低分子肝素联合丹参注射液治疗急性心肌梗死的临床研究

目的:观察低分子肝素联合丹参注射液治疗急性ST段抬高型心肌梗死的临床疗效及安全性。方法:按照随机原则将78例急性心肌梗死患者分成两组,在常规溶栓治疗的基础上,其中对照组39人采用低分子肝素治疗,治疗组患者在对照组治疗的基础上给予丹参注射液治疗,对两组临床费用、住院时间和冠脉再通进行评价。结果:治疗组的临床费用、住院时间和冠脉再通与对照组相比,有统计学差异(P0.05)。结论:低分子肝素联合丹参注射液治疗急性心肌梗死的临床疗效确切,值得临床推广。     

MYOCARDIAL INFARCTION FOLLOWING CAROTID ENDARTERECTOMY

Myocardial infarction has been the major cause of mortality following operation for cerebrovascular insufficiency. In our institution, a clinical diagnosis of coronary artery disease was made in 37 of 125 (29.6%) consecutive male patients having carotid endarterectomy. Six of these 37 patients developed postoperative myocardial infarction. In contrast, none of the 88 patients without coronary artery disease developed myocardial infarction. A more recently treated group of 20 patients who had undergone carotid artery surgery and had previously undergone coronary artery bypass for angina did not develop postoperative myocardial infarction. These data suggest that in patients with both coronary artery and carotid artery disease, prior or concomitant coronary artery bypass should be considered. Myocardial infarction has been the leading cause of early and late death following operation for cerebrovascular insufficiency.(1) DeBakey(2) found operative mortality in patients having surgery for cerebrovascular insufficiency directly related to the incidence of coronary artery disease. An increased operative mortality due to reinfarction has been found in patients recovering from recent myocardial infarction.(3) Cooley(4) found that in patients having aortocoronary bypass there was no increased operative mortality 30 days after myocardial infarction and this may apply to patients having carotid endarterectomy. Subendocardial postoperative infarction associated with minor T wave changes and slight enzyme elevation had a better prognosis than did transmural infarction causing significant Q waves, sequential ST and T wave changes and marked enzyme elevations.(5) The purpose of this study was to document our experience with myocardial infarction in patients undergoing carotid artery operation for clinical coronary artery disease. Consideration of the role of saphenous vein bypass in those patients with coronary artery disease was the background for this review even though the evidence that myocardial infarction can be prevented with saphenous vein bypass operation is only preliminary at the present time.(6)     

负荷量阿托伐他汀对稳定型冠心病患者非心脏手术围手术期保护作用的研究

目的:探讨负荷量阿托伐他汀对稳定型冠心病患者非心脏的择期外科手术围手术期主要不良心脏事件的保护作用。方法:将拟行非心脏外科手术的60名稳定型冠心病患者随机分为负荷量阿托伐他汀组(n=30)和对照组(n=30),其中负荷量阿托伐他汀治疗组在术前12小时给予阿托伐他汀80 mg顿服,术前2小时阿托伐他汀40 mg顿服,且每晚服用阿托伐他汀40 mg,对照组术前每晚服用阿托伐他汀20 mg,而后进行非心脏的外科手术(主要病种为慢性胆囊结石胆囊炎、慢性阑尾炎、消化性溃疡、疝气),术后负荷量组给予每晚服用阿托伐他汀40 mg,对照组每晚服用阿托伐他汀20 mg。比较两组围手术期主要不良心脏事件(包括心脏性猝死,急性心肌梗死,非计划性血运重建)的发生情况。结果:对照组出现1例急性前壁ST段抬高型心肌梗死并行急诊前降支介入再灌注治疗和7例无症状型心肌梗死,负荷量阿托伐他汀组出现1例无症状型心肌梗死,围手术期心肌梗死发生率较对照组明显降低(P0.05)。结论:负荷量阿托伐他汀可显著降低稳定型冠心病患者非心脏的择期外科手术围手术期主要不良心脏事件如心肌梗死,特别是无症状型心肌梗死的发生率,但该结果尚需大样本多中心随机对照临床试验进一步证实。     

Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus,Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group.

