with post-MI depression than in comparable patients without mood disorder. Ongoing research will address whether treating depression improves prognosis. Until this question is answered, efforts should focus on enhancing adherence to treatment regimens in this group of patients, who are clearly at risk for noncompliance. Cardiac rehabilitation programs and increasing levels of social support may help improve symptoms and should be recommended to all patients. Treatment of depression itself should be individualized until safety and efficacy are determined for antidepressant therapy in patients who recently have had an MI.

Even minimal symptoms of depression increase mortality risk after acute myocardial infarction.

Mild to moderate levels of depressive symptoms as characterized by Beck Depression Inventory (BDI) scores of > or =10 are associated with decreased survival after acute myocardial infarction (AMI). We investigated whether lower levels of depressive symptoms are also associated with increased mortality risk after AMI. We prospectively studied 285 patients with AMI who survived to discharge for evidence, at the time of hospitalization, of a DSM-IIIR mood disorder (using a structured clinical interview) and for symptoms of depression (using the BDI). The overall mortality rate at 4 months was 6.7%. Multiple logistic regression (chi-square 35.79, p < or =0.001) revealed that the independent predictors of mortality were: age > or =65 years, left ventricular ejection fraction <35%, diabetes mellitus, and any depression (DSM-IIIR mood disorder or BDI > or =10) present at the time of AMI. Among patients > or =65 years old with left ventricular ejection fraction <35%, the 4-month mortality was 12%. However, in this same group, those with any depression at the time of AMI had a 4-month mortality of 50% (relative risk 4.1, p = 0.01). Among patients aged > or =65 years, the mortality according to BDI scale grouping 0 to 3, 4 to 9, and 10+ was 2.6%, 17.1%, and 23.3%, respectively (p <0.002). Highest mortality rates were observed in patients with most severe depressive symptoms. However, compared with those without depression, higher mortality was also observed at very low levels of depressive symptoms (BDI 4 to 9) not generally considered clinically significant and below the level usually considered predictive of increased post-AMI mortality.

Determinants of shear stress-stimulated endothelial nitric oxide production assessed in real-time by 4,5-diaminofluorescein fluorescence.

The extremely short biological half-life of endothelial-derived nitric oxide (NO) has impeded real-time measurements of NO synthesis. We used the membrane-permeable fluorescent probe 4,5-diaminofluorescein diacetate (DAF-2 DA) to study determinants of NO synthesis in bovine aortic endothelial cells (BAECs). A step increase in shear stress (SS) from 0.3 to 3.4 dyne/cm(2) triggered an increase in DAF-2 fluorescence starting 3.0 +/- 0.5 min after the flow rise and peaking at 44.7 +/- 7.2 min. This was abolished by intracellular Ca(2+) chelation, but was unaffected by blocking extracellular Ca(2+) influx or by inhibiting SS-related changes in intracellular pH. The increase in DAF-2 fluorescence occurred significantly earlier in BAECs transfected with either superoxide dismutase (SOD) or catalase (CAT), indicating concomitant reactive oxygen species (ROS) generation by SS and "competition" between ROS- and DAF-2-NO interactions. These data provide novel insights into several NO signaling determinants and reveal that DAF-2 can assess real-time SS-stimulated NO synthesis in endothelial cells. This should facilitate the analysis of NO-signaling pathways.

Vascular NAD(P)H oxidase is distinct from the phagocytic enzyme and modulates vascular reactivity control.

