Reciprocal change in ST segment in acute myocardial infarction: correlation with findings on exercise electrocardiography and coronary angiography.

The clinical relevance of reciprocal changes in the ST segment occurring at the time of acute myocardial infarction was studied prospectively in 85 consecutive uncomplicated cases. Reciprocal depression of the ST segment was defined as depression of 1 mm or more in electrocardiogram leads other than those reflecting the infarct. All patients underwent maximal, symptom limited treadmill stress testing two weeks after the infarct and coronary angiography six weeks after infarction. Forty six patients had inferior, 34 anterior, and five true posterior infarction. Of the 51 patients with reciprocal changes, 45 (88%) developed exercise induced ST segment depression in areas remote from the infarction zone. At angiography all 45 patients were shown to have stenoses greater than 70% in at least two major vessels. Four patients had negative exercise electrocardiograms and were sequently shown to have single vessel disease subtending their infarct, and the remaining two patients had a false negative treadmill test result. Of the 27 patients without reciprocal changes, 21 (78%) had negative treadmill stress test results associated with single vessel coronary disease. Five had positive stress test results and multivessel coronary disease, and one had a false negative stress test result. The remaining seven patients had ST segment elevation without Q wave formation in the reciprocal areas and were assessed separately. Of these, six had positive stress test results and multivessel coronary disease and one had a negative stress test result and single vessel coronary disease to the infarct area. Twenty one patients with anterior infarcts (62%) and 27 with inferior infarcts (59%) had reciprocal changes. No differences emerged in the relation between infarct site, reciprocal change, and presence of additional coronary disease. At follow up of the 51 patients with reciprocal changes in the ST segment 36 had become symptomatic, of whom 29 had undergone coronary artery bypass surgery. By contrast, only four of the 27 patients without reciprocal changes in the ST segment had developed symptoms, and two of these had undergone coronary revascularisation. Reciprocal ST segment depression at the time of acute myocardial infarction may identify patients with severe coronary disease who are at risk of subsequent cardiac events and appears to be as reliable as results of early postinfarction treadmill stress testing in predicting the underlying coronary anatomy. When the electrocardiogram does not show reciprocal changes treadmill testing provides valuable additional information.     

Assessment of radical activity during the acute phase of myocardial infarction following fibrinolysis: Utility of assaying plasma malondialdehyde

Numerous experimental and clinical studies have reported a role of radical forms of oxygen in the etiology of the manifestations of reperfusion of the ischemic myocardium. However, clinical results remain controversial. The aim of this study was to ascertain the existence of reperfusion-related radical stress after thrombolysis with a marker that is easy to use and reliable. Thirty patients hospitalized for acute myocardial infarction were involved in the study. Of these, 18 had been subjected to intravenous thrombolysis (Group I) and 12 had not (Group II). They were compared to two control groups who had no history of myocardial infarction. Of these, 16 were patients with coronary heart disease hospitalized for stable angina (Group III) and 17 were patients free of any known cardiovascular disease (Group IV). Radical activity was assessed in plasma samples taken from a peripheral vein over a 10-day period of hospitalization by measuring (1) malondialdehydes (MDA) concentration using fluorometry techniques or HPLC, (2) the antioxidant activity of glutathione peroxidase (GPx), and (3) the concentration of various antiradical compounds (β-carotene, vitamins A and E, uric acid). All patients in Group I had a patent artery on coronary angiography and showed a significant increase in plasma MDA when compared to those who had not been subjected to thrombolysis (3.15 ± 0.62 and 2.70 ± 0.40 mole/l of plasma, respectively). Furthermore, GPx plasma activity was also significantly increased following thrombolysis. By contrast, there was no significant alteration in the antiradical compounds measured. These data suggest that MDA measurements (an early measurement 1–2 days and a late measurement 5–7 days after reperfusion) by fluorometry is a good marker of radical stress during reperfusion in man. The assessment of this marker in patients might represent a simple and reliable test of reperfusion efficacy following thrombolysis, and it might enable one to test the effect of various antioxidant therapies associated with thrombolytic treatment.     

Changes in severity of myocardial infarction and three year survival rates after myocardial infarction in Auckland, 1966-7 and 1981-2.

Mortality from coronary heart disease has been declining steadily over the past 20 years in Auckland. The possibility that improved survival contributed to this decline was examined in patients who survived four weeks after myocardial infarction, changes in the severity of the disease being controlled for. Patients who had had myocardial infarction in 1966-7 (191 patients) or 1981-2 (203) were compared to determine whether three year survival rates had changed and the severity of the disease altered. With a coronary prognostic index taken as the measure of severity the 1981-2 group had significantly more severe myocardial infarctions than the 1966-7 group, but despite this the three year survival was significantly better (86% in the 1981-2 group v 75% in the 1966-7 group). These findings suggest that improved survival after myocardial infarction contributed to the decline in mortality.     

