Sex related differences in short and long-term prognosis after acute myocardial infarction: 10 year follow up of 3073 patients in database of first Danish Verapamil Infarction Trial.

OBJECTIVE--To re-examine the prevailing hypothesis that women fare worse than men after acute myocardial infarction. DESIGN--10 year follow up of all patients with confirmed acute myocardial infarction registered in the database of the Danish verapamil infarction trial in 1979-81. SETTING--16 coronary care units, covering a fifth of the total Danish population. PATIENTS--3073 consecutive patients with acute myocardial infarction, 738 (24%) women and 2335 (76%) men. MAIN OUTCOME MEASURES--Early mortality (before day 15). For patients alive on day 15: mortality, cause of death, admission with recurrent infarction, and mortality after reinfarction. RESULTS--Early mortality increased significantly with age (P < 0.0001) but was not significantly related to sex, with a 15 day mortality of 17% in women and 16% in men. Adjustment for age and sex simultaneously revealed a significant interaction (P = 0.02) between these variables, with a greater increase with age in early mortality for men than for women (early mortality was equal for the two sexes at age 64 years). Ten year mortality in patients alive on day 15 was 58.8%. The overall age adjusted hazard ratio (95% confidence interval) for women versus men was 0.90 (0.80 to 1.01); 0.90 (0.78 to 1.04) for 10 year reinfarction (48.8%); and 0.98 (0.82 to 1.16) for 10 year mortality after reinfarction (82.3%). No difference in cause of death was found between the sexes. With a follow up of up to 10 years for patients alive on day 15 mortality, rate of reinfarction, and mortality after reinfarction increased with increasing age (P < 0.0001). CONCLUSION--Sex by itself is not a risk factor after acute myocardial infarction.     

ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase,oral aspirin,both, or neither

Objective: To assess effects of intravenous streptokinase, one month of oral aspirin, or both, on long term survival after suspected acute myocardial infarction. Design: Randomised, “2×2 factorial,” placebo controlled trial. Setting: 417 hospitals in 16 countries. Subjects: 17 187 patients with suspected acute myocardial infarction randomised between March 1985 and December 1987. Follow up of vital status complete to at least 1 January 1990 for 95% of all patients and to mid-1997 for the 6213 patients in United Kingdom. Interventions: Intravenous streptokinase (1.5 MU in 1 hour) and oral aspirin (162 mg daily for 1 month) versus matching placebos. Main outcome measures: Mortality from all causes during up to 10 years’ follow up, with subgroup analyses based on 4 year follow up. Results: After randomisation, 1841 deaths were recorded in days 0-35, 991 from day 36 to end of year 1, 1478 in years 2-4, and 1230 in years 5-10. Allocation to streptokinase was associated with 29 (95% confidence interval 20 to 38) fewer deaths per 1000 patients during days 0-35. This early benefit persisted (death rate ratio 0.98 (0.92 to 1.04) for additional deaths between day 36 and end of year 10), so that there were 28 (14 to 42) and 23 (2 to 44) fewer deaths per 1000 patients treated with streptokinase after 4 years and 10 years respectively. There was no evidence that absolute survival benefit increased with prolonged follow up among any category of patient, including those presenting early after symptoms started or with anterior ST elevation. Nor did the early benefits seem to be lost in any category (including those aged over 70). Allocation to one month of aspirin was associated with 26 (16 to 35) fewer deaths per 1000 during first 35 days, with little further benefit or loss during subsequent years (death rate ratio 0.99 (0.93 to 1.06) between day 36 and end of year 10). The early benefit obtained with combination of streptokinase and one month of aspirin also seemed to persist long term. Conclusions: The early survival advantages produced by fibrinolytic therapy and one month of aspirin started in acute myocardial infarction seem to be maintained for at least 10 years.