An NAD(P)H oxidase has been hypothesized to be the main source of reactive oxygen species (ROS) in vessels; however, questions remain about its function and similarity with the neutrophil oxidase. Therefore, vascular superoxide generation was measured by electron paramagnetic resonance spectroscopy using the spin-trap 5,5'-dimethly-pyrroline-N-oxide in aortas from wild-type (WT) and gp91(phox)-deficient mice (gp91(phox)-/-), which do not have a functioning neutrophil NADPH oxidase. There was no significant difference between radical adduct formation by WT or gp91(phox)-/- mouse aortas either at baseline or after stimulation with NADPH or NADH. Also, spin-adduct formation was identical in the 100,000-g pellets obtained from WT and gp91(phox)-/- mouse aortas. SOD mimetics and the flavoenzyme inhibitor diphenyleneiodonium blocked spin-adduct formation from both intact vessels and particulate fractions. Other pharmacological inhibitors of metabolic pathways involved in ROS generation had no effect on this phenomenon. To examine the role of this enzyme in vascular tone control, aortic rings were suspended in organ chambers and preconstricted with phenylephrine to reach half-maximal contraction. Exposure to NADPH elicited a 20% increase in vascular tone, which was decreased by SOD mimetics in a concentration-dependent manner, suggesting that superoxide was responsible for this phenomenon. NADH had no effect on vascular tone. Thus superoxide is generated in the vessel wall by an NAD(P)H-dependent oxidase, which modulates vascular contractile tone. This enzyme is structurally and genetically distinct from the neutrophil NADPH oxidase.

Depression after myocardial infarction.

Depression is an independent risk factor for increased postmyocardial infarction morbidity and mortality, even after controlling for the extent of coronary artery disease, infarct size, and the severity of left ventricular dysfunction. This risk factor takes on added significance when one considers that almost half of patients recovering from a myocardial infarction have major or minor depression and that major depression alone occurs in about one in five of these individuals. Despite the well-documented risk of depression, questions remain about the mechanism of the relationship between mood disturbance and adverse outcome. The link may be explained by an association with lower levels of social support, poor adherence to recommended medical therapy and lifestyle changes intended to reduce the risk of subsequent cardiac events, disturbances in autonomic tone, enhanced platelet activation and aggregation, and systemic immune activation. Unfortunately, questions about the pathophysiologic mechanism of depression in this setting are paralleled by uncertainties about the optimal treatment of depression for patients recovering from a myocardial infarction and by a lack of knowledge about whether treating depression lowers the associated increased mortality risk. Ongoing research studies will help to determine the benefits of psychosocial interventions and of antidepressant therapy for patients soon after myocardial infarction. Although the identification of depression as a risk factor may by itself be a reason to incorporate a comprehensive psychological evaluation into the routine care of patients with myocardial infarction, this practice should certainly become standard if studies show that treating depression reduces the increased mortality risk of these patients.

Magnesium use in the treatment of acute myocardial infarction in the United States (observations from the Second National Registry of Myocardial Infarction).

The use of magnesium in patients with acute myocardial infarction (AMI) is debated, largely as a result of conflicting data from randomized controlled trials. This study evaluated the use and impact on mortality of intravenous magnesium in the treatment of patients with AMI in the United States based on data from the Second National Registry of Myocardial Infarction. Only 5.1% of 173,728 patients from 1,326 hospitals received intravenous magnesium within the first 24 hours after an AMI, and this was more common in the 59,798 patients who received thrombolytic therapy or who underwent primary percutaneous transluminal coronary angioplasty (PTCA) or coronary bypass grafting (CABG) than in the 113,930 patients who did not receive any reperfusion therapy (8.5% vs 3.4%, p <0.01). Magnesium use was associated with younger age, Q-wave AMI, congestive heart failure on admission, thrombolytic therapy, primary PTCA or CABG, ventricular tachycardia or ventricular fibrillation, and beta blocker or lidocaine use in the first 24 hours (all odds ratio > 1.2, p <0.001). Magnesium use was associated with increased mortality (odds ratio 1.25, 95% confidence interval 1.12 to 1.34) and with a higher mortality in patients without initial reperfusion therapy (20.2% vs 13.2%, p <0.0001) or who underwent primary PTCA or CABG (10.2% vs 7.3%, p = 0.002), but not in patients who received thrombolytic therapy (6.2% vs 5.9%, p = NS). Thus, magnesium is used infrequently in the treatment of AMI and may be associated with worse outcome.

