General practitioners' management of acute myocardial infarction and cardiac arrest: relevance to thrombolytic treatment.

A questionnaire was sent to 61 general practitioners who had participated 18 months previously in a study of their experience of cardiopulmonary resuscitation and defibrillation in acute myocardial infarction. Fifty (82%) replies were received. Only 16 of the 50 respondents thought that every general practitioner should have a defibrillator, but 46 thought that every group practice should have one. Most practitioners felt the need for more tuition and practice in advanced life support, but 15 did not have the practice defibrillator with them when on call. Only nine doctors normally had an electrocardiograph with them when on call, most relying on clinical acumen to make an operational diagnosis; there appeared to be reluctance to use any drugs other than opiates and atropine in the management of acute myocardial infarction. This study highlights the difficulty of maintaining readiness to deal effectively with myocardial infarction in the community and the problems of relying on the electrocardiogram in deciding who should be given thrombolytic treatment.     

Prospective observational cohort study of time saved by prehospital thrombolysis for ST elevation myocardial infarction delivered by paramedics

Objectives To evaluate a system of prehospital thrombolysis, delivered by paramedics, in meeting the national service framework''s targets for the management of acute myocardial infarction.Design Prospective observational cohort study comparing patients with suspected acute myocardial infarction considered for thrombolysis in the prehospital environment with patients treated in hospital.Setting The catchment area of a large teaching hospital, including urban and rural areas.Participants 201 patients presenting concurrently over a 12 month period who had changes to the electrocardiogram that were diagnostic of acute myocardial infarction or who received thrombolysis for suspected acute myocardial infarction.Main outcome measures Time from first medical contact to initiation of thrombolysis (call to needle time), number of patients given thrombolysis appropriately, and all cause mortality in hospital.Results The median call to needle time for patients treated before arriving in hospital (n=28) was 52 (95% confidence interval 41 to 62) minutes. Patients from similar rural areas who were treated in hospital (n=43) had a median time of 125 (104 to 140) minutes. This represents a median time saved of 73 minutes (P < 0.001). Sixty minutes after medical contact 64% of patients (18/28) treated before arrival in hospital had received thrombolysis; this compares with 4% of patients (2/43) in a cohort from similar areas. Median call to needle time for patients from urban areas (n=107) was 80 (78 to 93) minutes. Myocardial infarction was confirmed in 89% of patients (25/28) who had received prehospital thrombolysis; this compares with 92% (138/150) in the two groups of patients receiving thrombolysis in hospital.Conclusions Thrombolysis delivered by paramedics with support from the base hospital can meet the national targets for early thrombolysis. The system has been shown to work well and can be introduced without delay.     

Effect of "fast track" admission for acute myocardial infarction on delay to thrombolysis.

OBJECTIVE--To evaluate the impact of a fast track triage system for patients with acute myocardial infarction. DESIGN--Comparison of delays in admission to hospital and in receiving thrombolytic treatment before and after introducing fast track system with delays recorded in 1987-8. Patients fulfilling clinical and electrocardiographic criteria for myocardial infarction were selected for rapid access to the cardiac care team, bypassing evaluation by the medical registrar. SETTING--Major accident and emergency, cardiac and trauma centre. SUBJECTS--359 patients admitted to the cardiac care unit during 1 February to 31 July 1990 with suspected acute infarction. MAIN OUTCOME MEASURES--Accuracy of diagnosis and delay from arrival at hospital to thrombolytic treatment. RESULTS--248 of the 359 patients had myocardial infarction confirmed, of whom 127 received thrombolytic treatment. The fast track system correctly identified 79 out of 127 (62%) patients who subsequently required thrombolytic treatment. 95% (79/83) of patients treated with thrombolysis after fast track admission had the diagnosis confirmed by electrocardiography and enzyme analysis. The median delay from hospital admission to thrombolytic treatment fell from 93 minutes in 1987-8 to 49 minutes in fast track patients (p less than 0.001). Delay in admission to the cardiac care unit was reduced by 47% for fast tract patients (median 60 minutes in 1987-8 v 32 minutes in 1990, p less than 0.001) and by 25% for all patients (60 minutes v 45 minutes, p less than 0.001). CONCLUSION--This fast track system requires no additional staff or equipment, and it halves inhospital delay to thrombolytic treatment without affecting the accuracy of diagnosis among patients requiring thrombolysis.     