Key messages

• Large randomised trials have shown that the survival benefits of intravenous fibrinolytic therapy for patients with acute myocardial infarction persist for at least one year, but there is relatively little information about longer term effects
• By contrast, this report from the ISIS-2 trial of intravenous streptokinase and of one month of oral aspirin includes nearly 4000 deaths between the start of year 2 and the end of year 10
• The early survival benefits of fibrinolytic therapy persist for at least 10 years after treatment and do not seem to increase or decrease with prolonged follow up in any category of patients, including elderly subjects
• The survival benefits of short term aspirin treatment in acute myocardial infarction also persist long term and are additional to those of fibrinolytic therapy, and other studies show that these benefits can be increased by continuing aspirin treatment for some years after myocardial infarction

     

Late outcome of patients with myocardial infarction complicated by mural thrombi in the left heart ventricle]

The study was aimed at the evaluating of the remote clinical course and death rate in patients with myocardial infarction, in whom mural thrombi in the left cardiac ventricle were diagnosed during hospitalization. During a 24-month follow up, 23 (20%) out of 116 patients died, including 10 (43.5%) patients with myocardial infarction complicated with mural thrombi during hospitalization. There were 39% of sudden deaths. Ninety three (80%) patients, including 27 (29%) patients of the group with myocardial infarction complicated with mural thrombi in left ventricle during hospitalization, were reported for the ambulatory examination. Features of the postinfarction heart failure, cardiac arrhythmias, the second myocardial infarction or exacerbations of the coronary disease which required hospitalization were significantly more frequent in this group.     

Prognosis after myocardial infarction: results of 15 year follow up.

A total of 271 out of 757 patients who had suffered a myocardial infarction during 1966-7 were still alive after six years; these patients were subsequently followed up 15 years after the infarction. Two hundred and sixty eight (99%) of the patients alive at six years and 519 (95%) of the 549 originally discharged from hospital were traced. A coronary prognostic index, which had predicted survival both to three years and from three to six years after recovery from the infarct also predicted survival from six to 15 years after recovery. The major factor affecting survival to 15 years was age at the time of the original infarct. Among patients aged under 60 at the time of infarction women fared better than men (p = 0.027). Factors in the coronary prognostic index that were associated with impairment of left ventricular function at the time of infarction and that had predicted mortality to three years and from three to six years also predicted mortality from six to 15 years. These factors were cardiac enlargement, pulmonary venous congestion, and the presence of infarction before the index infarct. The dominant cause of death remained coronary heart disease and its complications.     

Course of angina pectoris after an acute coronary event.

The course of postcoronary angina pectoris was examined in 555 men who had survived a first attack of myocardial infarction or unstable angina. Patients were aged less than 60 and were followed up yearly for up to 17 years. Only 25 (4.5%) had coronary artery bypass surgery. Most patients with angina were treated by nitrates alone. One year after infarction 24.1% of survivors (124/515) reported the presence of angina pectoris, and the proportions at five, 10, and 15 years were 29.9%, 30.4%, and 43.5% respectively. Seventeen years after the initial event 35.3% of the survivors had never reported postcoronary anginal symptoms. The patients who experienced anginal symptoms in the year after their coronary attack had a poorer long term survival than the group who were symptom free over the first year. These patients also had longer subsequent periods with angina, though in 41.7% angina resolved before death after a median of 2.9 years. Throughout follow up mortality during periods in which patients experienced angina was higher than in the symptom free periods. This long term follow up study of patients after a coronary event confirms that the presence or absence of angina may vary considerably over time in patients treated medically and that the presence of angina is associated with a poorer prognosis. These findings have important implications when assessing the effects of various treatment modalities on postcoronary angina, including coronary artery bypass surgery.     

Randomised trial of treatment of hypertension in elderly patients in primary care.

A randomised trial of the treatment of hypertension in 884 patients aged 60 to 79 years at the onset showed a reduction of 18/11 mm Hg in blood pressure over a mean follow up period of 4.4 years. The principal antihypertensive agents were atenolol and bendrofluazide. There was a reduction in the rate of fatal stroke in the treatment group to 30% of that in the control group (95% confidence interval 11-84%, p less than 0.025). The rate of all strokes (fatal and non-fatal) in the treatment group was 58% of that in the control group (95% confidence interval 35-96%, p less than 0.03). The incidence of myocardial infarction and total mortality was unaffected by treatment. Questionnaires completed by the patients and their relatives failed to identify any differences in symptoms that were likely to be due to treatment.     