Hypoxia/reoxygenation stimulates intracellular calcium oscillations in human aortic endothelial cells.

BACKGROUND: We have previously shown that hydrogen peroxide stimulates endothelial [Ca(2+)](i) oscillations. This study was performed to determine whether posthypoxic reoxygenation stimulates [Ca(2+)](i) oscillations in vascular endothelial cells. METHODS AND RESULTS: Hypoxia (glucose-free 95% N(2)/5% CO(2) bicarbonate buffer for 60 minutes) stimulated an increase in [Ca(2+)](i) from 111.9+/-7. 9 to 161.7+/-17.7 nmol/L (n=12, P:<0.01) in indo 1-loaded human aortic endothelial cells. On reoxygenation (glucose-containing 95% air/5% CO(2) bicarbonate buffer), 13 of 16 cells responded with repetitive [Ca(2+)](i) oscillations with an average amplitude of 570. 6+/-59.3 nmol/L, occurring at a mean interval of 0.28+/-0.04/min and persisting for >/=60 minutes. [Ca(2+)](i) oscillations were still observed in 4 of 7 cells studied in Ca(2+)-free buffer but did not occur when the intracellular Ca(2+) store was first depleted during hypoxia by either 1 micromol/L thapsigargin or by 10 mmol/L caffeine (n=6 for each). Reoxygenation-induced [Ca(2+)](i) oscillations were abolished by 10 micromol/L diphenyleneiodonium, an inhibitor of NAD(P)H oxidase (n=7), and by polyethylene glycol (PEG)-catalase (5000 U/mL, n=4) but were not prevented by inhibitors of xanthine oxidase (n=5), cyclooxygenase (n=4), nitric oxide synthase (n=5), the mitochondrial electron transport chain (n=4), or by PEG-superoxide dismutase (n=5). CONCLUSIONS: Posthypoxic reoxygenation stimulates repetitive [Ca(2+)](i) oscillations that are dependent on Ca(2+) release from an intracellular pool and require extracellular Ca(2+) to be maintained. These oscillations may be initiated by NAD(P)H oxidase-derived hydrogen peroxide and may play a role in signal transduction during ischemia/reperfusion in vivo.

Calcium signaling and oxidant stress in the vasculature.

Recent evidence suggests that oxidant stress plays a major role in several aspects of vascular biology. Oxygen free radicals are implicated as important factors in signaling mechanisms leading to vascular pathologies such as postischemic reperfusion injury and atherosclerosis. The role of intracellular Ca(2+) in these signaling events is an emerging area of vascular research that is providing insights into the mechanisms mediating these complex physiological processes. This review explores sources of free radicals in the vasculature, as well as effects of free radicals on Ca(2+) signaling in vascular endothelial and smooth muscle cells. In the endothelium, superoxides enhance and peroxides attenuate agonist-stimulated Ca(2+) responses, suggesting differential signaling mechanisms depending on radical species. In smooth muscle cells, both superoxides and peroxides disrupt the sarcoplasmic reticulum Ca(2+)-ATPase, leading to both short- and long-term effects on smooth muscle Ca(2+) handling. Because vascular Ca(2+) signaling is altered by oxidant stress in ischemia-related disease states, understanding these pathways may lead to new strategies for preventing or treating arterial disease.

In vitro system to study realistic pulsatile flow and stretch signaling in cultured vascular cells.

