CORONARY PREVENTION

1.AUTHOR Borghi-C, Ambrosioni-E.
INSTITUTION Department of Internal Medicine, University of Bologna, Italy.
TITLE Primary and secondary prevention of myocardial infarction.
SOURCE Clin-Exp-Hypertens 1996 Apr-May, VOL: 18 (3-4), P: 547-58, ISSN: 1064-1963 22 Refs.
Abstract The prevention of coronary artery disease (CHD) and particularly of myocardial infarction (MI) is based on some well designed strategies aimed at treating both asymptomatic high-risk patients (primary prevention) and patients with established CHD (secondary prevention). A positive impact from primary prevention can be basically achieved trough a reduction in high blood pressure and by correcting dyslipidemia. The benefit can be substantially increased by smoking cessation, increasing physical exercise, reduction of body weight, use of post-menopausal oestrogen, moderate alcohol consumption and use of high doses of vitamin E in those patients who are compliant with the specific strategies. Secondary prevention of MI can be again obtained by controlling blood pressure and reducing serum cholesterol in patients surviving acute MI who can also benefit from the administration of beta-blockers, aspirin and probably ace-inhibitors particularly in presence of left ventricular dysfunction. We suggest that in both arms of prevention, significant results can be achieved mainly by a multifactorial approach capable of correcting all the modifiable risk factors that contribute to the rather complex pathogenesis of CHD. Author.

2.AUTHOR Collins-R, Peto-R, Baigent-C, Sleight-P.
INSTITUTION Clinical Trial Service Unit, Nuffield Department of Clinical Medicine, University of Oxford, United Kingdom.
TITLE Aspirin, heparin, and fibrinolytic therapy in suspected acute myocardial infarction.
SOURCE N-Engl-J-Med 1997 Mar 20, VOL: 336 (12), P: 847-60, ISSN: 0028-4793 97 Refs.

3.AUTHOR Grassman-E-D, Johnson-S-A, Krone-R-J.
INSTITUTION Division of Cardiology, Loyola University Medical Center, Maywood, Illinois 60153, USA. [email protected]
TITLE Predictors of success and major complications for primary percutaneous transluminal coronary angioplasty in acute myocardial infarction. An analysis of the 1990 to 1994 Society for Cardiac Angiography and Interventions registries.
SOURCE J-Am-Coll-Cardiol 1997 Jul, VOL: 30 (1), P: 201-8, ISSN: 0735-1097.
Abstract OBJECTIVES:

The purpose of this study was to determine predictors of successful coronary angioplasty for acute myocardial infarction (MI) and associated predictors of the major complications of in-hospital mortality and emergency coronary artery bypass graft surgery.

BACKGROUND:

Primary angioplasty is being increasingly used to treat acute MI, but factors affecting the success and major complications have not been well studied. Forty laboratories have been contributing clinical and procedural data to the Society of Cardiac Angiography and Interventions (SCA&I) on primary angioplasty for acute MI.

METHODS:

Univariable and stepwise multivariable logistic regression analysis of clinical and procedural variables was used to calculate predictors of success and major complications.

RESULTS:

There were 4,366 primary angioplasty procedures reported from 1990 through 1994, with an overall success rate of 91.5%, an in-hospital mortality rate of 2.5% and a rate of emergency surgery of 4.3%. Higher laboratory primary angioplasty volume and lower age were predictive of success. An intraaortic balloon pump in place, cardiogenic shock and a moribund condition had negative predictive effects. Unsuccessful angioplasty, cardiogenic shock or a moribund state were predictive of in-hospital death. Unsuccessful angioplasty, the absence of a history of hypertension and the absence of congestive heart failure were predictive of emergency surgery.

CONCLUSIONS:

The rates of success and major complications in the SCA&I Registry are similar to other series. Predictors of success and major complications can be assessed and may be useful for risk stratifying candidates for primary angioplasty in acute MI. Author.

4.AUTHOR Sergeant-P, Blackstone-E, Meyns-B
INSTITUTION Cardiac Surgery Department, Gasthuisberg University Hospital Leuven, Belgium. Paul.[email protected]
TITLE Early and late outcome after CABG in patients with evolving myocardial infarction.
SOURCE Eur-J-Cardiothorac-Surg 1997 May, VOL: 11 (5), P: 848-56, ISSN: 1010-7940.
Abstract OBJECTIVE:

To study the determinants of early and late outcome after coronary artery bypass grafting (CABG) for evolving myocardial infarction.

