Teesside coronary survey: an epidemiological study of acute attacks of myocardial infarction.

A 12-month epidemiological survey of attacks of acute myocardial infarction was carried out in a large urban population. The incidence and mortality at all ages and in both sexes were examined. Altogether, 1938 attacks were diagnosed--an overall incidence of 4-89 per 1000 population. The 28-day fatality rate was 50-5%. A third of the patients were treated at home and these patients had a lower fatality rate than those in hospital, a difference that could not be attributed to age, sex, or severity of attack. Half of the deaths that were witnessed occurred suddenly and a further 21% occurred within the next two hours. The median time to patients coming under care was about three hours. As used at present, coronary care units are unlikely to improve fatality rates. Future advances in treatment must take place outside hospital and will require re-education of the public and the general practitioner.     

Randomised trial comparing propranolol with atenolol in immediate treatment of suspected myocardial infarction.

The value of beta-blockade for suspected acute myocardial infarction was assessed by determining the six-week and one-year mortality rates in patients started on propranolol, atenolol, or placebo immediately on entry to a coronary care unit. A total of 388 patients entered this double-blind, randomised study, and when analysed on the basis of the initial, intention-to-treat categories there was no significant difference between the three groups in respect of the mortality rate at one year. There was, however, a high withdrawal rate from the trial; the reasons for this illustrate problems of physician compliance and interpretation of data, which are common to all early-entry trials of haemodynamically active agents in acute myocardial infarction.     

Acute myocardial infarction and sudden death in Sioux Indians.

While some Indian tribes have low rates of acute myocardial infarction, Northern Plains Indians, including the Sioux, have rates of morbidity and mortality from acute myocardial infarction higher than those reported for the United States population in general. In a review of diagnosed cases of acute myocardial infarction over a 3-year period in 2 hospitals serving predominantly Sioux Indians, 8% of cases were found misclassified, and 22% failed to meet rigorous diagnostic criteria, although the patients did indeed have ischemic heart disease. Patients had high frequencies of complications and risk factors and a fatality rate of 16% within a month of admission. Sudden deaths likely due to ischemic heart disease but in persons not diagnosed as having acute myocardial infarction by chart review occurred 3 times more frequently than deaths occurring within a month of clinical diagnosis.     

尿激酶静脉溶栓治疗急性心肌梗死的疗效观察--附35例报告

目的 观察尿激酶静脉溶栓治疗急性心肌梗死的疗效.方法将66例急性心肌梗塞住院患者随机分成两组,溶栓组35例在常规治疗的同时,用尿激酶静脉溶栓治疗,非溶栓组仅用常规治疗,两组进行比较分析.结果 溶栓组血管再通率74.3%,非溶栓组为25.81%,两组间有明显差异(P<0.05),住院4周的病死率,溶栓组为2.86%,非溶栓组为16.16%,两组间有显著差异(P<0.01).结论 尿激酶静脉溶栓能明显提高急性心肌梗死患者的血管再通率和抢救成功率,降低近期病死率.     

Immunoscintigraphy for detecting acute myocardial infarction without electrocardiographic changes.

OBJECTIVE--To establish whether immunoscintigraphy with antibody to myosin may detect acute myocardial infarction without electrocardiographic changes. DESIGN--Prospective study of patients with suspected acute myocardial infarction or unstable angina with cardiac imaging with 111indium myosin antibody, estimation of cardiac enzyme concentrations, electrocardiography, 201thallium imaging, and radionuclide ventriculography. SETTING--Coronary care unit in a district general hospital. PATIENTS--119 Consecutive patients with suspected acute myocardial infarction or unstable angina. Patients with cardiomyopathy, myocarditis, valvular heart disease, myocardial infarction or cardiac surgery in the previous two weeks or with left bundle branch block and women of childbearing age were excluded. RESULTS--Of 75 patients with suspected acute myocardial infarction, seven had no diagnostic electrocardiographic changes despite normal conduction patterns. Immunoscintigraphy with myosin antibody disclosed necrosis in all seven patients, which was localised in regions supplied by diseased coronary arteries in all but one. Six patients had abnormal images on 201thallium imaging, and all seven had abnormal wall motion at the site of antibody uptake. One patient with minimal left main stem and right coronary artery atheroma had uptake of antibody at two discrete sites. CONCLUSIONS--Immunoscintigraphy with antibody to myosin confirms myocardial infarction in the absence of electrocardiographic changes and discloses the site of infarction.     