We developed a novel real-time servo-controlled perfusion system that exposes endothelial cells grown in nondistensible or distensible tubes to realistic pulse pressures and phasic shears at physiological mean pressures. A rate-controlled flow pump and linear servo-motor are controlled by digital proportional-integral-derivative feedback that employs previously digitized aortic pressure waves as a command signal. The resulting pressure mirrors the recorded waveform and can be digitally modified to yield any desired mean and pulse pressure amplitude, typically 0-150 mmHg at shears of 0.5-15 dyn/cm(2). The system accurately reproduces the desired arterial pressure waveform and cogenerates physiological flow and shears by the interaction of pressure with the tubing impedance. Rectangular glass capillary tubes [1-mm inside diameter (ID)] are used for real-time fluorescent imaging studies (i. e., pH(i), NO, Ca(2+)), whereas silicon distensible tubes (4-mm ID) are used for more chronic (i.e., 2-24 h) studies regarding signal transduction and gene expression. The latter have an elastic modulus of 12.4. 10(6) dyn/cm(2) similar to in vivo vessels of this size and are studied with the use of a benchtop system. The new approach provides the first in vitro application of realistic mechanical pulsatile forces on vascular cells and should facilitate studies of phasic shear and distension interaction and pulsatile signal transduction.

Opposite effects of pressurized steady versus pulsatile perfusion on vascular endothelial cell cytosolic pH: role of tyrosine kinase and mitogen-activated protein kinase signaling.

Endothelial cytosolic pH (pH(i)) modulates ion channel function, vascular tone, and cell proliferation. Steady shear induces rapid acidification in bicarbonate buffer. However, in vivo shear is typically pulsatile, potentially altering this response. We tested effects and mechanisms of pH(i) modulation by flow pulsatility, comparing pressurized steady versus pulse-flow responses in bovine aortic endothelial cells cultured within glass capillary tubes. Cells were loaded with the fluorescent pH(i) indicator carboxy seminaphthorhodafluor-1 and perfused with physiological pulsatile pressure and flow generated by a custom servo-control system. Raising mean pressure from 0 to 90 mm Hg at 0.5 mL/min steady flow in bicarbonate buffer induced sustained acidification (-0.33+/-0.09 pH units, P<0.01). A subsequent increase in steady flow resulted in further acidification. In contrast, if mean pressure and flow were unchanged but perfusion made pulsatile, pH(i) rose +0.3+/-0.03 (P<0. 0001) over 30 to 60 minutes. HCO(3)(-) removal and use of acid/base exchange inhibitors 5-(N-ethyl-N-isopropyl)amiloride or diisothiocyanato stilbene disulfonic acid identified both extracellular Na(+)-independent Cl(-)-HCO(3)(-) and Na(+)-H(+) exchangers as activated by static pressure, whereas pulsatility activated extracellular Na(+)-dependent Cl(-)-HCO(3)(-) and Na(+)-H(+) exchangers to raise pH(i). Pulse-perfusion alkalinization occurred with or without flow reversal and increased 1.6-fold in Ca(2+)-free buffer. Inhibition of c-Src tyrosine kinase (4-amino-5-[4-chlorophenyl]-7-[t-butyl]pyrazolo [3,4-d]pyrimidine; PP2) or MEK-1 (mitogen-activated protein kinase [MAP]/extracellular signal-regulated kinase [ERK]-1) (PD98059, blocking ERK1/2) blocked or reversed the pulsatile-flow pH(i) change to acidification. In contrast, PP2 had no effect on steady flow acidification, whereas MEK-1 inhibition converted it to alkalinization. Thus, pulsatile and steady flow trigger opposite effects on endothelial pH(i) by differential activation of acid/base exchangers linked to c-Src and MAP kinase phosphorylation, but not to Ca(2+). These data highlight specific signaling responses triggered by phasic shear profiles.

A patient with syncope, only "vagally" related to the heart.

Syncope due to atrioventricular block may occur as a result of a cardiac vasodepressor reflex. This article reports a case of syncope in a 58-year-old man with high-grade atrioventricular block documented by ambulatory ECG monitoring at home. What makes this case unusual is that the patient's principal diagnosis was noncardiac.

Patients with depression are less likely to follow recommendations to reduce cardiac risk during recovery from a myocardial infarction.