Acute Myocardial Infarction Attributable to Adrenergic Crises in a Patient with Pheochromocytoma and Neurofibromatosis 1

ObjectiveTo describe a rare case of acute myocardial infarction in a patient with neurofibromatosis 1 and pheochromocytoma and to review the literature on the coexistence of these 2 diseases, the causes of myocardial injury in patients with pheochromocytoma, and the utility of genetic testing and pheochromocytoma screening for those patients and their families.MethodsWe present a case report, including the detailed clinical, laboratory, and radiographic data, results of adrenal mass pathology, and results of coronary angiography. We also survey other relevant reports available in the literature.ResultsA 43-year-old woman with a history of longstanding hypertension, neurofibromatosis 1, headaches, sweating, and palpitations presented to the hospital with chest pain and shortness of breath. She was found to have an acute myocardial infarction and pulmonary edema, as well as a right adrenal mass. A pheochromocytoma was suspected, and phenoxybenzamine was added to her treatment regimen. Cardiac catheterization showed nonobstructive coronary disease. The levels of plasma catecholamine metabolites were extremely high. The patient underwent uncomplicated laparoscopic right adrenalectomy 2 weeks after this admission. Surgical pathology confirmed the diagnosis of pheochromocytoma.ConclusionAdrenergic crisis attributable to pheochromocytoma can result in acute myocardial infarction even in the absence of obstructive coronary disease. Inclusion of pheochromocytoma in the differential diagnosis of hypertension in patients with neurofibromatosis is very important and helps avoid mistakes in the management of such patients. (Endocr Pract. 2007;13:269-273)     

Ventricular tachycardia due to cardiac ischaemia: assessment by exercise electrocardiography

Although ventricular tachycardia is a well-known complication of myocardial ischaemia and may be provoked by exercise, many patients may appreciate only the angina and be unaware of the unduly rapid heart rate that precipitates it. Exercise testing is needed to show this arrhythmia and to enable treatment to be started.Twenty-three patients were found to have chronic ischaemic heart disease complicated by ventricular tachycardia. Six patients with old myocardial infarction had ventricular tachycardia at rest which required conversion to sinus rhythm; 17 patients developed ventricular tachycardia only when they exercised. In 12 of these 17 patients coronary angiography showed disease of the anterior descending branch of the left coronary artery; other vessels were usually also affected. Although beta-adrenergic blocking drugs increased exercise tolerance, ventricular tachycardia still occurred when the heart rate on exercise reached a level similar to that before treatment. In five patients coronary artery bypass surgery was performed because of angina and exercise-induced ventricular tachycardia. Exercise tolerance was increased in all three patients who underwent exercise tests after operation, and in two of these patients, both of whom were known to have patent grafts, ventricular tachycardia was abolished.If part of the beneficial effect of coronary bypass surgery is preventing life-threatening ventricular arrhythmias it is essential to detect these, and ambulatory monitoring and stress testing have a complementary role.     

Results of intracoronary stenting made in different periods after diagnostic coronary angiography

The high cost of tools and expendable materials and its associated necessity of solving organizational issues force to delay the implementation of stenting for nonmedical reasons in many cases. This gives a convenient way to evaluate how much effective and safe stenting would be made just after coronary angiography or delayed intervention would be performed and at the same time to consider the way delay in stenting may affect its clinical and angiographic results. The study covered 136 patients with coronary heart disease who had been implanted an intracoronary stent. All this patients were divided into 3 groups. Group 1 included 16 patients who had undergone stent implantation just after diagnostic coronary angiography, Group 2 comprised 42 patients who had the similar procedure no later than a month after coronary angiography, and Group 3 consisted of 78 patients who had it a month or later following angiography. The angiographic success rates of stenting was 100% in Group 1, 97.6% in Group 2, and 92.3% in Group 3. The causes of poor results were evolving myocardial infarction (2.4%) and technical failure (2.4%) in Group 2; evolving myocardial infarction (2.6%), emergency aortocoronary bypass surgery (1.3%), and technical failure (3.8%) in Group 3. In Group 2, 4.8% cases of those undergone delayed stenting showed more significant stenosis than those having diagnostic intervention. In Group 3, there was more progressive stenosis in 16.7% and a transition of stenosis to occlusion in 7.8%. There were no complications (such as hemorrhage, retroperitoneal hematoma, etc.) at the site of puncture in Group 1, but in Group 2 and 3 they were 3.8 and 6.5%, respectively. Delayed stenting frequently adversely affects the outcomes of endovascular treatment due to the higher incidence of complication and to the increasing technical sophistication of the procedure no late than a month after diagnostic coronary angiography.     