OBJECTIVES: To test the hypothesis that intensive metabolic treatment with insulin-glucose infusion followed by multidose insulin treatment in patients with diabetes mellitus and acute myocardial infarction improves the prognosis. DESIGN: Patients with diabetes mellitus and acute myocardial infarction were randomly allocated standard treatment plus insulin-glucose infusion for at least 24 hours followed by multidose insulin treatment or standard treatment (controls). SUBJECTS: 620 patients were recruited, of whom 306 received intensive insulin treatment and 314 served as controls. MAIN OUTCOME MEASURE: Long term all cause mortality. RESULTS: The mean (range) follow up was 3.4 (1.6-5.6) years. There were 102 (33%) deaths in the treatment group compared with 138 (44%) deaths in the control group (relative risk (95% confidence interval) 0.72 (0.55 to 0.92); P = 0.011). The effect was most pronounced among the predefined group that included 272 patients without previous insulin treatment and at a low cardiovascular risk (0.49 (0.30 to 0.80); P = 0.004). CONCLUSION: Insulin-glucose infusion followed by intensive subcutaneous insulin in diabetic patients with acute myocardial infarction improves long term survival, and the effect seen at one year continues for at least 3.5 years, with an absolute reduction in mortality of 11%. This means that one life was saved for nine treated patients. The effect was most apparent in patients who had not previously received insulin treatment and who were at a low cardiovascular risk.     

急诊PCI 治疗中应用血栓抽吸术及主动脉内球囊反搏术 与血浆脑钠肽水平、心功能参数的关系

目的:观察血栓抽吸术与主动脉内球囊反搏术(IABP)联用在急诊冠状动脉介入治疗(PCI)的疗效。方法:ST段抬高型急性心肌梗塞(AMI)行急诊冠状动脉造影提示大量血栓征象、并行血栓抽吸术患者98例,随机分为实验组和对照组,实验组术前行IABP后联合血栓抽吸;对照组仅进行血栓抽吸。观察两组患者的BNP及心功能参数。结果:术后24小时两组BNP有普遍升高趋势,对照组升高更明显(P<0.01),术后2周普遍回降,实验组下降更明显(P<0.01);2周后实验组的心脏指数(CI)、每搏指数(SI)、混合静脉血氧饱和度(SvO2)均高于对照组(P<0.01)。结论:对于行急诊冠状动脉介入治疗的患者联合使用主动脉内球囊反搏术和血栓抽吸术,可以明显改善患者的心肌缺血情况,增加冠脉灌注,有利于患者心功能的恢复。     

Emergency aorto-coronary venous bypass graft in cardiogenic shock

The mortality rate of shock complicating myocardial infarction is extremely high (80-100%) despite intensive medical management. Five patients with acute myocardial infarction and cardiogenic shock received an emergency aorto-coronary bypass graft, from three hours to five days after the onset of infarction and three to nine hours after the onset of shock. Selective coronary angiography was performed in all cases prior to operation. Four of the five patients survived and were discharged from hospital. Two cases with A-V dissociation and complete heart block reverted to normal sinus rhythm after the operation. This limited experience indicates that emergency aortocoronary bypass graft surgery can reduce mortality significantly in properly selected cases of cardiogenic shock.     

The role fo collateral circulation in the course of coronary heart disease: 10-year clinical and angiographic follow-up

The paper presents the results of a 10-year prospective follow-up of 59 patients with coronary heart disease (CHD) concurrent with functional classes II-IV angina pectoris. Coronarography was made in all the patients whose coronary arteries and collateral blood flow were assessed. The experimental group comprised 37 patients with CHD and collateral circulatory insufficiency. The control group included 22 patients with effective collateral circulation. The experimental group showed a worse prognosis than did the control one. Myocardial infarction developed in 54 and 27% of cases, coronary heart disease mortality was 29.7 and 9% in the experimental and control groups, respectively. Effective collateral circulation is a prerequisite of successful surgical myocardial infarction.     

Indications for admission to a coronary care unit in patients with unstable angina.

One hundred cases with an admission diagnosis of acute coronary insufficiency or unstable angina were reviewed to establish criteria for admission to a coronary care unit. Myocardial infarction was subsequently diagnosed in 20 of the patients. Ventricular tachycardia occurred in 16 patients and ventricular fibrillation in 1 patient. Clinical features found to predict an increased risk of myocardial infarction included chest pain for more than 30 minutes within 24 hours prior to admission, new nonspecific electrocardiographic abnormalities consistent with ischemia, and diaphoresis. All patients with ventricular tachydysrhythmias had presented with both prolonged chest pain prior to admission and new electrocardiographic changes. The sensitivity, specificity and predictive value of various clinical criteria for identifying patients likely to have a myocardial infarction were calculated, and criteria with very high (greater than 90%) sensitivity were identified. These could be used to establish which patients are at increased risk of myocardial infarction and therefore require admission to a coronary care unit.     