BACKGROUND: Patients with depression are at greater risk of cardiac death in the first few months after a myocardial infarction (MI). This study was performed to determine whether depression affects adherence to recommendations intended to reduce the risk of cardiac events after an MI. METHODS: All consenting patients admitted to a university-affiliated teaching hospital during an 18-month period were interviewed 3 to 5 days following an acute MI using the Beck Depression Inventory to assess symptoms of depression and using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition, to determine the presence of major depression and/or dysthymia. Accessible survivors (n=204; 116 men and 88 women) were interviewed by telephone 4 months later using the Medical Outcomes Study Specific Adherence Scale to measure self-reported adherence to recommendations to modify cardiac risk. RESULTS: Patients who were found in the hospital to have symptoms of at least mild to moderate depression (Beck Depression Inventory score > or =10, n=35 [17.2%]) or to have major depression and/or dysthymia (n=31 [15.2%]) reported lower adherence to a low-fat diet, regular exercise, reducing stress, and increasing social support 4 months later. Those with major depression and/or dysthymia also reported taking medications as prescribed less often than those without major depression and/or dysthymia. Diabetic patients with major depression and/or dysthymia were less likely to follow a diet for patients with diabetes than diabetic patients without depression. CONCLUSIONS: Patients with depression following an acute MI are less likely to adhere to recommended behavior and lifestyle changes intended to reduce the risk of subsequent cardiac events. This finding could explain why depression in the hospital is related to long-term prognosis in patients recovering from an MI.

NADPH oxidase activation increases the sensitivity of intracellular Ca2+ stores to inositol 1,4,5-trisphosphate in human endothelial cells.

Many stimuli that activate the vascular NADPH oxidase generate reactive oxygen species and increase intracellular Ca(2+), but whether NADPH oxidase activation directly affects Ca(2+) signaling is unknown. NADPH stimulated the production of superoxide anion and H(2)O(2) in human aortic endothelial cells that was inhibited by the NADPH oxidase inhibitor diphenyleneiodonium and was significantly attenuated in cells transiently expressing a dominant negative allele of the small GTP-binding protein Rac1, which is required for oxidase activity. In permeabilized Mag-indo 1-loaded cells, NADPH and H(2)O(2) each decreased the threshold concentration of inositol 1,4,5-trisphosphate (InsP(3)) required to release intracellularly stored Ca(2+) and shifted the InsP(3)-Ca(2+) release dose-response curve to the left. Concentrations of H(2)O(2) as low as 3 microm increased the sensitivity of intracellular Ca(2+) stores to InsP(3) and decreased the InsP(3) EC(50) from 423.2 +/- 54.9 to 276.9 +/- 14. 4 nm. The effect of NADPH on InsP(3)-stimulated Ca(2+) release was blocked by catalase and by diphenyleneiodonium and was not observed in cells lacking functional Rac1 protein. Thus, NADPH oxidase-derived H(2)O(2) increases the sensitivity of intracellular Ca(2+) stores to InsP(3) in human endothelial cells. Since Ca(2+)-dependent signaling pathways are critical to normal endothelial function, this effect may be of great importance in endothelial signal transduction.

[Ca(2+)](i) oscillation frequency regulates agonist-stimulated NF-kappaB transcriptional activity.

In nonexcitable cells, stimulation by high agonist concentrations typically produces a biphasic increase in cytosolic Ca(2+) ([Ca(2+)](i)). This response is characterized by a transient initial increase because of intracellular Ca(2+) release followed by a sustained elevation which varies in amplitude depending on the nature of the stimulus. In contrast, low-level stimulation often evokes oscillatory changes in [Ca(2+)](i). The specific information provided by repetitive [Ca(2+)](i) spikes appears to be encoded in the frequency rather than in the amplitude of [Ca(2+)](i) oscillations. The specific, membrane-permeable inositol 1,4, 5-trisphosphate (Ins-1,4,5-P(3)) receptor blocker Xestospongin C (XeC, 2-20 microM) was used to affect [Ca(2+)](i) signaling in human aortic endothelial cells (HAEC) during an established response to low-level (1 microM) histamine stimulation. XeC produced a dose-dependent decrease in the frequency of [Ca(2+)](i) oscillations during histamine stimulation without affecting oscillation amplitude. Histamine stimulated a 14-fold increase in NF-kappaB-chloramphenicol acetyltransferase reporter gene activity that was dose-dependently decreased by XeC. Thus, during low-level agonist stimulation, [Ca(2+)](i) oscillation frequency regulates nuclear transcription in HAEC.

