Arina Richter

Early prediction of acute myocardial infarction from clinical history, examination and electrocardiogram in the emergency room

The possibility of early prediction of acute myocardial infarction (AMI) was assessed in 7,157 consecutive patients coming to our emergency room during a 21-month period with chest pain or other symptoms suggestive of AMI. Of these patients 921 developed an AMI during the first 3 days in the hospital. Of the 4,690 patients admitted to hospital, 1,576 (34%) had a normal admission electrocardiogram, and 90 of these (6%) developed AMI. Of 1,964 patients with an abnormal electrocardiogram without signs of acute ischemia (42% of those admitted), 268 (14%) developed AMI, and 563 (51%) of 1,109 patients with acute ischemia on the electrocardiogram (24%) developed AMI. All patients were prospectively classified in the emergency room on the basis of history, clinical examination and electrocardiogram into 1 of 4 categories, according to the initial degree of suspicion of AMI. Of 279 admitted patients judged to have an obvious AMI (6% of the 4,690), 245 (88%) actually developed AMI; of 1,426 with a strong suspicion of AMI (30%), 478 (34%) developed one; of 2,519 with a vague suspicion of AMI (54%), 192 (8%) developed one; and of 466 with no suspicion of AMI (10%), 6 (1%) developed one. Thus, only a low percentage of the patients with a normal initial electrocardiogram or a vague initial suspicion of AMI developed a confirmed AMI.

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.

Prognosis in Patients with ST-T Changes but No Rise in Serum Enzyme Activity as Compared with Non-Q-Wave Infarction

We evaluated the prognosis for 419 patients admitted to hospital due to suspected acute myocardial infarction (AMI) who developed ST-T changes, but no rise in serum enzyme activity, and compared it to that of 508 patients developing non-Q-wave AMIs. We conclude that these patients have a high 1-year mortality (13%), although significantly lower than in patients with non-Q-wave AMIs (31%). The mortality is higher in patients with only ST depression (n = 86; 22%) than in patients with only T-wave inversion (n = 264; 8%).

One-year mortality rate after discharge from hospital in relation to whether or not a confirmed myocardial infarction was developed.

Consecutive patients admitted to our hospital with suspected acute myocardial infarction during 21 months were prospectively evaluated. One-year mortality after discharge from hospital was related to whether or not an infarction developed (infarct versus non-infarct patients). Of patients discharged alive after developing an infarct, there was a mortality of 17% (n = 777) versus 12% (n = 1830) (P less than 0.001) for all patients not developing infarction. In a high risk group (any of the following: age greater than or equal to 75 years, previous history of myocardial infarction, diabetes mellitus or congestive heart failure) patients developing infarction had a mortality of 24% (n = 457) versus 17% (n = 1221) for those who did not (P less than 0.001). In a low risk group (none of the high risk criteria), the corresponding mortality was 8% (n = 316) for patients suffering infarction and 3% (n = 603) for those not having infarction (P less than 0.001). The difference in mortality between patients with and without infarction was most marked in women (21% vs 11%; P less than 0.01) and in hypertensives (25% vs 12%; P less than 0.001), but less marked in men (16% vs 13%; NS) and in patients without hypertension (13% vs 12%; NS). Among patients not suffering infarction, mortality was particularly high in those with previous congestive heart failure (23%) and diabetes mellitus (21%).