Å Hjalmarson

EFFECT ON MORTALITY OF METOPROLOL IN ACUTE MYOCARDIAL INFARCTION: A Double-blind Randomised Trial

The effect of metoprolol on mortality was compared with that of placebo in a double blind randomised trial in patients with definite or suspected acute myocardial infarction. Treatment with metoprolol or placebo started as soon as possible after the patients arrival in hospital and was continued for 90 days. Metoprolol was given as a 15 mg intravenous dose followed by oral administration of 100 mg twice daily. 1395 patients (697 on placebo and 698 on metoprolol) were included in the trial. Definite acute myocardial infarction developed in 809 and probable infarction in 162. Patients were allocated to various risk groups and within each group patients were randomly assigned to treatment with metoprolol or placebo. There were 62 deaths in the placebo group (8.9%) and 40 deaths in the metoprolol group (5.7%), a reduction of 36% (p less than 0.03). Mortality rates are given according to the treatment group to which the patients were initially randomly allocated.

Distress correlates with the degree of chest pain: a description of patients awaiting revascularisation.

AIM: To describe various symptoms other than pain among consecutive patients on the waiting list for possible coronary revascularisation in relation to estimated severity of chest pain. DESIGN: All patients were sent a postal questionnaire for symptom evaluation. SUBJECTS: All patients in western Sweden on the waiting list in September 1990 who had been referred for coronary angiography or coronary revascularisation (n = 904). RESULTS: 88% of the patients reported chest pain symptoms that limited their daily activities to a greater or lesser degree. Various psychological symptoms including anxiety and depression were strongly associated with the severity of pain (P < 0.001), as were sleep disturbances (P < 0.001), and dyspnoea and various psychosomatic symptoms (P < 0.001). Nevertheless only 44% of the patients reported chest pain as the major disruptive symptom, whereas the remaining 56% reported uncertainty about the future, fear, or unspecified symptoms as being the most disturbing. CONCLUSIONS: In a consecutive series of patients on the waiting list for possible coronary revascularisation, half the participants reported that uncertainty and fear were more disturbing than chest pain.

Prognosis of acute myocardial infarction in diabetic and non-diabetic patients

We evaluated the prognosis of 858 patients with acute myocardial infarction (MI), of whom 97 (11%) had a history of diabetes mellitus. Among patients with diabetes the 1‐year mortality rate was 41% versus 26% for non‐diabetic patients (p < 0.01), and the 1‐year reinfarction rates were 23% and 14%, respectively (p = 0.05). Diabetic patients with a history of hypertension had a similar mortality rate as comapred with diabetic patients without hypertension. In a multivariate analysis including age and history of cardiovascular disease, diabetes did not significantly contribute to death or reinfarction. Among diabetic patients the only independent risk factor for death was age. The place and mode of death appeared similar in the two groups. Patients with and without a history of diabetes had a similar infarct size. We conclude that diabetic patients with acute myocardial infarction have a very poor prognosis. Within 1 year nearly half of them are dead and one‐quarter develop reinfarction. The mode of death appeared to be similar in diabetic patients as compared with non‐diabetic patients.

Patients with uncomplicated coronary artery disease have reduced heart rate variability mainly affecting vagal tone