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.     

Trial of early nifedipine in acute myocardial infarction: the Trent study.

Over 30 months 9292 consecutive patients admitted to nine coronary care units with suspected myocardial infarction were considered for admission to a randomised double blind study comparing the effect on mortality of nifedipine 10 mg four times a day with that of placebo. Among the 4801 patients excluded from the study the overall one month fatality rate was 18.2% and the one month fatality rate in those with definite myocardial infarction 26.8%. A total of 4491 patients fulfilled the entry criteria and were randomly allocated to nifedipine or placebo immediately after assessment in the coronary care unit. Roughly 64% of patients in both treatment groups sustained an acute myocardial infarction. The overall one month fatality rates were 6.3% in the placebo treated group and 6.7% in the nifedipine treated group. Most of the deaths occurred in patients with an in hospital diagnosis of myocardial infarction, and their one month fatality rates were 9.3% for the placebo group and 10.2% for the nifedipine group. These differences were not statistically significant. Subgroup analysis also did not suggest any particular group of patients with suspected acute myocardial infarction who might benefit from early nifedipine treatment in the dose studied.     

重组组织型纤溶酶原激活剂静脉溶栓治疗发病4.5小时内急性脑梗死近期疗效的回顾性研究

目的:研究发病4.5小时内的急性脑梗死患者早期应用重组组织型纤溶酶原激活剂(rt-PA)静脉溶栓治疗的临床效果。方法:回顾性分析2018年07月1日到2020年10月31日我院神经内科收治的发病在4.5小时内的652例急性脑梗死患者的临床资料,其中使用rt-PA静脉溶栓治疗的患者285例为溶栓组,未溶栓仅使用抗血小板聚集、他汀类降脂、脑保护等常规治疗的患者367例为对照组。记录两组患者治疗前及治疗后24小时、7天、14天的美国国立卫生研究院卒中量表(NIHSS)评分和治疗3个月后的改良Rankin量表(mRS)评分。对于有吞咽障碍的患者,收集洼田饮水试验结果。统计两组患者出血情况和死亡率。结果:溶栓组治疗后24小时、7天、14天的NIHSS评分以及治疗后3个月的mRS评分改善明显,与对照组相比,差异有统计学意义(P<0.05);对于有吞咽障碍的患者,溶栓组的治疗有效率高于对照组(P<0.05);溶栓组轻微出血的概率大于对照组(P<0.05);两组在症状性及致死性脑出血方面的差异无统计学意义(P>0.05);溶栓后大量及致死性脑出血部位多在梗死的中心区、出血量多大于10 mL,患者临床NIHSS评分≥24分。溶栓组死亡率较对照组下降(P<0.05)。结论:发病4.5小时内的急性脑梗死患者接受rt-PA静脉溶栓治疗的近期治疗效果良好,轻微出血风险较高,但是死亡率下降。临床神经功能缺损重、NIHSS评分≥24分、出血风险大的患者预后不良,不推荐溶栓治疗。     

Treatment of acute myocardial infarction with anisoylated plasminogen streptokinase activator complex.

A controlled trial in 149 patients admitted to a district hospital with probable myocardial infarction tested the effect of 30 units of anisoylated plasminogen streptokinase activator complex (APSAC) on indices of infarct size. Patients were grouped prospectively according to whether they entered the trial within two and a half hours (early entry) or between two and a half and four hours (late entry) after onset of the symptoms. Sixty seven of 73 patients in the control group showed increased plasma activity of myocardial creatine kinase isoenzyme that was diagnostic of infarction compared with only 60 of 76 who received APSAC. The difference was significant overall but occurred predominantly in the early entry group. The patients who received APSAC had more early ventricular arrhythmias, compatible with reperfusion, and showed greater preservation of R waves during admission to hospital. Unwanted effects were generally minor and more common in the actively managed group than the control group (26% v 3%). After nine to 12 months of follow up 12 patients in the control group had died compared with seven in the actively managed group. The ease of administration and the apparent efficacy of APSAC suggest that it is suitable for use in a district hospital for patients with suspected acute myocardial infarction.     