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.     

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.     

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.     

First electrocardiogram in recent myocardial infarction.

The admission electrocardiogram (ECG) was studied in 898 patients admitted to a coronary care unit over two years. The diagnosis made from this tracing was compared with that made at the end of the patient''s stay. About half the cases of recent myocardial infarct were diagnosed from the admission ECG, but accuracy rose to 83% with serial ECG''s in the unit. The ECG is important but not entirely reliable in the early detection of acute myocardial infarction, which should be largely a clinical diagnosis.     

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.     

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)     

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.     

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

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

院前急救联合绿色通道模式对急性心肌梗死PPCI术患者救治效果和术后不良心血管事件的影响

摘要 目的：探讨院前急救联合绿色通道模式对行急诊经皮冠状动脉介入术（PPCI）的急性心肌梗死（AMI）患者救治效果和术后不良心血管事件的影响。方法：选取2017年1月~2019年6月期间我院收治的行PPCI术的AMI患者200例,采用随机数字表法将患者分为对照组（n=100）和研究组（n=100）,对照组患者予以传统急诊模式,研究组患者予以院前急救联合绿色通道模式,比较两组患者救治效果、满意度、确诊时间、心肌再灌注治疗时间、住院时间、术后不良心血管事件。结果：研究组抢救时间、急救反应时间、确诊时间、心肌再灌注治疗时间以及住院时间均短于对照组（P<0.05）。研究组治疗后的临床总有效率高于对照组（P<0.05）。研究组的总满意度为91.00%（91/100）,高于对照组的76.00%（76/100）（P<0.05）。研究组术后不良心血管发生事件发生率为2.00%（2/100）,低于对照组的17.00%（17/100）（P<0.05）。结论：行PPCI术的AMI患者给予院前急救联合绿色通道模式,救治效果显著,可有效提高患者满意度,减少术后不良心血管事件的发生率。     

Use of psychiatric services by patients in a general hospital.

OBJECTIVE--To identify physical disorders associated with increased rate of use of psychiatric services. DESIGN--Retrospective analysis of routine abstracts of general hospital inpatient records linked with those of psychiatric care, for inpatients with physical disorders with possible psychiatric associations and for controls. SETTING--Oxfordshire health district. SUBJECTS--Inpatients aged 15-64 years discharged from general hospitals during 1975-85 with a diagnosis among 14 selected diagnostic groups (including potentially life threatening conditions, chronic disabling diseases, and non-specific symptomatic conditions) and control inpatients with acute conditions. MAIN OUTCOME MEASURES--Observed and expected numbers of patients receiving psychiatric care. RESULTS--Observed use of psychiatric services before and after index admission was close to that expected for controls. For most other diagnoses the observed use was significantly increased in the year preceding and that subsequent to the admission. For four diagnostic groups it was significantly greater in the year after admission than in that before (acute myocardial infarction (ratio before to after 2.17, 95% confidence interval 1.5 to 3.3), cancer (2.05, 1.7 to 2.5), diabetes mellitus (1.89, 1.4 to 2.9), and chest pain (1.78, 1.3 to 2.4)). During four years after the admission the use of psychiatric services was significantly higher than in the general population for nonspecific symptomatic conditions (observed/expected: abdominal pain 1.7, chest pain 2.0, and headache 4.2), cirrhosis of the liver (10.4), and fractures in road accidents and other fractures (1.3, 1.6). CONCLUSIONS--More patients with certain physical conditions used psychiatric services. Alternative methods of service delivery may be needed, especially for disabling chronic physical illness, alcohol related disorders, and non-specific symptomatic conditions.     

腔隙性和非腔隙脑梗塞患者的血压差异研究

目的:比较腔隙性(LI)与非腔隙性(NLI)脑梗塞患者血压变化,评价血压与腔隙性脑梗塞的相关性。方法:选取在我院住院治疗的249例急性脑梗塞患者,根据不同亚型将患者分为腔隙性脑梗塞组(LI组,n=187)与非腔隙性脑梗塞组(NLI组,n=62),比较两组患者血压差异,采用线性相关分析与cox相关分析评估血压与脑梗塞及其危险因素的相关性。结果:LI组患者入院3天收缩压、舒张压显著高于NLI患者组,差异有统计学意义(分别P=0.003,P=0.009);线性回归分析表明,入院时收缩压、入院第3天收缩压、入院第3天舒张压与LI显著相关(均P0.05);cox单因素与多因素分析表明,入院第3天收缩压与LI显著相关(分别P=0.009与P=0.006),与其他协变量不相关(均P0.05)。而患者出院时血压与m RS或NIHSS不相关(分别P=0.788和P=0.898)。结论:与相同严重程度NLI患者比较,LI患者高血压与LI独立相关。LI患者血压显著高于NLI患者,二者差异虽与临床疾病严重程度无关,但很可能是患者发生急性脑梗塞的根本原因。     

