Myocardial infarction: a comparison between home and hospital care for patients.

To compare the results of home and hospital treatment in men aged under 70 years who had suffered acute myocardial infarction within 48 hours 1895 patients were considered for study in four centres in south-west England. Four-hundred-and-fifty patients were randomly allocated to receive care either at home by their family doctor or in hospital, initially in an intensive care unit. The randomised treatment groups were similar in age, history of cardiovascular disease, and incidence of hypotension when first examined. They were followed up for up to a year after onset. The mortality rate at 28 days was 12% for the random home group and 14% for the random hospital group; the corresponding figures at 330 days were 20% and 27%. On average, older patients and those without initial hypotension fared rather better under home care. The patients who underwent randomisation were similar to those whose place of care was not randomised, except that the non-randomised group contained a higher proportion of initially hypotensive patients, whose prognosis was poor wherever treated. These results confirm and extend our preliminary findings. Home care is a proper form of treatment for many patients with acute myocardial infarction, particularly those over 60 years and those with an uncomplicated attack seen by general practitioners.     

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.     

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.     

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.     

Factors Affecting Admission to a Coronary Care Unit

Of 103 patients with suspected myocardial infarction admitted to an intensive care unit in a general hospital half were admitted within four and a half hours of the onset of symptoms. In general, patients who attended the casualty department were under intensive care sooner than patients who sought attention from their general practitioner before admission. Patients who were seen by a locum from the emergency treatment service at night or weekends were more likely to remain at home until seen the next day by their own general practitioner, compared with patients seen by their own general practitioner initially.     

Teesside coronary survey: an epidemiological study of acute attacks of myocardial infarction.

A 12-month epidemiological survey of attacks of acute myocardial infarction was carried out in a large urban population. The incidence and mortality at all ages and in both sexes were examined. Altogether, 1938 attacks were diagnosed--an overall incidence of 4-89 per 1000 population. The 28-day fatality rate was 50-5%. A third of the patients were treated at home and these patients had a lower fatality rate than those in hospital, a difference that could not be attributed to age, sex, or severity of attack. Half of the deaths that were witnessed occurred suddenly and a further 21% occurred within the next two hours. The median time to patients coming under care was about three hours. As used at present, coronary care units are unlikely to improve fatality rates. Future advances in treatment must take place outside hospital and will require re-education of the public and the general practitioner.     

Comparison of Mobilization after Two and Nine Days in Uncomplicated Myocardial Infarction

A total of 189 patients with uncomplicated myocardial infarction were selected at random for early or late mobilization and discharge from hospital. Patients were admitted to the study after 48 hours in a coronary care unit if they were free of pain and showed no evidence of heart failure or significant dysrhythmia. Randomization was achieved by monthly cross-over of the three medical wards to which the patients were discharged. One group of patients was mobilized immediately and discharged home after a total of nine days in hospital, and the second group was mobilized on the ninth day and discharged on the 16th day. Out-patient assessment was carried out six weeks after admission. No significant differences were observed between the groups in terms of mortality or morbidity, as reflected by the incidence of recurrent chest pain or myocardial infarction, heart failure, dysrhythmia, or venous thromboembolism detected either clinically or by ¹²⁵I-labelled fibrinogen scanning.     

Home or Hospital Care after Myocardial Infarction: Is This the Right Question?

This article attempts to lay down guide-lines for the general practitioner faced with a patient with a myocardial infarction in his home. A too rigid distinction between home or hospital care should not be attempted. Rather the general practitioner should look at home and hospital care and decide which is more appropriate in a particular case. In particular, he must distinguish clearly between cases he sees very soon after an attack and those he sees some hours later. Two hours is suggested as a useful dividing time between the two groups of patients.     

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.     

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.     

Role of the general practitioner in managing patients with myocardial infarction: impact of thrombolytic treatment. Report of a British Heart Foundation Working Group.