Shock Following Myocardial Infarction: A Clinical Survey of 140 Cases

All admissions for acute myocardial infarction to a metropolitan general hospital over a 10-year period have been reviewed. One hundred and forty patients developed complications meeting the criteria for cardiogenic shock. The mortality rate in this group of patients was 83%. The mortality rate in 95 patients who received treatment with intravenous noradrenaline was no different from that in 45 patients who did not receive this type of therapy (p = >0.8). Patients dying from cardiogenic shock were younger than those dying of other complications. Autopsy study of this group of shocked patients revealed a significantly lower incidence of previous healed myocardial infarction (p = <0.01).A decline in the annual incidence of cardiogenic shock was noted over the decade surveyed. It is suggested that this may be due to the earlier and more frequent use of intravenous noradrenaline. Despite the reduction in the incidence of shock, the annual mortality rate from myocardial infarction has remained unaltered.     

Influence of preoperative variables upon the results of coronary artery bypass surgery

One thousand ninety-six consecutive patients who received aorta-to-coronary artery bypass vein grafts were followed up to 4 years postoperatively. The early mortality was 1.7%; the 4-year survival rate, computed by actuarial methods, was 93.1%; the incidence of peri-operative myocardial infarction was 1.9%. After 4 years, 94.4% of the patients were free of peri- and postoperative infarcts. Angina pectoris was relieved in 85.7% and eliminated in 62.8% of the survivors. An analysis of the effects of ten preoperative variables on operative results showed that operative risk (early mortality, perioperative myocardial infarction) was not influenced by any of the variables. Late results (4-year mortality, 4-year infarction rate), however, were negatively affected by impaired ventricular function. Symptomatic improvement was more pronounced in men than in women.     

Body weight and risk of myocardial infarction and death in the adult population of eastern Finland.

Body mass index (weight (kg) divided by height squared (m2] and its association with the risk of myocardial infarction and death from all causes were studied prospectively in a randomly selected population sample in eastern Finland aged 30-59 at outset in 1972. The study population consisted of 3786 men and 4120 women. The participation rate in the survey in 1972 was over 90%. All deaths and admissions to hospital in the sample were obtained from the National Death Certificate and Hospital Discharge Registers. During the seven years of follow up until 1978, 170 men and 52 women had acute myocardial infarction, and during the nine years up to 1980, 223 men and 92 women died. Independent of age, men with a body mass index of 28.5 or more had a significantly higher incidence of acute myocardial infarction. This effect was also independent of smoking but not independent of biological coronary risk factors--that is, serum cholesterol concentration and blood pressure. In the analysis stratified for smoking in men the body mass index total mortality curve was J shaped among non-smokers, whereas smoking entirely outweighed body mass index as a predictor of death. Body mass index did not contribute significantly to the risk of either acute myocardial infarction or death in women. It is concluded that a body mass index of around 29.0-31.0 or more is not only a marker for coronary risk factors but is also a predictor of acute myocardial infarction in men.     

Inpatient deaths from acute myocardial infarction, 1982-92: analysis of data in the Nottingham heart attack register.