急性缺血性脑卒中患者入院时血浆BNP水平与梗死部位关系

目的：分析急性缺血性脑卒中患者入院时血浆脑钠肽（BNP）水平与缺血性脑卒中梗死部位的关系。方法：随机入选88例急性缺血性脑卒中患者,按梗死部位,将其分为前循环病灶组（66名）和后循环病灶组（22名）两组进行比较。测定入院时血浆脑钠肽（BNP）水平进行比较。两组脑卒中病人的危险因素血糖、糖化血红蛋白、血脂全套,肝肾功能分析对比,并将急性缺血性脑卒中患者梗死部位相关的多个变量采用单因素logistic回归分析。结果：前循环病灶组血浆脑利钠肽水平的中位数是225.90 pg/mL,四分位数间距为596.00 pg/mL;后循环病灶组的中位数是750.95 pg/mL,四分位数间距为907.00 pg/mL。后循环病灶组血浆脑利钠肽水平要显著高于前循环病灶组血浆脑利钠肽水平,两个部位间入院时的脑利钠肽水平有统计学差异（P=0.004）。通过入院时脑利钠肽水平与缺血性脑卒中梗死部位的关系的ROC曲线,得出截点299.50 pg/mL。入院时血浆脑利钠肽水平≥299.50 pg/mL可以作为后循环病灶组的预测指标,其敏感性72.72%,特异性62.12%。结论：急性缺血性脑卒中患者入院时血浆BNP水平可作为急性期区别前后循环脑梗死的预测因子。     

淋巴细胞/单核细胞比值对急性脑梗死患者预后的预测价值研究

目的:探讨淋巴细胞/单核细胞比值(LMR)对急性脑梗死预后的预测价值。方法:回顾性分析急性脑梗死患者242例的临床资料,根据发病90天改良m RS评分分为预后良好组(163例,m RS 0-2分)和预后不良组(79例,m RS 3-6分),比较其入院时一般人口学资料、美国国立卫生研究院卒中量表评分(NIHSS评分)、血常规、血生化、C反应蛋白(CRP)等资料,根据入院时淋巴细胞与单核细胞计数计算出LMR值,采用logistics回归分析评估LMR与急性脑梗死预后的关系。采用受试者工作特征(ROC)曲线评价入院时LMR水平对急性脑梗预后的预测价值。结果:与预后良好组相比,预后不良组年龄、入院时NIHSS评分、伴随房颤、尿素氮、白细胞、CRP较高,而LMR水平较低,组间差异具有统计学意义(P0.05)。预后不良组LMR水平较预后良好组明显降低(3.48±2.23 vs. 4.39±1.84,P0.05),入院时NIHSS评分增高与低水平LMR是预后不良的独立危险因素(OR值分别为2.066、0.835,95%可信区间为1.668-2.559、0.759-0.946,P0.05)。入院时LMR水平ROC曲线下面积为0.762(95%CI 0.692-0.832),Youden法计算出LMR低于2.633(最佳临界值)预示预后不良,敏感性为86.9%,特异性为47%。结论:入院时LMR水平与急性脑梗死预后不良负相关,低水平LMR对预测急性脑梗死患者预后不良具有一定的参考价值。     

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

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

Study of "discharge communications" from hospital.

All hospital discharge communications concerned with acute admission from one general practice over a three month period were analysed. There was an appreciable delay between the time that the patient was discharged and the information was received by the general practitioner. Just over half of the patients had contacted their general practitioner after discharge before the general practitioner had received any information. The content of the communications was variable, and important subjects were frequently omitted. No communication was received for 11% of the discharged patients. There is a need for more efficient communication between secondary and primary care.     

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

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

Background and setting

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

Key measures for improvement

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

Strategies for change

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

Effects of change

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

Lessons learnt

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