HEPARIN IN ACUTE MYOCARDIAL INFARCTION—Observations Indicating the Potential Advantages of Using It as the Sole Anticoagulant in Therapy

There is a considerable body of experimental evidence that heparin is superior as an anticoagulant to any prothrombin depressing drugs. Furthermore its lipemia-clearing action affords other benefits which result from the removal of fat from the bloodstream. Important among these beneficial effects is the increased tissue and myocardial oxygen consumption which results from the injection of heparin in atherosclerotic patients.Because of these advantages of heparin over oral anticoagulants, the use of heparin as the sole anticoagulant for three weeks in patients with severe acute myocardial infarction was evaluated as opposed to the customary therapy where heparin is given for several days and then oral anticoagulants are used. The mortality in the dicoumarin treated group was 38 per cent, as compared with 28 per cent in the patients who received only heparin for three weeks.     

Influence of iloprost on eicosanoid generation and lipid levels in experimental myocardial ischemia in dogs

Anaesthetized mongrel dogs were subjected to occlusion of a coronary artery. The resulting myocardial infarction was observed for three hours. One hour after occlusion, infusion of the stable prostacyclin analogue iloprost or saline was started. In the control group myocardial infarction was associated with an increase of the ratio TXB2/6-keto-PGF1a which was abolished by iloprost treatment. After occlusion in the control group, the atherosclerosis index (TC-HDLC): HDLC was increased, but in the iloprost-treated group it was significantly decreased. The results of this study suggest that the administration of iloprost is able to prevent changes in eicosanoid metabolism and lipoprotein pattern after coronary artery occlusion in dogs.     

Risks of discontinuing anticoagulant therapy in a selected group of patients with atherosclerotic heart disease: a prospective study

In 134 patients with coronary artery disease, long-term oral anticoagulant therapy (mean duration, 56 months) for acute myocardial infarction (98 patients), acute coronary insufficiency (25 patients) or severe chronic angina (11 patients) was terminated abruptly in 50 patients (group 1) and gradually in 84 (group 2). The 134 patients represented a homogeneous population of patients with coronary artery disease since most patients older than 75 years and those with conditions known to increase the risks of thromboembolic complications were excluded. The two groups were comparable in terms of sex, age, presence of risk factors, duration of anticoagulant therapy, and presence of angina and abnormal resting electrocardiograms during therapy. Patients were evaluated 6 months after cessation of anticoagulant therapy and, since abrupt withdrawal of therapy did not carry a higher risk than gradual discontinuation, data for groups 1 and 2 were tabulated together.Of the 84 patients with angina at the end of therapy 15 experienced an increase in its severity and this symptom appeared in another patient (relapse rate, 18%). Angina progressed to fatal acute myocardial infarction in four (mortality, 3%) and nonfatal infarction in two; however, all six had extensive coronary artery disease and poor left ventricular function. The results of this study suggest that neither abrupt nor gradual cessation of anticoagulant therapy is associated with an inordinate exacerbation of heart disease.     

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。     

Prognostic significance of acute systolic hypertension after myocardial infarction.

The clinical behaviour and mean peak serum aspartate aminotransferase (SGOT) values of 106 patients admitted to a coronary care unit with acute myocardial infarction who displayed acute systolic hypertension were studied. Another 106 normotensive patients with acute myocardial infarction acted as controls. Neither group had established hypertension. The mortality rate, incidence of cardiac failure, major arrhythmias, and mean peak SGOT were significantly greater in the hypertensive group, within which the duration of hypertension was correlated with mean peak SGOT levels--through there was no definite relation between the height of systolic or diastolic pressure and SGOT. Transient systolic hypertension after acute myocardial infarction was therefore associated with a relatively poor prognosis, but our observations suggest that patients with a systolic blood pressure of at least 170 mm Hg might benefit from early hypotensive treatment.     

Late ventricular potentials--a new risk factor for cardiac arrhythmias in recent myocardial infarction

The study involved 150 patients with recent myocardial infarction. Ventricular lat potentials were registered in these patients during the first 48 hours and repeated in the third week. Ventricular late potentials were found in 31 patients (21%) in the first 48 hours, and in 27 out of 134 patients (20%) before the release from the hospital. Comparing potentials registration in the acute and late phase of the myocardial infarction it was found that ventricular late potentials occurred in 6 and disappeared in 4 patients. Stable ventricular tachycardia was significantly more frequent (p less than 0.001) within the first 48 hours in patients with ventricular late potentials than those without them (19% vs 3%). Ventricular late tachycardia (over 48 hours) was more frequent (p less than less than 0.001) in patients with ventricular late potentials (21% vs 1%). Premature ventricular excitations of Lown class 2-5 were also more frequent (p less than 0.001) in the group of patients with ventricular late potentials than those without these potential (81% vs 24%) when registered with a 24-hour Holter ECG in the third week following myocardial infarction. Antiarrhythmic drugs did not produce the regression of ventricular late potentials. Non-invasive registration of ventricular late potentials helps to select patients with life-threatening ventricular arrhythmias following the acute myocardial infarction.     