Thrombolytic treatment, combined with aspirin, has been shown to reduce mortality by half in patients in hospital with suspected acute myocardial infarction if it is given early after the onset of symptoms. This fact adds to the importance of prompt and skillful intervention. At present in the United Kingdom the median time for receiving suitable management for this condition is about four to six hours. With better organisation this delay could, in most areas, be reduced to two or three hours. A major change in the care of patients with myocardial infarction is needed in which the general practitioner should have a crucial role. Health authorities, hospital physicians, general practitioners, and the ambulance services must coordinate their efforts if the potential reduction in mortality is to be realised. The district medical officer should consult colleagues and draw up guidelines for organising the care of patients who have had heart attacks. The management of patients who have had heart attacks in the community and in hospital should be continually audited. There are dangers inherent in the use of thrombolytic treatment, particularly when conditions other than myocardial infarction are treated in error. This treatment should be given only when the diagnosis is highly probable and when close observation of the patient can be ensured during the ensuing hours. Thrombolytic treatment should not, therefore, be given out of hospital except when trained, equipped personnel are in attendance. Treatment can be given in any hospital (including community hospitals) provided there are adequate diagnostic facilities and suitably experienced nursing staff.     

Do women with acute myocardial infarction receive the same treatment as men?

OBJECTIVE--To determine whether women with acute myocardial infarction in the Nottingham health district receive the same therapeutic interventions as their male counterparts. DESIGN--Retrospective study. SETTING--University and City Hospitals, Nottingham. PATIENTS--All patients admitted with a suspected myocardial infarction during 1989 and 1990. MAIN OUTCOME MEASURES--Route and timing of admission to hospital, ward of admission, treatment, interventions in hospital, and mortality. RESULTS--Women with myocardial infarction took longer to arrive in hospital than men. They were less likely to be admitted to the coronary care unit and were therefore also less likely to receive thrombolytic treatment. They seemed to have more severe infarcts, with higher Killip classes, and had a slightly higher mortality during admission. They were less likely than men to receive secondary prophylaxis by being discharged taking beta blockers or aspirin. CONCLUSIONS--Survival chances both in hospital and after discharge in women with acute myocardial infarction are reduced because they do not have the same opportunity for therapeutic intervention as men.     

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.     

High mortality in obese women diabetics with acute myocardial infarction.

The factors associated with mortality in 89 diabetics and 793 non-diabetics with acute myocardial infarction who were initially admitted to a coronary care unit were analysed retrospectively. During their stay in hospital diabetics had twice the mortality of non-diabetics. The higher mortality among diabetics was largely accounted for by obese women, who had a hospital mortality of 43%. There was an increased incidence of congestive heart failure in such patients. A therapeutic trial should be performed in such patients to assess whether insulin has an effect on infarct size.     

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.     

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.     

Relation of trauma to disease; aspects of correlation in cases involving compensation

As a general rule, it is not believed possible to classify patients with acute myocardial infarction as to the future severity of their illness at the time of the initial examination. However, classifications are possible from complete clinical data of the first few days with regard to the predicted mortality rates. Whether to manage the patient in the hospital or at home depends on the community facilities. The patient should be in bed for a period of two to three weeks if unquestioned infarction has occurred. The main avenue of investigation as to lowering of mortality needs to be directed toward the prevention of heart failure or sudden unexpected death probably related to arrhythmia. If the patient is hospitalized and laboratory facilities are available, anticoagulant therapy can be safely and effectively carried out without undue risk or prohibitive increase in the cost of management. The experience of the author and his colleagues has led to the belief that anticoagulants given routinely to patients with myocardial infarction are effective in decreasing the incidence of thromboembolic complications.     

ACUTE MYOCARDIAL INFARCTION—A Discussion of Certain Controversial Issues

As a general rule, it is not believed possible to classify patients with acute myocardial infarction as to the future severity of their illness at the time of the initial examination. However, classifications are possible from complete clinical data of the first few days with regard to the predicted mortality rates. Whether to manage the patient in the hospital or at home depends on the community facilities. The patient should be in bed for a period of two to three weeks if unquestioned infarction has occurred.The main avenue of investigation as to lowering of mortality needs to be directed toward the prevention of heart failure or sudden unexpected death probably related to arrhythmia. If the patient is hospitalized and laboratory facilities are available, anticoagulant therapy can be safely and effectively carried out without undue risk or prohibitive increase in the cost of management. The experience of the author and his colleagues has led to the belief that anticoagulants given routinely to patients with myocardial infarction are effective in decreasing the incidence of thromboembolic complications.     