Cold pressor test in diagnosis of coronary artery disease: echophonocardiographic method.

The cold pressor test was used to induce myocardial ischaemia in patients with coronary artery disease and the rise in left ventricular filling pressure used as the index of myocardial ischaemia. Left ventricular filling pressure was derived from a non-invasive echophonocardiographic method. A study group of 19 consecutive patients with chest pain underwent the cold pressor test before coronary angiography. Eighteen responded with a rise in filling pressure exceeding 30% and, of these, 17 had serious coronary artery disease (three single vessel, one two vessel, and 13 triple vessel disease; one had coronary artery spasm only). The remaining patient, who showed no rise in filling pressure, did not have coronary artery disease. None of 15 normal controls showed a rise greater than 5% (patients with coronary artery disease versus normal controls p less than 0.001). The cold pressor test would be suitable for patients who cannot or should not exercise and may be combined with exercise electrocardiograms to improve the information content, as it uses a different marker of myocardial ischaemia.     

平板运动试验对冠心病的诊断意义

目的:探讨平板运动试验(TET)对诊断冠状动脉粥样硬化性心脏病(冠心病)的临床意义。方法:对比分析217例疑诊或临床诊断冠心病患者的平板运动试验和选择性冠状动脉造影(CAG)结果。结果:以选择性冠状动脉造影为标准,平板运动试验敏感性为68.4%,特异性为88.4%,阳性预测值为77.1%,阴性预测值为82.9%。结论:简便、易行及无创的平板运动试验是诊断冠心病的重要手段。     

STEMI or non-STEMI: that is the question

Acute coronary syndromes are usually classified on the basis of the presence or absence of ST elevation on the ECG: ST-elevation myocardial infarction or non-ST-elevation myocardial infarction (NSTEMI)patients with acute myocardial infarction (AMI) need immediate therapy, without unnecessary delay and primary percutaneous coronary intervention (PPCI) should preferably be performed within 90 min after first medical contact. However, in AMI patients without ST-segment elevation (pre) hospital triage for immediate transfer to the catheterisation laboratory may be difficult. Moreover, initial diagnosis and risk stratification take place at busy emergency departments and chest pain units with additional risk of ‘PPCI delay’. Optimal timing of angiography and revascularisation remains a challenge. We describe a patient with NSTEMI who was scheduled for early coronary angiography within 24 h but retrospectively should have been sent to the cath lab immediately because he had a significant amount of myocardium at risk, undetected by non-invasive parameters.     

Long-term Prognosis following Ventricular Fibrillation in Acute Ischaemic Heart Disease

Of 160 patients who survived ventricular fibrillation complicating acute ischaemic heart disease, 80 had had a clinically mild coronary attack. Most of the long-term survivors had ventricular fibrillation within 24 hours of the onset of symptoms. The longterm prognosis of the survivors was similar to that of patients whose myocardial infarction was not complicated by ventricular fibrillation. Those patients who survived ventricular fibrillation which occurred within four hours of the onset of symptoms were younger, usually had had a mild coronary attack, and had the most favourable longterm prognosis. The number of episodes of ventricular fibrillation did not affect adversely the long-term prognosis. Of those who at the time of review were eligible to work, 86% were fit to work and 68% were actually at work.     

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)     

Diagnostic and prognostic value of absence of coronary artery calcification in patients with stable chest symptoms

The aim of this study was to determine the prognostic value of a coronary artery calcium score (CACS) of 0 in patients with stable chest symptoms and to compare it as a first-line test with bicycle exercise testing (X-ECG). Altogether, 315 consecutive patients over 44 years of age, with stable chest symptoms and no previous diagnosis of coronary artery disease (CAD) visited the outpatient clinic of our community hospital and underwent both CACS and X-ECG. The mean age was 60.54 years (SD 9.7; range 45–88 years). Of these patients, 141 had no detectable coronary calcium (44.8%) We excluded patients who did not sign informed consent (n = 4). Three patients were lost to follow-up. The follow-up group therefore consisted of 134 patients. The mean follow-up period was 44.6 months (25th–75th percentile: 35.5–54.3 months), during which no major adverse cardiac events (MACE) occurred. The negative predictive value (NPV) was 100%. X-ECG was negative in only 89 patients, equivocal in 39 patients and false-positive in 6 patients requiring additional stress myocardial imaging in 45 patients. NPV as a first-line test was therefore 66.4%. In conclusion: patients over 44 years with stable chest symptoms and no detectable coronary calcium have an excellent prognosis. CACS performs better compared with X-ECG as an initial test in patients with stable chest symptoms.     

