Dag Elmfeldt

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.

A controlled trial of physical training after myocardial infarction: Effects on risk factors, nonfatal reinfarction, and death☆

Abstract The purpose of the trial was to analyze whether supervised physical training could reduce death and nonfatal reinfarction in a nonselected series of postinfarct patients. All patients born in 1913 and later, who were hospitalized for a myocardial infarction during 1968–1970 in Goteborg Sweden, were randomized to a training group (158 patients) and a control group (157 patients). Other treatment was exactly the same and standardized for the two groups. Twenty-seven percent were excluded from training. Training started 3 months after the infarct and was scheduled for three times a week. The training group had higher physical working capacity after 1 yr than the control group. Blood pressure was lower, but there was no differences in blood lipids. During 4 yr of follow-up, 28 patients died in the training group and 35 in the control group. The numbers of nonfatal reinfarcts were 25 and 28, respectively. Within the training group patients adhering to the program had lower mortality than those who did not, but the former also had lower initially predicted risk of dying. A special analysis of patients who attended the training program in comparison to matched controls also showed a lower mortality. No differences in mortality between the training group and the control group were statistically significant, however.

Registration of myocardial infarction in the city of Göteborg, Sweden

Abstract Since 1968 all cases of acute myocardial infarction (A.M.I.) up to certain ages have been registered in the city of Goteborg, Sweden. The method of registration of fatal as well as non-fatal cases is reported. By means of special investigations it is shown that less than 10 per cent of the survivors with clinical A.M.I, are missed in the routine registration. Clinically unrecognized cases were estimated to about 1 5 of all A.M.I. Morbidity and mortality data for men and women in quinquennial age groups up to 64 yr are given. Place of death is also reported, about 50 per cent occurring outside hospital. The need for strict diagnostic criteria and the necessity to register both morbidity and mortality in A.M.I. when studying and comparing different regions are stressed. The use of the register is exemplified.

Effect of metoprolol on indirect signs of the size and severity of acute myocardial infarction

In a double-blind randomized trial, 1,395 patients with suspected acute myocardial infarction (MI) were investigated to evaluate the possibility of limiting indirect signs of the size and severity of acute MI with the beta 1-selective adrenoceptor antagonist metoprolol. Metoprolol (15 mg) was given intravenously and followed by oral administration for 3 months (200 mg daily). Placebo was given in the same way. The size of the MI was estimated by heat-stable lactate dehydrogenase (LD[EC 1.1.1.27]) analyses and precordial electrocardiographic mapping. Lower maximal enzyme activities compared with placebo were seen in the metoprolol group (11.1 +/- 0.5 mukat X liter-1) when the patient was treated within 12 hours of the onset of pain (13.3 +/- 0.6 mukat X liter-1; n = 936; p = 0.009). When treatment was started later than 12 hours, no difference was found between the 2 groups. Enzyme analyses were performed in all but 20 patients (n = 1,375). Precordial mapping with 24 chest electrodes was performed in patients with anterior wall MI. The final total R-wave amplitude was higher and the final total Q-wave amplitude lower in the metoprolol group than in the placebo group. Patients treated with metoprolol less than or equal to 12 hours also showed a decreased need for furosemide, a shortened hospital stay, and a significantly reduced 1-year mortality compared with the placebo group, whereas no difference was observed among patients treated later on. After 3 months, however, there was a similar reduction in mortality among patients in whom therapy was started less than or equal to 12 hours and greater than 12 hours after the onset of pain. The results support the hypothesis that intravenous metoprolol followed by oral treatment early in the course of suspected myocardial infarction can limit infarct size and improve long-term prognosis.

Serum Lipids and Lipoproteins in Men after Myocardial Infarction compared with Representative Population Sample

A nonselected series of 229 postmyocardial infarction (MI) patients was studied for up to 2 years following hospitalization. Their lipoprotein patterns, serum cholesterol, and triglyceride values were compared to those of a random population sample of men at comparable ages.Hyperlipoproteinemia, cholesterol, and triglyceride elevations were more common in MI patients than in men in the random sample, occurring with greatest frequency in the younger patients. There was a trend toward higher mortality among patients with hyperlipoproteinemia. Types II A and B were very common in young patients.Serum cholesterol values were significantly higher in the youngest patients and serum triglycerides higher than in the controls in age groups ≦ 40, 46-50, and 51-55 years.