Hydrogen peroxide decreases pHi in human aortic endothelial cells by inhibiting Na+/H+ exchange.

Postischemic endothelial dysfunction may occur as a result of the effects of endogenous oxidants like hydrogen peroxide. Since endothelium-dependent vasodilator function may be affected by pHi, the effect of hydrogen peroxide on endothelial pHi was examined. Hydrogen peroxide (100 micromol/L for 10 minutes) decreased pHi from 7.24+/-0.01 to 7.02+/-0.02 and inhibited recovery from an ammonium chloride-induced intracellular acid load in carboxy SNARF 1 (c-SNARF 1)-loaded human aortic endothelial cells in bicarbonate-free solution. Prior inhibition of Na+/H+ exchange with 5-(N-ethyl-N-isopropyl)amiloride (10 micromol/L), by removal of extracellular Na+, or by glycolytic inhibition with iodoacetic acid blocked the subsequent effect of hydrogen peroxide on pHi. A 2-minute exposure to 100 micromol/L H2O2 decreased intracellular ATP levels by approximately 40%; this was prevented by 3-aminobenzamide and nicotinamide (1 mmol/L each), inhibitors of the DNA repair enzyme poly(ADP-ribose) polymerase. Both 3-aminobenzamide and nicotinamide significantly inhibited the hydrogen peroxide-induced intracellular acidification and the effect of hydrogen peroxide on recovery from an intracellular acid load. Hydrogen peroxide decreases pHi in human endothelial cells by inhibiting Na+/H+ exchange. This appears to be mediated by activation of the DNA repair enzyme poly(ADP-ribose) polymerase and subsequent depletion of intracellular ATP. Since a decrease in pHi in this range may alter the activity of NO synthase or affect the synthesis of vasodilator prostaglandins, the effect of hydrogen peroxide on the endothelial Na+/H+ exchanger may be important in the pathogenesis of postischemic endothelial dysfunction.

Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I.

BACKGROUND: To determine whether there are sex differences in the demographics, treatment, and outcome of patients with acute myocardial infarction in the United States, data from the National Registry of Myocardial Infarction-I from September 1990 to September 1994 were examined. METHODS: The National Registry of Myocardial Infarction-I is a national observational database consisting of 1234 US hospitals in which each hospital submits data from each patient with acute myocardial infarction to a central data collection center. For these analyses, the following variables were examined in 354 435 patients with acute myocardial infarction: demographics; use of medical therapy including thrombolytic agents; use of procedures including cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery; length of hospital stay; adverse events (stroke, major bleeding, or recurrent myocardial infarction); and causes of death. RESULTS: In comparison with men, women experiencing acute myocardial infarction in the United States are older, with 55.7% older than 70 years. Women have a higher mortality rate than men even when controlled for age and die less often from arrhythmia but more often from cardiac rupture whether or not thrombolytic therapy is used. Treatment with aspirin, heparin, or beta-blockers is less frequent in women. When thrombolytic therapy is used, women are treated an average of almost 14 minutes later than men and experience a greater incidence of major bleeding. Cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery are used less often in women. CONCLUSIONS: Observations from the National Registry of Myocardial Infarction-I document important sex differences in demographics, treatment, and outcome of patients with acute myocardial infarction in the United States.