Acquired hemophilia in a patient with myeloma.

The generally accepted indications for stress testing in patients with coronary artery disease include confirming the diagnosis of angina, determining the limitation of activity caused by angina, assessing prognosis in patients with known coronary artery disease, assessing perioperative risk, and evaluating responses to therapy. In patients with a clinical scenario strongly suggestive of angina, testing is not necessary to diagnose coronary artery disease. The exercise treadmill-electrocardiogram test is the oldest and most extensively used stress test and can be reliably performed in patients who are clinically stable and who have an interpretable resting electrocardiogram. The addition of myocardial imaging agents such as thallium 201, technetium Tc 99m sestamibi, and technetium Tc 99m teboroxime increases the sensitivity and specificity for detecting coronary disease. Pharmacologic agents such as dipyridamole, adenosine, and dobutamine may be used in patients who cannot exercise adequately. Myocardial ischemia can also be evaluated by echocardiography, computed tomography, or magnetic resonance imaging, especially when additional information such as left ventricular and valvular function is desired. We review the indications for the noninvasive evaluation of coronary artery disease and the rationale for selecting a diagnostic test.     

Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross sectional and cohort studies

ObjectiveTo compare risks of cardiovascular outcomes between patients with type 2 diabetes and patients with established coronary heart disease.DesignCross sectional study and cohort study using routinely collected datasets.SettingTayside, Scotland (population 400 000) during 1988-95.SubjectsIn the cross sectional study, among patients aged 45-64, 1155 with type 2 diabetes were compared with 1347 who had had a myocardial infarction in the preceding 8 years. In the cohort study 3477 patients of all ages with newly diagnosed type 2 diabetes were compared with 7414 patients who had just had a myocardial infarction.ResultsIn the cross sectional study the adjusted risk ratio for death from all causes was 2.27 (95% confidence interval 1.82 to 2.83) for patients who had had myocardial infarction compared with those with diabetes, and the risk ratio for hospital admission for myocardial infarction was 1.33 (1.14 to 1.55). In the cohort study, patients who had just had a myocardial infarction had a higher risk of death from all causes (adjusted risk ratio 1.35 (1.25 to 1.44)), cardiovascular death (2.93 (2.54 to 3.41)), and hospital admission for myocardial infarction (3.10 (2.57 to 3.73)).ConclusionsPatients with type 2 diabetes were at lower risk of cardiovascular outcomes than patients with established coronary heart disease.

What is already known on this topic

A recent influential study suggested that patients with type 2 diabetes without established cardiovascular disease have as high a risk of cardiovascular events and death as non-diabetic patients who have had a myocardial infarctionSome clinicians therefore advocate aggressive treatment of cardiovascular risk factors in the presence of diabetes

What this study adds

Patients with type 2 diabetes are at lower risk of death from all causes or cardiovascular causes and of hospital admission for myocardial infarction than patients with established coronary heart disease     

How well can we predict coronary heart disease? Findings in the United Kingdom Heart Disease Prevention Project.

The probability of myocardial infarction developing over five years in a group of middle aged men was predicted with knowledge of their ages, blood pressures, cholesterol concentrations, and smoking habits as recorded in an initial screening examination. Although the top 15% of the risk distribution predicted 115 (32%) of the subsequent cases of myocardial infarction, there was a considerable overlap in predicted risk between those subjects who did and those who did not go on to develop a myocardial infarction. Of the subjects in the top 15% of risk, only 72 (7%) of those initially free of coronary heart disease and 43 (22%) of those initially with coronary heart disease actually developed a myocardial infarction over the subsequent five years. Thus, although a group of subjects at high risk can be identified, among whom will be a high proportion of potential victims of heart attack, many subjects will be wrongly classified. These findings may explain part of the difficulty in persuading patients of the potential benefits of reducing risks and highlight the need for research to improve the prediction of the development of coronary heart disease.     

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.     