OBJECTIVE: To assess longitudinal trends in admissions, management, and inpatient mortality from acute myocardial infarction over 10 years. DESIGN: Retrospective analysis based on the Nottingham heart attack register. SETTING: Two district general hospitals serving a defined urban and rural population. SUBJECTS: All patients admitted with a confirmed acute myocardial infarction during 1982-4 and 1989-92 (excluding 1991, when data were not collected). MAIN OUTCOME MEASURES: Numbers of patients, background characteristics, time from onset of symptoms to admission, ward of admission, treatment, and inpatient mortality. RESULTS: Admissions with acute myocardial infarction increased from 719 cases in 1982 to 960 in 1992. The mean age increased from 62.1 years to 66.6 years (P < 0.001), the duration of stay fell from 8.7 days to 7.2 days (P < 0.001), and the proportion of patients aged 75 years and over admitted to a coronary care unit increased significantly from 29.1% to 61.2%. A higher proportion of patients were admitted to hospital within 6 hours of onset of their symptoms in 1989-92 than in 1982-4, but 15% were still admitted after the time window for thrombolysis. Use of beta blockers increased threefold between 1982 and 1992, aspirin was used in over 70% of patients after 1989, and thrombolytic use increased 1.3-fold between 1989 and 1992. Age and sex adjusted odds ratios for inpatient mortality remained unchanged over the study period. CONCLUSIONS: Despite an increasing uptake of the "proved" treatments, inpatient mortality from myocardial infarction did not change between 1982 and 1992.     

Specific and gender differences between hospitalized and out of hospital mortality due to myocardial infarction

In this paper, the authors evaluate gender related differences of myocardial infarction mortality before and after hospital admittance. Myocardial infarction mortality in the Clinical Hospital Split in the seven years period between 2000 and 2006, have been analyzed together with out of hospital sudden death patients with acute myocardial infarction established during autopsy. During the seven year period between 2000 and 2006, 3434 patients were treated for myocardial infarction in the Split Clinical Hospital, 2336 (68%) males and 1098 (32%) females with a 12% total mortality (427 patients). The annual number of hospitalized persons has been increasing during that period (474 in yr. 2000 us. 547 in yr. 2006), while mortality decreased from 15% in 2000 to 9.6% in 2006. Female patients had significantly higher hospital mortality than male patients, (228 or 21% vs. 202 or 9%, p<0.05). Women also had significantly higher total AMI mortality (23.7% vs. 15,7%, p <0.05). Anterior myocardial infarction with ST elevation in precordial leads had significantly higher mortality (19%) compared to patients with lateral (11%), inferior (10%) myocardial infarction with ST elevation and also NSTEMI (4%) mortality p<0.05. Female patients more frequently die in hospital, 84% (230) than out of hospital 16% (43). From the total number of AMI deaths (388) in male patients, 56% (217) were in hospital and 44% (171) out of hospital (p<0.001). Men had significantly higher prehospital mortality rate than women (81% vs. 19%, p<0.05). Men also more frequently died from ventricular fibrillation (22% vs. 10%, p<0.05), while women died more frequently of heart failure, cardiogenic shock, and myocardial rupture (33% vs. 15% p<0.05). Regarding the total number of deaths from myocardial infarction men had significantly higher prehospital mortality compared to women (178 or 7.3% vs. 43 or 3.7%, p<0.05). Anterior myocardial infarction had a significantly higher rate in patients dying pre-hospital (58%), in contrast to inferior (36%) and lateral myocardial infarction with ST elevation (6%) p<0.05. We have concluded that male patients die more frequently within the first few hours of AMI mostly due to malignant arrhythmias, while female patients died in sub acute stage due to heart failure while being hospitalized. Nevertheless total mortality of AMI remains significantly higher in women.     

Sudden death and its predictors in myocardial infarction survivors in an Indian population

ObjectiveThis study was conducted to assess the incidence of sudden cardiac death (SCD) in post myocardial infarction patients and to determine the predictive value of various risk markers in identifying cardiac mortality and SCD.MethodsLeft ventricular function, arrhythmias on Holter and microvolt T wave alternans (MTWA) were assessed in patients with prior myocardial infarction and ejection fraction ≤ 40%. The primary outcome was a composite of cardiac death and resuscitated cardiac arrest during follow up. Secondary outcomes included total mortality and SCD.ResultsFifty-eight patients were included in the study. Eight patients (15.5%) died during a mean follow-up of 22.3 ± 6.6 months. Seven of them (12.1%) had SCD. Among the various risk markers studied, left ventricular ejection fraction (LVEF) ≤ 30% (Hazard ratio 5.6, 95% CI 1.39 to 23) and non-sustained ventricular tachycardia (NSVT) in holter (5.7, 95% CI 1.14 to 29) were significantly associated with the primary outcome in multivariate analysis. Other measures, including QRS width, heart rate variability, heart rate turbulence and MTWA showed no association.ConclusionsAmong patients with prior myocardial infarction and reduced left ventricular function, the rate of cardiac death was substantial, with most of these being sudden cardiac death. Both LVEF ≤30% and NSVT were associated with cardiac death whereas only LVEF predicted SCD. Other parameters did not appear useful for prediction of events in these patients. These findings have implications for decision making for the use of implantable cardioverter defibrillators for primary prevention in these patients.     