Intravenous tissue plasminogen activator and size of infarct,left ventricular function,and survival in acute myocardial infarction.

STUDY OBJECTIVE--To assess effect of intravenous recombinant tissue type plasminogen activator on size of infarct, left ventricular function, and survival in acute myocardial infarction. DESIGN--Double blind, randomised, placebo controlled prospective trial of patients with acute myocardial infarction within five hours after onset of symptoms. SETTING--Twenty six referral centres participating in European cooperative study for recombinant tissue type plasminogen activator. PATIENTS--Treatment group of 355 patients with acute myocardial infarction allocated to receive intravenous recombinant plasminogen activator. Controls comprised 366 similar patients allocated to receive placebo. INTERVENTION--All patients were given aspirin 250 mg and bolus injection of 5000 IU heparin immediately before start of trial. Patients in treatment group were given 100 mg recombinant tissue plasminogen activator over three hours (10 mg intravenous bolus, 50 mg during one hour, and 40 mg during next two hours) by infusion. Controls were given placebo by same method. Full anticoagulation treatment and aspirin were given to both groups until angiography (10-22 days after admission). beta Blockers were given at discharge. END POINT--Left ventricular function at 10-22 days, enzymatic infarct size, clinical course, and survival to three month follow up. MEASUREMENTS AND MAIN RESULTS--Mortality was reduced by 51% (95% confidence interval -76 to 1) in treated patients at 14 days after start of treatment and by 36% (-63 to 13) at three months. For treatment within three hours after myocardial infarction mortality was reduced by 82% (-95 to -31) at 14 days and by 59% (-83 to -2) at three months. During 14 days in hospital incidence of cardiac complications was lower in treated patients than controls (cardiogenic shock, 2.5% v 6.0%; ventricular fibrillation, 3.4% v 6.3%; and pericarditis, 6.2% v 11.0% respectively), but that of angioplasty or artery bypass, or both was higher (15.8% v 9.6%) during the first three months. Bleeding complications were commoner in treated than untreated patients. Most were minor, but 1.4% of treated patients had intracranial haemorrhage within three days after start of infusion. Enzymatic size of infarct, determined by alpha hydroxybutyrate dehydrogenase concentrations, was less (20%, 2p = 0.0018) in treated patients than in controls. Left ventricular ejection fraction was 2.2% higher (0.3 to 4.0) and end diastolic and end systolic volumes smaller by 6.0 ml (-0.2 to -11.9) and 5.8 ml (-0.9 to -10.6), respectively, in treated patients. CONCLUSION--Recombinant tissue type plasminogen activator with heparin and aspirin reduces size of infarct, preserves left ventricular function, and reduces complications and death from cardiac causes but at increased risk of bleeding complications4+     

Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction: results of one year follow up.

OBJECTIVE--To test whether a fat reduced diet rich in soluble dietary fibre, antioxidant vitamins, and minerals reduces complications and mortality after acute myocardial infarction. DESIGN--Randomised, single blind, controlled trial. SETTING--Primary and secondary care research centre for patients with myocardial infarction. SUBJECTS--505 patients with suspected acute myocardial infarction. Those with definite or possible acute myocardial infarction and unstable angina based on World Health Organisation criteria were assigned to diet A (n = 204) or diet B (n = 202) within 24-48 hours of infarction. INTERVENTIONS--Both groups were advised to follow a fat reduced diet. Group A was also advised to eat more fruit, vegetables, nuts, and grain products. MAIN OUTCOME MEASURES--Mortality from cardiac disease and other causes. Serum lipid concentrations and compliance with diet. RESULTS--Blood lipoprotein concentrations and body weight fell significantly in patients in group A compared with those in group B (cholesterol fell by 0.74 mmol/l in group A v 0.32 mmol/l in group B, 95% confidence interval of difference 0.14 to 0.70, and weight by 7.1 v 3.0 kg, 0.52 to 7.68). The incidence of cardiac events was significantly lower in group A than group B (50 v 82 patients, p less than 0.001). Group A also had lower total mortality (21 v 38 died, p less than 0.01) than group B. CONCLUSIONS--Comprehensive dietary changes in conjunction with weight loss immediately after acute myocardial infarction may modulate blood lipoproteins and significantly reduce complications and mortality after one year.