Duke Treadmill Score in prioritizing patients for coronary angiography: retrospective study of a Croatian regional hospital

Aim of the study was to determine the potential of Duke Treadmill Score (DTS) in prioritizing patients for coronary angiography in a transitional country clinical setting. We analyzed 114patients with suspected stable coronary artery disease who underwent exercise treadmill testing, and coronary angiography in Slavonski Brod General Hospital. DTS was calculated from treadmill test as: exercise time--(5 x ST deviation in mm)--(4 x exercise angina). Regarding the score, patients were grouped into three groups of risk for coronary artery disease: low risk, medium risk, and high risk patients. All patients underwent coronary angiography, and were grouped in accordance to the severity of the coronary artery disease into three groups: insignificant, significant, or severe coronary artery disease. All patients scored as high risk DTS had significant or severe coronary artery disease. Medium and low risk DTS patients had insignificant coronary artery disease in 50%, and 90% of cases, respectively. Medium risk patients with significant or severe coronary artery disease were significantly older, and had more frequent history of typical chest pain with higher number of episodes per week (P<0.05), whereas there were no differences regarding gender or presence of risk factors. There were no significant differences among medium risk patients regarding the severity of coronary artery disease in exercise time or ST deviation. However, the presence of limiting exercise angina in medium risk patients was significantly more related with significant and severe coronary artery disease (P<0.05). High risk DTS result showed great potential in stratifying patients for immediate coronary angiography. This scoring system may be used in prioritizing patients for coronary angiography in a transitional clinical setting.     

Vitamin C deficiency and risk of myocardial infarction: prospective population study of men from eastern Finland.

OBJECTIVE: To examine the association between plasma vitamin C concentrations and the risk of acute myocardial infarction. DESIGN: Prospective population study. SETTING: Eastern Finland. SUBJECTS: 1605 randomly selected men aged 42, 48, 54, or 60 who did not have either symptomatic coronary heart disease or ischaemia on exercise testing at entry to the Kuopio ischaemic heart disease risk factor study in between 1984 and 1989. MAIN OUTCOME MEASURES: Number of acute myocardial infarctions; fasting plasma vitamin C concentrations at baseline. RESULTS: 70 of the men had a fatal or non-fatal myocardial infarction between March 1984 and December 1992.91 men had vitamin C deficiency (plasma ascorbate < 11.4 mumol/l, or 2.0 mg/l), of whom 12 (13.2%) had a myocardial infarction; 1514 men were not deficient in vitamin C, of whom 58 (3.8%) had a myocardial infarction. In a Cox proportional hazards model adjusted for age, year of examination, and season of the year examined (August to October v rest of the year) men who had vitamin C deficiency had a relative risk of acute myocardial infarction of 3.5 (95% confidence interval 1.8 to 6.7, P = 0.0002) compared with those who were not deficient. In another model adjusted additionally for the strongest risk factors for myocardial infarction and for dietary intakes of tea fibre, carotene, and saturated fats men with a plasma ascorbate concentration < 11.4 mumol/l had a relative risk of 2.5 (1.3 to 5.2, P = 0.0095) compared with men with higher plasma vitamin C concentrations. CONCLUSIONS: Vitamin C deficiency, as assessed by low plasma ascorbate concentration, is a risk factor for coronary heart disease.     

Comparative analysis of the X-ray morphology of coronary atherosclerosis and the results of endovascular interventions performed in the subacute period and 6 months after prior myocardial infarction

The study was undertaken to analyze the morphology of coronary lesion and the angiographic results of interventions made in the subacute period and 6 months after prior myocardial infarction. It included 593 patients with and without prior Q-wave myocardial infarction. The X-ray morphological parameters of the coronary bed were analyzed in the patients who had undergone invasive studies within a month (n = 362) and 6 months (n = 231) after sustained myocardial infarction. In both groups, the successful intervention rate was also estimated during endovascular treatment. The study showed that the number of stenoses with the complicated morphology (type B) was significantly more 6 months after sustained myocardial infarction than that in the subacute period. The number of occluded segments with the characteristics that were unfavorable for endovascular intervention (bridge collaterals, extended occlusions) was also significantly more in the late periods. In the subacute period, the angiographic success rate of endovascular recanalizations of chronic occlusions was 83.4%, which was significantly higher than that (62.6%) 6 months following infarction. The findings have led us to the conclusion that it is necessary to make routine coronary angiography in all postinfarction patients during their hospital stay in order to define the potentialities of early revascularization.     

Cardiac predictors of death after non-cardiac surgery evaluated by intention to treat.

Cardiac risk factors were studied among patients who were admitted to hospital with appendicitis or a fracture of the proximal femur less than one year after being admitted with myocardial infarction. Of 99 patients with myocardial infarction and appendicitis, 87 underwent appendicectomy; and of 221 with myocardial infarction and hip fracture, 179 were operated on. The patients were studied on an intention to treat basis. The mortality within one month was 9% and 16% respectively. A history of congestive heart failure was the dominating risk factor, while ischaemic heart disease (recent myocardial infarction or angina pectoris) had no independent association with mortality. If the ventricular function is known additional preoperative information about the heart is of negligible value when estimating the mortality of non-cardiac surgery.