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.     

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.     

Advanced Heart Block During Acute Myocardial Infarction Treated with an Electrode Pacing Catheter

The mortality rate is high from advanced atrioventricular block associated with acute myocardial infarction. There is reason to believe that if in these patients the hearts are electrically paced with an endocardial pacing catheter, the mortality rate can be considerably decreased. Five patients in second- and third-degree heart block associated with acute myocardial infarction were paced with a considerable lowering of the expected mortality rate. Twenty-three cases from the literature are also presented and discussed. A silastic bipolar electrode catheter was used in these five cases. Four of the five cases returned to normal sinus rhythm within the first 10 days. The average duration of pacing was 6.7 days. It is the opinion of the author that second- and third-degree heart block associated with acute myocardial infarction should have a pacing catheter introduced at the earliest possible moment for continuous or demand endocardial pacing.     

Survival in acute myocardial infarction; factors observed in 318 patients

Factors influencing survival in a group of 318 cases of acute myocardial infarction were analyzed. The mortality rate for the entire series was 41 per cent. Among the men it was 39.5 per cent; among women, 44.4 per cent. The mortality rate increased with the age of the patient. Twenty-six per cent of all deaths occurred within the first 24 hours, 44 per cent within 72 hours, and 71 per cent within the first week following hospital admission. Increased mortality rate was associated with previous history of congestive failure, myocardial infarction, hypertension or cardiomegaly. As to circumstances immediately preceding an infarction, the only ones that seemed to be related to a high mortality rate were hemorrhage and the postoperative state. Not only the presence but the degree of shock, congestive failure, cyanosis and dyspnea adversely influenced chances for survival. Duration, location, radiation and number of attacks of pain did not appear to be associated with extraordinary mortality rates. Anterior was slightly more common than posterior infarctions, and the mortality rate was much higher. Thromboembolic complications and certain disorders of rhythm and of conduction definitely worsen prognosis. Comparison of average mortality data as reported in different studies on acute myocardial infarction is improper and misleading because of the great differences between the kinds of patients included in various series reported upon. A standard method of grading the severity of acute myocardial infarction would help toward sounder comparisons.     

Initial Heparin Therapy in Acute Myocardial Infarction

The administration of heparin during the first 48 hours following acute myocardial infarction is widely practised. Heparin treatment is also recommended for acute coronary insufficiency on the grounds that it may prevent development of an impending myocardial infarction. These measures had been accepted without support of a controlled clinical trial. By random selection, 101 patients hospitalized with a provisional diagnosis of acute myocardial infarction received heparin (100 mg. intravenously every eight hours for 48 hours) and 105 patients were assigned to a control group. Both groups of patients received bishydroxycoumarin (Dicumarol). The mortality in the heparin series was 30% and in the control group, 28%. A significantly large number of the heparin-treated patients developed clinical and laboratory proof of recent myocardial infarction. It is concluded that early intermittent intravenous heparin treatment does not lower the mortality in patients with acute myocardial infarction nor does it prevent impending myocardial infarction in patients with acute coronary insufficiency.     

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.     

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.     

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.     

Mortality rate in subsequent years following myocardial infarction]

Eight hundred out of 997 patients with myocardial infarction hospitalized at cardiological ward in Kielce in 1977-1985 survived. Seven hundred seventy one patients were followed up for 2-10 years. Basing on the obtained results, tables of the mortality rates and probability of survival depending on sex, age, and classification into appropriate prognosis group have been prepared. The highest mortality rate (9.6%) was seen in the first year following myocardial infarction. Mean annual mortality rate in this group was 6% during 10 years of the follow up. Mortality rate in women with myocardial infarction was significantly lower than in men during 10 years of the follow up.     

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.     

Procedural and long-term outcome of primary percutaneous coronary intervention in octogenarians

Background/objectives. To investigate the procedural and long-term outcome of primary percutaneous coronary intervention (PCI) in octogenarians with an acute myocardial infarction. Methods. We performed a retrospective analysis of all consecutive octogenarian patients (n=98) with an acute myocardial infarction treated with primary PCI in the Catharina Hospital in the year 2006. We compared procedural results and outcome with a matched control group composed of non-octogenarians undergoing primary PCI. Follow-up period was one year. Results. The initial success rate of PCI was similar in the two groups but short-term mortality was higher among the elderly patients: 30-day mortality 26.3 vs. 9.6%. Age-adjusted mortality between 30 days and one year was comparable in the two groups and similar to natural survival in the Netherlands. Octogenarians were less likely to have a normal left ventricular function during follow-up (48.3 vs. 66.7%). New York Heart Association (NYHA) class and recurrence rate of myocardial infarction was higher among octogenarians. Conclusion. Technical success rate during primary PCI was as good for octogenarians as in younger patients, but 30-day mortality, though acceptable, was higher among the elderly. After 30 days, age-adjusted mortality was comparable in both groups. (Neth Heart J 2010;18:129-34.)     

Effect of intravenous infusion of insulin in diabetics with acute myocardial infarction.