Influence of oral magnesium supplementation on cardiac events among survivors of an acute myocardial infarction.

OBJECTIVE--To investigate the effect of long term oral magnesium treatment on incidence of cardiac events among survivors of an acute myocardial infarction. DESIGN--Double blind, placebo controlled parallel study in which patients were randomised to treatment or placebo. SETTING--Two coronary care units and corresponding outpatient clinics. SUBJECTS--468 survivors of an acute myocardial infarction (289 men and 178 women) aged 31-92. INTERVENTIONS--One tablet of 15 mmol magnesium hydroxide or placebo daily for one year. MAIN OUTCOME MEASURES--Incidences of reinfarction, sudden death, and coronary artery bypass grafting in one year. RESULTS--There was no significant difference between treatment and placebo groups in the incidence of each of the three cardiac events, but when the events were combined and drop outs were excluded from calculations there was a significantly higher incidence of events in the treatment group (56/167 v 33/153; relative risk 1.55 (95% confidence interval 1.07 to 2.25); p = 0.02). When the timing of events was incorporated by means of a Kaplan-Meier plot the treatment group showed a significantly higher incidence of events whether drop outs were included or excluded (p < 0.025). CONCLUSION--Long term oral treatment with 15 mmol magnesium daily doses not reduce the incidence of cardiac events in survivors of an acute myocardial infarction and, indeed, seems to increase the risk of developing a cardiac event. Consequently, this treatment cannot be recommended as secondary prophylaxis for such patients.     

Quality improvement report: Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

ProblemDelay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.DesignAudit of “door to needle times” for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.

Background and setting

The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.

Key measures for improvement

Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes

Strategies for change

In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a “coronary care thrombolysis nurse.” If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).

Effects of change

Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.

Lessons learnt

Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework''s targets for door to needle times can be achieved.     

老年急性心肌梗死并心源性休克冠状动脉介入治疗的临床效果分析

目的:对比分析介入治疗和保守治疗对急性心梗合并心源性休克的老年患者的治疗效果。方法:回顾性分析急性心肌梗死并心源性休克患者,共入选230例,按照医生评估进行分组治疗,分为介入治疗组和非介入治疗组,介入组患者120例,接受冠脉介入治疗;非介入组患者110例,接受非介入治疗。对比分析危险因素以及治疗效果。结果:介入组中心肌梗死病史及心衰病史患者明显高于非介入组(24.2%vs 20%P<0.05;25%vs 17.3%,P<0.05),经皮冠状动脉介入治疗与非介入治疗相比能显著降低急性心梗合并心源性休克的老年患者住院病死率(40.8%vs 71.8%,P<0.05),非介入治疗组心律失常发生率高于介入治疗组(26.7%vs 21.8%,P<0.05),同时非介入治疗组肺部感染及肾衰的发病率较高(11.8%vs 5.8%P<0.05;8.2%vs 2.0%,P<0.05)。结论:针对急性心梗合并心源性休克的老年患者制定治疗方案时,虽然介入治疗存在更多的并发症,但是可以显著改善患者预后。     