Short and long term prognosis of acute myocardial infarction since introduction of thrombolysis.

OBJECTIVE--To record prognosis and determinants of outcome in patients with acute myocardial infarction since thrombolysis was introduced. DESIGN--Observational study. SETTING--London district general hospital. PATIENTS--608 consecutive patients admitted to the coronary care unit with acute myocardial infarction between 1 January 1988 and 31 December 1991. MAIN OUTCOME MEASURE--All cause mortality, non-fatal ischaemic events (myocardial infarction, unstable angina), and revascularisation. RESULTS--Of the 608 patients, 89 (14.6%) died in hospital. 507 [corrected] patients were followed up after discharge from hospital. Mortality (95% confidence interval) at 30 days, one year, and three years was 16.0% (13.4% to 19.2%), 21.7% (18.6% to 25.2%), and 29.4% (25.3% to 33.9%) respectively. Event free survival (survival without a non-fatal ischaemic event) was 80.4% (77.0% to 83.4%) at 30 days, 66.8% (62.8% to 70.5%) at one year, and 56.1% (51.3% to 60.6%) at three years. Survival in patients treated with thrombolysis was considerably higher than in those not given thrombolysis (three year survival: 76.7% v 54.3%), although the incidence of non-fatal ischaemic events was the same in the two groups. Multivariate determinants of six month survival were left ventricular failure, treatment with thrombolysis and aspirin, smoking history, bundle branch block, and age. For patients who survived six months, age was the only factor related to long term survival. CONCLUSIONS--Although patients treated by thrombolysis had a relatively good prognosis, long term mortality and the incidence of non-fatal recurrent ischaemic events remained high. Effective strategies for the identification and treatment of high risk patients need to be reassessed.     

Feasibility,safety, and efficacy of domiciliary thrombolysis by general practitioners: Grampian region early anistreplase trial. GREAT Group.

OBJECTIVE--To assess the feasibility, safety, and efficacy of domiciliary thrombolysis by general practitioners. DESIGN--Randomised double blind parallel group trial of anistreplase 30 units intravenously and placebo given either at home or in hospital. SETTING--29 rural practices in Grampian admitting patients to teaching hospitals in Aberdeen (average distance 36 (range 16-62) miles). PATIENTS--311 patients with suspected acute myocardial infarction and no contraindications to thrombolytic therapy seen at home within four hours of onset of symptoms. MAIN OUTCOME MEASURES--Time saving, adverse events, Q wave infarction, left ventricular function. RESULTS--Anistreplase was administered at home 101 minutes after onset of symptoms, while anistreplase was given in hospital 240 minutes after onset of symptoms (median times). Adverse events after thrombolysis were infrequent and, apart from cardiac arrest, not a serious problem when they occurred in the community: seven of 13 patients were resuscitated after cardiac arrest out of hospital. By three months after trial entry the relative reduction of deaths from all causes in patients given thrombolytic therapy at home was 49% (13/163 (8.0%) v 23/148 (15.5%); difference -7.6% (95% confidence interval -14.7% to -0.4%), p = 0.04). Full thickness Q wave infarction was less common in patients with confirmed infarction receiving treatment at home (65/122 (53.3%) v 76/112 (67.9%); difference -14.6% (95% confidence interval -27.0% to -2.2%), p = 0.02). CONCLUSIONS--General practitioners provided rapid pre-hospital coronary care of a high standard. Compared with later administration in hospital, giving anistreplase at home resulted in reduction in mortality, fewer cardiac arrests, fewer Q wave infarcts, and better left ventricular function. Benefits were most marked where thrombolytic therapy was administered within two hours of the onset of symptoms.