Diabetes mellitus is associated with a high mortality after myocardial infarction. To see whether this may be decreased by improved diabetic control the effect of an insulin infusion regimen was studied in patients with acute myocardial infarction. From April 1982 to April 1983, 33 diabetics were admitted with acute myocardial infarction. Those being treated with diet alone or oral hypoglycaemic drugs continued with this unless control was poor, when they were changed to a "sliding scale" regimen of subcutaneous insulin injections thrice daily. Those already receiving insulin were maintained on thrice daily subcutaneous injections. From April 1983 to April 1984, 29 diabetics had acute myocardial infarction. Those receiving treatment with oral hypoglycaemic drugs or insulin were changed to continuous intravenous infusion of insulin, the aim being to maintain the blood glucose concentration at 4-7 mmol/I (72-126 mg/100 ml). Those being treated with diet alone continued with this if blood glucose concentrations were acceptable. Total mortality fell from 42% in the first year to 17% in the second (p less than 0.05). Over the same period mortality among non-diabetic patients with myocardial infarction did not change significantly. There was a significant fall in cardiac arrhythmias (expressed as the percentage of patients in whom arrhythmias were recorded) from 42% to 17% (p less than 0.05). The most significant fall in the incidence of complications occurred in those who had been receiving oral hypoglycaemic drugs on entry to the study (87% to 50%, p less than 0.05).     

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.     

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.     

Calcium channel blockers in acute myocardial infarction and unstable angina: an overview.

OBJECTIVE--To assess the effects of calcium channel blockers on development of infarcts, reinfarction, and mortality. DESIGN--A systematic overview of all randomised trials of calcium channel blockers in myocardial infarction and unstable angina. PATIENTS--19,000 Patients in 28 randomised trials. RESULTS--In the trials of myocardial infarction 873 deaths occurred among 8870 patients randomised to active treatment compared with 825 deaths among 8889 control patients (odds ratio of 1.06, 95% confidence interval of 0.96 to 1.18). There was no evidence of a beneficial effect on development and size of infarcts or rate of reinfarction. The results were similar in short term trials in which treatment was confined to the acute phase and those in which treatment was started some weeks later and continued for a year or two. There was no evidence of heterogeneity among different calcium channel blockers in their effects on any end point. The results were similar in the unstable angina trials (110 out of 561 patients treated with calcium channel blocker compared with 104 out of 548 controls developed a myocardial infarction; 14 out of 591 treated compared with nine out of 578 controls died). CONCLUSIONS--Calcium channel blockers do not reduce the risk of initial or recurrent infarction or death when given routinely to patients with acute myocardial infarction or unstable angina.     

Myocardial Infarction: A Five-Year Follow-up of Patients

Patients with acute myocardial infarction (2,020) admitted to coronary care units (CCU) in Utah were studied for five years. Of these, 1,641 (81.4 percent) survived to leave the hospital. The male to female ratio was 3.5:1. At four months, one year and yearly thereafter from the date of admission to CCU, patients were mailed follow-up questionnaires. Cause of death was obtained from autopsy reports and death certificates. Patients were grouped yearly by the number of cardiac symptoms reported. Of patients discharged whose cases were followed, 925 (61.9 percent) were alive after five years. Reinfarction was the major cause of death in the hospital; however, during follow-up only 36.8 percent of deaths were attributable to myocardial infarction. At follow-up after a year, fewer cardiac symptoms were reported by patients who survived to the fifth year of follow-up than by patients who did not. Women were older and showed a higher death rate during follow-up. Increasing age was found to be a determining factor in long-term mortality after acute myocardial infarction.     

National Assessment of Statin Therapy in Patients Hospitalized with Acute Myocardial Infarction: Insight from China PEACE-Retrospective AMI Study, 2001, 2006, 2011

BackgroundStatin therapy is among the most effective treatments to improve short- and long-term mortality after acute myocardial infarction. The use of statin, and the intensity of their use, has not been described in acute myocardial infarction patients in China, a country with a rapidly growing burden of cardiovascular disease.ConclusionsThe use of statin therapy has dramatically increased over the past decade in Chinese patients with acute myocardial infarction. However, half of patients still did not receive intensive statin therapy in 2011.Given that guidelines strongly endorse intensive statin therapy for acute myocardial infarction patients, initiatives promoting the use of statin therapy, with attention to treatment intensity, would support further improvements in practice.     

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.     

Clinical observations and echocardiographic features of mural thrombi in the left ventricle during myocardial infarction]

The incidence and changes in the mural thrombi in left ventricle in ECHO-2D in the acute myocardial infarction as well as relationship between clinical parameters and echocardiographic indices of the left cardiac ventricle contractability asynergy and dynamics of changes in mural thrombi have been investigated. The studies included 137 consecutive patients (98 males and 39 females) treated for the acute myocardial infarction. Patients' age ranged from 35 to 87 years (mean 62 years). Infarction of the anterior and/or lateral wall was diagnosed in 67 patients, and infarction of the inferior and/or posterior wall in 70 patients. Mural thrombi were diagnosed in 42 (31%) patients. Eighteen thrombi (43%) were liquefied during hospitalization. Comparative analysis of patients in whom mural thrombi underwent liquefaction in the hospital and a group of patients with myocardial infarction and persisting mural thrombi showed that return of left ventricle movements with subsequent contractability facilitate liquefaction of mural thrombi. Higher mortality rate in the group of patients with myocardial infarction with mural thrombi is due to extension of the infarction accompanied by marked asynergy of left ventricular contractions which does not decrease in sequential examinations, and increasing congestive heart failure.     

Value of Routine Cardiac Monitoring in the Management of Acute Myocardial Infarction outside a Coronary Care Unit

In a coronary care unit patients and electrocardiographic monitors are under almost continuous observation by trained personnel. This paper suggests that in a general medical ward without this facility routine cardiac monitoring with E.C.G. oscilloscopes is unlikely to lower the overall mortality from acute myocardial infarction. A mortality of 25% for acute myocardial infarction was the same for a hospital without a coronary care unit where monitoring was routinely performed and for two neighbouring hospitals which did not routinely use monitoring during the period of analysis.The need to train personnel in the recognition of E.C.G. monitor tracings and the difficulties associated with monitor alarm systems are emphasized.