Ischaemic Heart Disease: A Secondary Prevention Trial Using Clofibrate

A trial is reported of the effects of giving clofibrate to prevent progression of pre-existing ischaemic heart disease. There were two groups randomly distributed between clofibrate (350 patients) and placebo (367 patients) regimens. The trial lasted about six years and was conducted in 19 hospitals in Scotland. The criteria of acceptance into the trial were precise and were monitored by one observer. The standards of diagnosis of events were defined and all protocols and electrocardiograms were read blind by one observer.Three categories of patients were admissible to the trial: (1) patients with one myocardial infarction (W.H.O. E.C.G. criteria) between 8 and 16 weeks before the start of the trial; (2) patients with angina of a duration of 3 to 24 months, provided their E.C.G. showed signs of myocardial ischaemia at rest or after exercise; and (3) patients with one recent myocardial infarction and pre-existing angina as defined above.There were fewer deaths in patients with angina (categories 2 and 3 above) treated with clofibrate than in those on placebo. The mortality in the former group was reduced by 62%, and this is a statistically significant difference. Clofibrate did not have any statistically significant effect in reducing the rate of non-fatal infarction in patients with angina or in those with myocardial infarction and pre-existing angina, though a beneficial trend was evident when both subgroups were combined (a 44% reduction compared with the placebo group). There was a significant reduction in all events (fatal and non-fatal) in patients with angina (“all anginas”) in the clofibrate-treated group; the rate was reduced by 53%.Clofibrate did not alter the overall mortality or morbidity rates in patients admitted to the trial with recent myocardial infarction without preceding angina of more than three months'' duration. In one subgroup there was a statistically significant adverse effect in the clofibrate-treated group. The lack of any overall effect in patients with myocardial infarction might be related to the unexpectedly low mortality rate (2·97%) in the placebo group; it is usually in the region of 4-9% per annum after first myocardial infarction.In patients categorized as “all anginas” there was significant reduction in events whether the initial serum cholesterol level was high (greater than 260 mg/100 ml) or normal. Clofibrate seemed to have a small but not significant beneficial effect in patients with myocardial infarction with initially high serum cholesterol levels, but was of no value in those with initially normal serum cholesterol levels. There was no significant relationship between the response or lack of response of serum cholesterol to clofibrate and the incidence of events either in patients with angina or in those with infarction.The main conclusion of this trial is that clofibrate had a beneficial effect in reducing mortality and, to a lesser extent, morbidity in patients who presented with angina (“all anginas”). This effect was independent of initial serum cholesterol levels or the extent to which serum cholesterol was lowered. The drug had no significant overall effect on prognosis in patients with myocardial infarction alone.     

急性心肌梗死后血糖变化对预后的影响研究

目的：探讨急性心肌梗死后血糖变化对患者预后的影响。方法：对314例急性心肌梗死患者于入院后第2日早晨测空腹血糖值后,并进行回顾性对比分析。结果：随着血糖水平的逐渐升高,心力衰竭及心源性休克的发生率和病死率逐渐升高（P〈0.05）,严重心律失常的发生率逐渐升高,但差异无统计学意义（P〉0.05）。结论：急性心肌梗死患者伴应激性血糖升高者,随着血糖水平升高,其心力衰竭及心源性休克的发生率和病死率升高。血糖正常组预后明显好于血糖升高组。     

Comparison of case fatality in south Asian and white patients after acute myocardial infarction: observational study.

OBJECTIVE--To compare mortality in south Asian (Indian, Pakistani, and Bangladeshi) and white patients in the six months after hospital admission for acute myocardial infarction. DESIGN--Observational study. SETTING--District general hospital in east London. PATIENTS--149 south Asian and 313 white patients aged < 65 years admitted to the coronary care unit with acute myocardial infarction from 1 December 1988 to 31 December 1992. MAIN OUTCOME MEASURE--All cause mortality in the first six months after myocardial infarction. RESULTS--The admission rate in the south Asians was estimated to be 2.04 times that in the white patients. Most aspects of treatment were similar in the two groups, except that a higher proportion of the south Asians received thrombolytic drugs (81.2% v 73.8%). After adjustment for age, sex, previous myocardial infarction, and treatment with thrombolysis or aspirin, or both, the south Asians had a poorer survival over the six months from myocardial infarction (hazard ratio 2.02 (95% confidence interval 1.14 to 3.56), P = 0.018), but a substantially higher proportion were diabetic (38% v 11%, P < 0.001), and additional adjustment for diabetes removed much of their excess risk (adjusted hazard ratio 1.26 (0.68 to 2.33), P = 0.47). CONCLUSION--South Asian patients had a higher risk of admission with myocardial infarction and a higher risk of death over the ensuing six months than the white patients. The higher case fatality among the south Asians, largely attributable to diabetes, may contribute to the increased risk of death from coronary heart disease in south Asians living in Britain.     

Sulphinpyrazone in acute myocardial infarction: studies on cardiac rhythm and renal function.

Ninety-eight patients with acute myocardial infarction were randomly allocated to receive sulphinpyrazone 200 mg four times daily or placebo on admission to a coronary care unit. Twenty-four-hour electrocardiogram tape recordings showed no significant reduction in serious arrhythmias in the sulphinpyrazone-treated group. In addition to the expected all in serum urate concentration, patients taking sulphinpyrazone showed a persistent increase in their serum urea and creatinine concentrations when compared with those in the placebo groups (p < 0.05 and p < 0.01 respectively). These differences could not be accounted for by differences in the extent and severity of the infarction between the two groups. These results suggest that sulphinpyrazone has no discernible antiarrhythmic effect in acute myocardial infarction.     