METHOD:

269 consecutive patients underwent isolated primary or repeat CABG from 1971 to 1992 for evolving myocardial infarction. By institutional policy, these were patients, strictly diagnosed, infarcting either in the cardiac cateterization laboratory, shortly after a previous CABG, or on cardiac intervention waiting lists. At operation, 125 patients were hemodynamically stable, 89 patients in cardiogenic shock 55 patients in cardiopulmonary resuscitation (CPR). Interval between infarct onset and surgical reperfusion ranged from 53 min to 15 h (median, 135 min; 90% between 75 and 360). An internal mammary artery graft (IMA) was used in 81 patients. Cross-sectional follow-up was 100% complete and multivariable analysis was conducted in the hazard function domain.

RESULT:

One-month, 1-year and 10-year survival was 86, 84 and 66%, respectively. The 1-year and 10-year survival, stratified by hemodynamic class, was respectively 98 and 77% for the stable patients, 77 and 60% for the patients in shock and 62 and 49% for those undergoing CPR. Shock and CPR were incremental risk factors for early but not late risk. Use of an IMA graft was not a risk factor early or late in either stable or unstable patients.

CONCLUSION:

CABG can be performed with acceptable early and long-term risk in selected patients with evolving myocardial infarction, whatever their hemodynamic state. Outcome as regards survival is neither adversely or advantageously affected by choice of bypassing conduit. An evolving myocardial infarction with stable hemodynamics carries a lesser risk than an unstable anginal state with changing ST-segment. Author.

5.AUTHOR Anderson-H-V, Gibson-R-S, Stone-P-H, Cannon-C-P, Aguirre-F, Thompson-B, Knatterud-G-L, Braunwald-E.
INSTITUTION Cardiology Division, University of Texas Health Science Center, Houston 77225, USA.
TITLE Management of unstable angina pectoris and non-Q-wave acute myocardial infarction in the United States and Canada (the TIMI III Registry).
SOURCE Am-J-Cardiol 1997 Jun 1, VOL: 79 (11), P: 1441-6, ISSN: 0002-9149.
Abstract Management of Q-wave acute myocardial infarction (AMI) has been shown to differ between the United States and Canada, with more catheterization and revascularization procedures performed in the United States, but with little or no apparent difference in clinical outcomes. No previous studies have evaluated management differences for the acute coronary syndromes of unstable angina pectoris and non- Q-wave AMI. We therefore compared treatments and outcomes between 14 United States and 4 Canadian tertiary
care centers participating in an observational registry of all consecutive admissions for unstable angina or non-Q-wave AMI between 1990 and 1993. A random, stratified sample was selected for detailed assessment and follow-up. There were 1,733 patients enrolled in United States centers and 642 in Canadian ones. In United States centers patients were less likely to receive intravenous nitroglycerin, heparin, beta blockers, calcium antagonists, or > or = 2 anti-ischemic agents. Coronary arteriography during index hospitalization was equally frequent in both countries (63.4% vs 66.9%, p = 0.781), but at 6 weeks and 1 year coronary arteriography was slightly less frequent in the United States patients. Revascularization by coronary angioplasty or bypass surgery was equivalent at 6 weeks and 1 year; however, there were trends toward less angioplasty and more bypass surgery in the
United States than in Canada. Patients at United States centers stayed in the hospital fewer days than patients at Canadian centers (mean 8.2 vs 12.1 days, p <0.001). Death or AMI by 6 weeks was not different (4.8% vs 4.4%, p = 0.633), nor was it different at 1 year (10.0% vs 10.2%, p = 0.836). The combined outcome of death, AMI, or recurrent ischemia was more common in United States than in Canadian patients at 6 weeks (18.4% vs 13.9%, p = 0.004). Our findings indicate that United States physicians and hospitals did
not consistently utilize more resources and were not more aggressive than their Canadian counterparts when treating acute coronary syndromes during this period. Author.

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