Delayed results after implantation of bifurcated prosthesis in aorto-iliac incompetence]

Early results and those seen after a 5-year follow up are discussed. Three hundred fifty one patients with aortoiliac incompetence were treated with the implantation of bifurcated aortoiliac prosthesis. Very favourable early result was achieved in 284 (81%) patients. Very favourable delayed effect was noted in 133 patients, i.e. in 75% of patients who reported for the control examination. In the follow up period, amputation of the limb was performed in 30 (8.5%) patients because of progressing ischemia. Hundred thirty seven (39%) followed up patients died during 5 years. Causes of so high mortality rate are discussed in view of risk factors and postoperative complications.     

Ten year mortality in patients with suspected acute myocardial infarction.

OBJECTIVE--To describe the 10 year mortality in patients with suspected acute myocardial infarction. DESIGN--Follow up of all patients below 76 years of age admitted with acute chest pain to 16 coronary care units participating in the Danish verapamil infarction trial in 1979-81. SUBJECTS--Of the 5993 patients included, 2586 had definite infarction, 402 had probable infarction, and 3005 did not have infarction. MAIN OUTCOME MEASURES--Death and cause of death. Standardised mortality ratio (observed mortality/expected mortality in background population). RESULTS--The estimated 10 year mortalities were 58.8%, 55.5%, and 42.8% in patients with definite, probable, and no infarction, respectively (P < 0.0001). Stratified Cox''s analysis identified a hazard ratio for mortality of 1.25 (95% confidence interval 1.08 to 1.44) for probable infarction compared with no infarction and of 1.15 (1.00 to 1.32) for definite compared with probable infarction. The standardised mortality ratio in the first year was 7.1 (6.5 to 7.8) for definite infarction, 5.0 (3.6 to 6.3) for probable infarction, and 4.7 (4.2 to 5.2) for no infarction. From the second year and onwards the annual standardised mortality ratio in the three groups did not differ significantly. Cardiac causes of deaths were recorded in 89%, 84%, and 71% of the deaths in patients with definite, probable, and no infarction, respectively. CONCLUSIONS--The 10 year mortality of patients with and without infarction is significantly higher than in the background population. Most deaths are caused by coronary heart disease, and these patients should consequently be further evaluated at the time of discharge and followed up closely.     

Improved prognosis since 1969 of myocardial infarction treated in a coronary care unit: lack of relation with changes in severity.

OBJECTIVE--To study changes from 1969 to 1983 in the prognosis of patients with acute myocardial infarction treated in a coronary care unit. DESIGN--Mortality follow up of all patients with definite acute myocardial infarction. SETTING--The coronary care unit of the Royal Melbourne Hospital, a tertiary referral centre. SUBJECTS--4253 Patients (3366 men, 887 women) admitted from 1969 to 1983. MAIN OUTCOME MEASURE--Mortality recorded at discharge from hospital and 12 months after admission. RESULTS--Details of clinical findings, history, electrocardiograms, arrhythmias, and radiological findings were recorded on admission. Mean ages were 63 for women and 57 for men, and women had haemodynamically more severe infarcts than men. In the later years patients were older and had less severe infarcts. Overall, hospital mortality in men was 16.7% in 1969-73 and 8.5% in 1979-83 and declined in all grades of the Norris and Killip infarct severity indices compared with a constant 19.2% in women. Even after adjustment for age and severity by logistic regression, hospital mortality fell in men by an average of 8% (95% confidence interval 4% to 11%) a year but remained constant in women. By 1983 male mortality was 60% that of women of similar age and comparable severity of infarction. Mortality of hospital survivors at 12 months declined by 7% (4% to 9%) a year in both sexes, even after adjustment for age and severity, with a male to female mortality ratio of about 0.8. New indices were derived to predict mortality in hospital and at 12 months. CONCLUSION--The observed declines in mortality cannot be explained by changes in severity of infarction or in prognostic characteristics of patients.     