渐进性肌肉放松训练对急性心肌梗死病人焦虑状态的影响

为了确定渐进性肌肉放松对急性心肌梗死患者焦虑情绪是否有缓解作用,本研究选取2016年4月至2019年4月期间在曲靖市第一人民医院心内科治疗的患者274例作为研究对象,随机分为对照组和观察组,每组137例,平均年龄(53.27±10.3)岁。对照组在治疗期间给予常规护理,而观察组在常规护理的基础上给予渐进性肌肉放松治疗。放松治疗每天2次,每次10组,一周4天,共治疗4周。分别于患者入院48 h和治疗后1个月对患者的血压、心率、并发症以及焦虑水平进行记录评估。研究显示,入院治疗1个月后,患者的血压、心率均有所下降,但无统计学差异;相较于对照组,观察组的并发症发病患者均明显下降(p<0.05);此外,患者入院时均有不同程度的焦虑情绪,经过一个月的治疗后患者的焦虑评分均明显下降,且在观察组中焦虑得分更显著低于对照组(p<0.05)。本实验在较大的临床样本中证实渐进性肌肉放松训练能明显降低患者的焦虑情绪并有助于降低患者并发症,能在治疗急性心肌梗死患者时提供较大帮助,为临床应用放松训练辅助治疗心肌梗死提供了较为可靠的实验证据,有重要的实用价值。     

小剂量重组组织纤溶酶原激活剂治疗急性心肌梗死临床研究概况

1990年代中期以来,国内130多家医院入组9378例急性心肌梗死患者,其中用小剂量（50mg）重组组织纤溶酶厚激活剂（rt-PA）治疗6693例,阻塞相关血管开通5318俐,开通率为79.46％;死亡293倒,病死率为4.38％;出血550俐,出血率勾8.22％,其中重度出血7例,颅内出血21例（0.31％）,再次梗塞60例（0.90％）。超过40家医院对rt-PA（50mg）与尿激酶治疗急性心肌梗死疗效进行了比较,共计入组3449倒急性心肌梗死患者,rt-PA治疗1689例,先静脉推注8mg,其余42mg在30或60和90min滴注;尿激酶治疗1760例,150万U位滴注30min。结果显示,阻塞相关冠脉血管开通率分别为79.40％（1341例）和5733％（1009例）,相差非常显著（P〈0.001）。12家医院研究了rt-PA50-9100mg治疗急性心肌梗死的效果,共计入组1054例患者,其中50mg组487例,100mg组567例,阻塞相关血管开通率分别为78.85％和82.36％。另有22家医院入组1017倒病人,行rt-PA50mg30rain给药临味试验,冠脉开通率达80.53％;18家医院行rt-PA50mg 60min给药临床试验,入组942例病人,阻塞相关血管开通率为77.92％;50家医院用rt-PA50mg 90min给药方案治疗急性心肌梗死患者,入组2768例患者,冠脉开通率为77.89％。6家医院对用rt-PA（50mg）与链激酶治疗急性心肌梗死的疗效进行了对比,结果表明相关血管开通率分别为81.4％和65.2％22家医院比较了小剂量rt-PA对急性心肌梗死患者症状发作不同时间的治疗效果,表明症状发作时间越短,用药的溶栓效果越好。刘光对入院前和入院后用小剂量rt-PA溶栓进行了比较研究,证明入院前溶栓比入院后效果好。对冠脉内输注rt-PA（50mg）和2次静脉推注小剂量rt-PA治疗急性心肌梗死的效果也进行了探索。     

Early identification of patients at low risk of death after myocardial infarction and potentially suitable for early hospital discharge.

OBJECTIVES--To find (a) whether data available shortly after admission for acute myocardial infarction can provide a reliable prognostic indicator of survival at 28 days, and (b) whether such an indicator might be used to identify patients at low risk of death and suitable for early discharge. DESIGN--Retrospective analysis of data collected on patients admitted to a coronary care unit for acute myocardial infarction. A validation sample was selected at random from these patients. SETTING--Coronary care units in Perth, Western Australia. SUBJECTS--6746 patients aged under 65 and resident in the Perth Statistical Division who during 1984-92 were admitted to a coronary care unit with symptoms of myocardial infarction. MAIN OUTCOME MEASURES--Sensitivity and specificity of several models for predicting survival at 28 days after myocardial infarction, and detailed performance characteristics of a particular model. RESULTS--Patients with a pulse rate of 100 beats/min or less, aged 60 or under, and with symptoms typical of myocardial infarction, no past history of myocardial infarction or diabetes, and no significant Q wave in the admission electrocardiogram had a very high chance of survival at 28 days (99.2%). These patients made up one third of all patients studied. CONCLUSION--The prognostic index identifies patients very soon after admission who are at low risk of death and potentially eligible for early discharge from hospital or the coronary care unit. Computing the index does not need complex cardiac investigations.     