Hypertension and myocardial infarction.

In a representative series of male patients (n = 504) surviving the hospital stay of a first myocardial infarction the prevalence of hypertension and the influence of hypertension on the prognosis during 2 yr follow-up were studied. According to the definitions used hypertension had been detected before or was detected after myocardial infarction in 36% of the patients. Two thirds had a history of hypertension known before infarction. The systolic and diastolic blood pressures measured at 3 months and 1 yr after infarction increased with age. There was no difference between patients with and without hypertension with respect to a number of different variables recorded during the hospital period, nor in multiple risk according to a logistic function. There was no difference in death rate between the two groups. However, the rate of non-fatal reinfarction was significantly higher among the hypertensive patients. Hypertension remained as a risk factor for after myocardial infarction when the possible confounding influences of serum lipid levels and tobacco smoking were analysed.

β-Blockers versus saluretics in hypertension: Comparison of total mortality, myocardial infarction, and sudden death: Study design and early results on blood pressure reduction

Abstract Beta-blocking drugs may be more effective than saluretic diuretics in reducing the total mortality and incidence of myocardial infarction, sudden death and stroke in middle-aged men with mild to moderate hypertension. To test this hypothesis, an international multicenter, randomized study is in progress, and its design and some early results are presented here. It is probable that 4,000–5,000 men will need to be enrolled for five years to show a statistically significant difference between treatments. Identical control of blood pressure in the two treatment groups is mandatory, and has been achieved using a fixed therapeutic schedule. The ongoing study will be completed during 1985–1990.

Alpha-lipoprotein cholesterol concentration in relation to subsequent myocardial infarction in hypercholesterolemic men

Abstract In a prospective study, α-lipoprotein (α-Lp) cholesterol concentration was studied in relation to subsequent myocardial infarction. Serum lipids including α-Lp cholesterol were studied in a hypercholesterolemic subsample of a random population sample. A group of 450 males (47–54 years old) was examined. Eighteen cases of myocardial infarction developed during the follow-up period. Controls were selected from the same subsample and controls were matched to patients with respect to age, serum cholesterol and triglyceride levels. Three controls were matched to each patient. There was no difference between patients and controls in α-Lp cholesterol concentration. Groups were also similar in both systolic and diastolic blood pressure and body weight. The only difference between patients and controls was a higher frequency of tobacco smokers among patients ( P The results suggest that α-Lp cholesterol level is not a risk factor for myocardial infarction in hypercholesterolemic subjects.

Blood coagulation and fibrinolysis in man after myocardial infarction compared with a representative population sample

Abstract Blood coagulation and fibrinolysis were studied in a group of 83 patients 3 months after their first myocardial infarction (MI). All patients were below 55 years of age (mean 49 years). A randomly selected subsample ( n = 76) of 55-year-old men from the general population was used as a control series. The MI group had shorter clotting time of recalcified plasma, shorter partial thromboplastin time (PTT) in silicone tubes but not in glass tubes and lower factor II-VII-X activity than the control series. No other significant differences were found. The possibilities of finding out the significance of blood coagulation and fibrinolysis for coronary thrombosis and MI are discussed.

Morbidity in representative male survivors of myocardial infarction compared to representative population samples

Abstract Non-selected male survivors of a first myocardial infarction aged 27–67 ( n = 299) were compared with representative population samples with respect to prevalence of previous diseases and symptoms. The infarction patients comprised 90% of all surviving, diagnosed cases of primary infarction in men aged 67 yr and below during the years 1968–1970 in Goteborg, Sweden. Among the patients there was a significantly higher proportion of men with angina pectoris on effort at least four weeks prior to the interview, dyspnea on effort, cerebrovascular stroke, intermittent claudication, diabetes mellitus, gallstone, and kidney stone than in the population samples. The differences did not, however, reach statistical significance in all age groups. Chronic bronchitis tended to be more common among the patients, but there was no difference with respect to peptic ulcer.