AIM To investigate whether uncomplicated chronic coronary artery disease causes changes in heart rate variability and if so, whether the heart rate variability pattern is different from that described in patients with acute myocardial infarction. METHODS Heart rate variability was studied in 65 patients with angina who had no previous myocardial infarcts, no other diseases, and were on no drug that could influence the sinus node. Results were compared with 33 age matched healthy subjects. The diagnosis of coronary artery disease in angina patients was established by coronary angiography in 58, by thallium scintigraphy in six, and by exercise test only in one. Patients and controls were Holter monitored 24 hours outside hospital, and heart rate variability was calculated in the frequency domain as global power (GP: 0.01–1.00 Hz), low frequency peak (LF: 0.04–0.15 Hz), high frequency peak (HF: 0.15–0.40 Hz), LF/HF in ms2, and in the time domain as SDNN (SD of normal RR intervals), SDANN (SD of all five minute mean normal RR intervals), SD (mean of all five minute SDs of mean RR intervals), rMSSD (root mean square of differences of successive normal RR intervals) (all in ms), and pNN50 (proportion of adjacent normal RR intervals differing more than 50 ms from the preceding RR interval) as per cent. RESULTS The mean age in patients and controls was 60.4 (range 32–81) and 59.1 (32–77) years, respectively (NS), the male/female ratio, 57/65 and 24/33 (NS), and the mean time of Holter monitoring, 23.0 (18–24) and 22.8 (18–24) hours (NS). Mortality in angina patients was 0% (0/65) at one year, 0% (0/56) at two years, and 3% (1/33) at three years. Compared with healthy subjects angina patients showed a reduction in GP (p = 0.007), HF (p = 0.02), LF (p = 0.02), SD (p = 0.02), rMSSD (p = 0.01), and pNN50 (p = 0.01). No significant difference was found in RR, LF/HF, SDNN, or SDANN. CONCLUSIONS Uncomplicated coronary artery disease without previous acute myocardial infarction was associated with reduced high and low frequency heart rate variability, including vagal tone. SDANN and SDNN, expressing ultra low and very low frequencies which are known to reflect prognosis after acute myocardial infarction, were less affected. This is in agreement with the good prognosis in uncomplicated angina in this study.

Eligibility for intravenous thrombolysis in suspected acute myocardial infarction.

Based on the registration of all the 7,157 patients admitted during a 21-month period to the emergency ward of a single hospital in an urban area with chest pain or other symptoms suggestive of acute myocardial infarction, we studied eligibility for intravenous thrombolysis in suspected acute myocardial infarction. We have limited the present analysis to those 1,715 patients with a strong suspicion of myocardial infarction, and for these patients, we have calculated the percentages eligible for thrombolysis when various electrocardiographic and delay time criteria are applied, but we have not considered contraindications to thrombolysis. We have also calculated the proportions of all infarctions in this group that would thereby receive the treatment, and the proportions of patients treated that would develop a confirmed infarction. Using the criteria ST elevation on the initial electrocardiogram and arrival in hospital within 6 hours from onset of symptoms, 18% of patients would have been given early intravenous thrombolysis, 37% of confirmed infarctions would have been treated, and 91% of all treated patients would have developed a confirmed infarction; with a delay time criterion of 12 hours, these percentages would have been 20%, 41%, and 91%, respectively; with a criterion of 24 hours, they would have been 22%, 45%, and 90%, respectively. By not considering the initial electrocardiogram and applying only the criterion of delay time, these percentages would have been 70%, 72%, and 45%, respectively, for a delay time of 6 hours; 83%, 84%, and 45%, respectively, for a delay time of 12 hours; and 91%, 92%, and 44%, respectively, for a delay time of 24 hours.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognosis in hypertensives with acute myocardial infarction

Objectives: A previous history of hypertension is overrepresented among patients with ischaemic heart disease. The present study aims at describing the influence of a previous history of hypertension upon the prognosis among patients hospitalized due to acute myocardial infarction. Design: Patients were followed for 1 year. Mortality and morbidity are described during hospitalization and after discharge from hospital. Setting: Sahlgrenska Hospital, serving half of the area of Gothenburg in Sweden. Patients: All patients admitted to Sahlgrenska Hospital during 21 months due to acute myocardial infarction regardless of age and whether they were admitted to the coronary care unit. Results: Among all patients with confirmed acute myocardial infarction (n = 917) a previous history of hypertension was reported in 324 patients. Hypertensives more frequently had a previous history of acute myocardial infarction, angina pectoris, congestive heart failure and diabetes mellitus. Their mortality during hospitalization was similar to that in normotensives. However, the total mortality during 1 year of follow-up was 35% in hypertensives and 25% for normotensives (P < 0.01), and a previous history of hypertension was an independent risk indicator for death after discharge from hospital. Place and mode of death appeared similar in normotensives and hypertensives. Reinfarction was twice as common in hypertensives as in normotensives, and a previous history of hypertension was an independent risk indicator for reinfarction. Conclusions: Among patients with acute myocardial infarction a previous history of hypertension indicates a poor prognosis, one-third of patients dying and one-quarter developing reinfarction during the first year after onset of acute myocardial infarction.

Variability of chest pain in suspected acute myocardial infarction according to subjective assessment and requirement of narcotic analgesics.