Home care for patients with suspected myocardial infarction: use made by general practitioners of a hospital team for initial management.

Two hundred and sixty three general practitioners were offered the use of a hospital based service consisting of a medical senior house officer, a nurse attached to a coronary care unit, and a specially equipped ambulance estate car to help with the initial management of patients with suspected myocardial infarction who might be suitable for home care. One hundred and sixty nine general practitioners registered as potential users of this service; during 22 months they called the hospital team to see 271 patients, 235 of whom the team suspected had indeed suffered a myocardial infarction. During the same period, however, these general practitioners also admitted 317 patients with suspected myocardial infarction directly to hospital. Other general practitioners admitted 323 patients and deputising doctors 258. A further 529 patients with suspected infarction were admitted without the intervention of a general practitioner. Of the patients seen by the team, 54 required immediate admission to hospital; 17 of the remaining patients who initially appeared suitable for home care later required admission to hospital. In a large city such as Nottingham the provision of hospital based facilities to help general practitioners with home management is unlikely to make an appreciable impact on the overall pattern of care of patients with suspected myocardial infarction.     

Acute Myocardial Infarction in Doncaster. II—Delays in Admission and Survival

The speed of admission of patients with suspected acute myocardial infarction was observed over a period of 12 months during which a “no refusal” coronary care scheme was functioning, with emphasis on minimizing delay. During the same period the duration of survival of cases diagnosed as coronary thrombosis by the coroner''s pathologist was measured. Comparison of the two series shows that 75% to 80% of the coroner''s cases had died before the median time of notification of the general practitioner by those patients referred to hospital.We argue that the provision of mobile coronary care on request from general practitioners is unlikely to have an appreciable effect in preventing deaths from acute myocardial infarction outside hospital.     

Prospective evaluation of eligibility for thrombolytic therapy in acute myocardial infarction.

OBJECTIVES--To determine the proportion of patients presenting with acute myocardial infarction who are eligible for thrombolytic therapy. DESIGN--Cohort follow up study. SETTING--The four coronary care units in Auckland, New Zealand. SUBJECTS--All 3014 patients presenting to the units with suspected myocardial infarction in 1993. MAIN OUTCOME MEASURES--Eligibility for reperfusion with thrombolytic therapy (presentation within 12 hours of the onset of ischaemic chest pain with ST elevation > or = 2 mm in leads V1-V3, ST elevation > or = 1 mm in any other two contiguous leads, or new left bundle branch block); proportions of (a) patients eligible for reperfusion and (b) patients with contraindications to thrombolysis; death (including causes); definite myocardial infarction. RESULTS--948 patients had definite myocardial infarction, 124 probable myocardial infarction, and nine ST elevation but no infarction; 1274 patients had unstable angina and 659 chest pain of other causes. Of patients with definite or probable myocardial infarction, 576 (53.3%) were eligible for reperfusion, 39 had definite contraindications to thrombolysis (risk of bleeding). Hence 49.7% of patients (537/1081) were eligible for thrombolysis and 43.5% (470) received this treatment. Hospital mortality among patients eligible for reperfusion was 11.7% (55/470 cases) among those who received thrombolysis and 17.0% (18/106) among those who did not. CONCLUSIONS--On current criteria about half of patients admitted to coronary care units with definite or probable myocardial infarction are eligible for thrombolytic therapy. Few eligible patients have definite contraindications to thrombolytic therapy. Mortality for all community admissions for myocardial infarction remains high.     

Mortality from Acute Myocardial Infarction Before and After Establishment of a Coronary Care Unit

A retrospective study of the mortality rate of acute myocardial infarction in two groups of patients treated before and after a coronary care unit was established showed no difference between them. Though it is difficult to compare two series retrospectively so far there are no well controlled studies to demonstrate clearly the value of coronary care units.