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.     

Predictive value of microalbuminuria in patients with insulin-dependent diabetes of long duration.

OBJECTIVE--To investigate the predictive value of microalbuminuria (albumin excretion rate 30-300 mg/24 h) as a risk factor for overt diabetic nephropathy in patients with longstanding insulin dependent diabetes. DESIGN--10 year follow up of patients with normoalbuminuria (albumin excretion rate < 30 mg/24 h), microalbuminuria (30-300 mg/24 h), and macroalbuminuria (> 300 mg/24 h) based on two out of three timed overnight urine samples. SETTING--Outpatient clinic of Helsinki University Hospital. SUBJECTS--72 consecutive patients who had had insulin dependent diabetes for over 15 years. MAIN OUTCOME MEASURES--Urinary albumin excretion rate, mortality, and prevalence of diabetic complications after 10 years. RESULTS--56 patients were re-examined at 10 year follow up, 10 had died, five were lost to follow up, and one was excluded because of non-diabetic kidney disease. At initial screening 22 patients had macroalbuminuria, 18 had microalbuminuria, and 26 had normal albumin excretion. Only five (28%, 95% confidence interval 10% to 54%) of the microalbuminuric patients developed macroalbuminuria during the 10 year follow up and none developed end stage renal failure. Two (8%, 1% to 25%) normoalbuminuric patients developed macroalbuminuria and four (15%, 4% to 35%) became microalbuminuric. Seven (32%, 14% to 55%) of the macroalbuminuric patients developed end stage renal failure and six (27%, 11% to 50%) died of cardiovascular complications. CONCLUSION--Microalbuminuria is not a good predictor of progression to overt nephropathy in patients with longstanding insulin dependent diabetes.     

Does stopping smoking delay onset of angina after infarction?

This study was designed to determine the relation between stopping smoking and angina after infarction in survivors of an acute coronary attack. The study population comprised 408 men aged under 60 who survived a first attack of unstable angina or myocardial infarction by 28 days and were smoking cigarettes at the time of their attack. These patients were followed up for an average of nine years. Three hundred and eighty four were alive at the one year follow up examination, when the presence or absence of angina together with habits of smoking were recorded. The prevalence of angina at one year was 19.5% in the 241 who had stopped smoking cigarettes compared with 32.2% in those who had continued (p less than 0.01). Six years later, however, the prevalence of angina after infarction was the same in the two groups. It is concluded that the onset of angina after infarction can be delayed by stopping smoking cigarettes but that this effect is not maintained in the long term.     

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+     

A Survey of Cardiac Infarctions: Hospital Experience

A study of patients with cardiac infarction, treated in hospital between 1950 and 1954 and followed up to the present, is reported. One hundred and forty-two patients suffered 169 attacks. In 95 attacks, the patients received anticoagulant therapy, with 15 acute deaths. Fifty-six were not so treated; among these there were 21 deaths. The rate of survival was best in younger patients with their first episode of infarction, without preexisting hypertension, cardiac failure, or systolic blood pressure persistently below 100. Angina preceding infarction disappeared in one-half of the subjects after the episode; half the survivors suffered recurrent myocardial infarction within five years. Moderate hypertension had no effect upon immediate or 10-year survival. No patient received long-term anticoagulant therapy. Of the survivors of acute infarction, 16 died in the first year after the acute attack, nine in the second year, nine in the third, six in the fourth and five in the fifth. At the end of five years, 51 subjects had survived 60 episodes. At the end of 10 years, 43 living patients had sustained 45 myocardial infarctions.