In 653 patients with suspected acute myocardial infarction the course of pain according to subjective assessment and morphine requirement is described. Patients were asked to score pain from 0-10 until a pain-free interval of 12 hours appeared. Different categories of patients constructed from clinical aspects were compared. Although the variability between groups was fairly small, subgroups were found in which the initial intensity of pain was more marked and the duration of pain was longer. Thus patients with larger infarcts according to maximum serum enzyme activity and patients with Q-wave infarction had more severe pain initially and also a longer duration and a higher morphine requirement compared with patients with a lower serum enzyme activity or a non-Q-wave infarction. Other groups with a more severe course of chest pain were those with more intensive pain at home, electrocardiographic signs of acute myocardial infarction on admission to hospital, and finally those with a high systolic blood pressure or a high rate-pressure product on admission to the Coronary Care Unit. We thus conclude that there is a variability of chest pain in suspected acute myocardial infarction and that there are defined groups of patients in which a more severe course of chest pain could be expected.

Delay time between onset of myocardial infarction and start of thrombolysis in relation to prognosis

In 292 patients with suspected acute myocardial infarction given thrombolytic agents, we describe the delay time between the onset of pain and the start of thrombolysis and relate the observations to the prognosis. In 3%, treatment was started 1 h or less and in 22% 2 h or less after onset of symptoms. The median delay time between onset of symptoms and arrival in hospital was 1 h 38 min, and the median delay time between the arrival in hospital and start of thrombolysis was 1 h 25 min. A very strong association between delay time to thrombolysis and mortality during 2 weeks and 1 year of follow-up was observed.

Metoprolol treatment for two years after coronary bypass grafting: effects on exercise capacity and signs of myocardial ischaemia.

OBJECTIVE--To evaluate whether prophylactic treatment with metoprolol for two years after coronary artery bypass grafting improves working capacity and reduces the occurrence of myocardial ischaemia in patients with coronary artery disease. METHODS--After coronary artery bypass grafting, patients were randomised to treatment with metoprolol or placebo for two years. Two years after randomisation, a computerised 12-lead electrocardiogram was obtained during a standardised bicycle exercise test in 618 patients (64% of all those randomised). RESULTS--The median exercise capacity was 140 W in the metoprolol group (n = 307) and 130 W in the placebo group (n = 311) (P > 0.20). An ST depression of > or = 1 mm at maximum exercise was present in 34% of the patients in the metoprolol group and 38% in the placebo group (P > 0.20) and an ST depression of > or = 2 mm at maximum exercise was present in 11% in the metoprolol group and 16% in the placebo group (P = 0.09). The median values for maximum systolic blood pressure were 200 mm Hg in the metoprolol group and 210 mm Hg in the placebo group (P < 0.0001), while the median values for maximum heart rate were 126 beats/min in the metoprolol group and 143 beats/min in the placebo group (P < 0.0001). The occurrence of cardiac and neurological clinical events two years postoperatively among exercised patients was comparable in the treatment groups. CONCLUSIONS--Treatment with metoprolol for two years after coronary artery bypass grafting did not significantly change exercise capacity or electrocardiographic signs of myocardial ischaemia.

Ten-year mortality among patients with suspected acute myocardial infarction in relation to early diagnosis

Previous studies have compared the outcome between patients with and without a confirmed acute myocardial infarction (AMI) mainly during the first few years after its onset. Our aim was to compare the prognosis between patients with and without a confirmed AMI during 10 years of follow-up. Patients participating in an early intervention trial with metoprolol in suspected AMI between 1976 and 1981 took part in this evaluation. The total 10-year mortality rate including hospital mortality was 51% for patients with confirmed AMI as compared with 32% for patients with a possible AMI and 23% for patients in whom AMI was definitely ruled out (p < 0.001). The 10-year mortality after discharge from hospital was in AMI 46%, possible AMI 32% and in definitely ruled out AMI 23% (p < 0.001). When simultaneously considering age, sex, previous history of cardiovascular disease and smoking, the development of AMI appeared as an independent predictor of death (p < 0.001). Thus, among patients hospitalized due to suspected AMI, 10-year mortality after discharge from hospital was directly related to the diagnosis during the first 3 days in hospital.