Kunihiro Kinjo

Depressive Symptoms Predict 12-month Prognosis in Elderly Patients with Acute Myocardial Infarction

Background Several studies have associated depressive symptoms with an increased risk for cardiac events after the onset of acute myocardial infarction (AMI). The aim of the present study is to investigate the impact of the depressive symptoms on prognosis of the elderly patients with AMI. Method Depression was assessed in consecutive patients with AMI (n=1042; mean age 63 ± 11 years) using the Zung Self-Rating Depression Scale (SDS). Patient with a score ≥ 40 was classified as having depressive symptoms. Cardiac events (cardiac death, nonfatal re-MI, coronary angioplasty or bypass surgery, readmission for heart failure, unstable angina, or uncontrolled arrhythmia) were examined during 12 months follow-up period. Results Depressive symptoms were observed in 438 patients (42.0%). Prevalence of depression was not dependent of age (P=0.60) and gender (P=0.91). The rate of cardiac events was 31.2% per year in patients with depressive symptoms whereas 23.9% per year in patients without depressive symptoms. Multiple logistic regression analyses showed that depression was significantly associated with 1-year cardiac events (odds ratio 1.41, 95% CI 1.03 to 1.92, P=0.03) after controlling for age, gender, severity of myocardial infarction, coronary risk factors, e.g. hypertension, diabetes mellitus and smoking habits. Depression was a significant risk factor for the cardiac events (log rank, P=0.02) in the elderly patients (≥65 years old, 501 patients). However, the association of depression with cardiac events in the young patients (< 65 years old, 541 patients) was not statistically significant (P=0.11). Conclusion Depression after AMI is a significant predictor of 1-year cardiac events for Japanese population, and its presence augments the risk especially in the elderly patients.

Impact of high-sensitivity c-reactive protein on predicting long-term mortality of acute myocardial infarction

Although the C-reactive protein (CRP) concentration measured shortly after acute myocardial infarction (AMI) is associated with infarct size, its prognostic value is controversial. The reduction of CRP is accelerated by reperfusion. Therefore, the CRP concentration, measured during the stable phase of AMI in patients treated predominantly with reperfusion therapies, may be independent of infarct size and may predict long-term mortality. We studied 1,309 patients with AMI enrolled in the Osaka Acute Coronary Insufficiency Study between April 1999 and June 2001. CRP was measured during the stable phase (mean 25 days after AMI onset). The patients were followed for an average of 522 days. Reperfusion therapies were performed in 90% of the patients. Patients in the highest quartile of CRP values (> or =0.38 mg/dl) were older, had higher prevalences of diabetes mellitus, and had higher Killip classes than patients in the lower 3 quartiles (<0.38 mg/dl). Multivariate logistic regression analysis revealed that CRP was independently associated with age and the absence of revascularization therapies. Patients in the highest quartile had a higher long-term mortality rate than patients in the lower 3 quartiles (8.9% vs 2.0%; p <0.001). Multivariate Cox regression analysis revealed that the highest quartile of CRP values was an independent predictor of long-term mortality (hazard ratio 4.94, 95% confidence interval 1.13 to 21.6). We conclude that CRP measured during the stable phase of AMI is not associated with infarct size in the reperfusion era but is significantly associated with long-term mortality of AMI.

Effect of successful late reperfusion by primary coronary angioplasty on mechanical complications of acute myocardial infarction.

It has been suggested that early treatment decreases, but late treatment increases, the risk of mechanical complications for a thrombolytic strategy. However, few studies have evaluated whether late reperfusion (LR) by primary coronary angioplasty decreases the risk of mechanical complications. A total of 2,209 patients with acute myocardial infarction treated with primary coronary angioplasty within 24 hours after the onset of symptoms were divided into 3 groups: early reperfusion (ER; < or =12 hours, n = 1,647), LR (>12 hours, n = 219), and failed reperfusion (FR; n = 343). We evaluated the incidence, risk ratio, and predictors of mechanical complications. The overall incidence of mechanical complications was 2.0%. The incidence of mechanical complications was highest in the FR group (ER 1.4%, LR 1.8%, FR 5.0%; p <0.01). After adjusting for clinical variables, the risk ratio for mechanical complications increased in the FR group compared with the LR group (risk ratio 7.34, 95% confidence interval [CI] 1.02 to 52.80; p = 0.04). Predictors of an increased risk of mechanical complications by multivariate analysis were age > or =70 years (odds ratio [OR] 3.68, 95% CI 1.56 to 8.64; p <0.01), Killip class > or =II (OR 3.73, 95% CI 1.53 to 9.12; p <0.01), absence of collateral vessels (OR 4.09, 95% CI 1.17 to 14.26; p = 0.03), and FR (OR 2.68, 95% CI 1.09 to 6.61; p = 0.03). In conclusion, successful LR by primary coronary angioplasty is associated with the reduced risk of mechanical complications in patients with acute myocardial infarction.

Variation during the week in the incidence of acute myocardial infarction: increased risk for Japanese women on Saturdays

Background: Variations in the incidence of acute myocardial infarction during the week may differ between and within communities, according to lifestyle. Objective: To identify potential triggering factors for acute myocardial infarction by examining variations in incidence in the days of the week within the Osaka area of Japan. Patients: Of 2511 consecutive patients in this region who were admitted to hospital for acute myocardial infarction between April 1998 and March 2001 and consented to take part, 2400 who had a definitely identified time of onset were enrolled. Results: For this group as a whole, no significant difference in incidence was noted between days of the week. However, in subgroup analyses women were shown to have significant variation through the week, peaking on Saturday with a 39% increase in relative risk (p = 0.037); working subjects showed a peak on Monday, with a 26% increase in relative risk (p = 0.038). Stratified analyses showed that in working men there was a prominent Monday peak in the onset of infarction, with a 30% increase in relative risk (p = 0.022), while in working women, there was no significant variation through the week. Conclusions: Earlier findings of a Monday peak linked to increased physical and mental occupational stress are confirmed. There is also an increase in uncertain risk factors on Saturdays for Japanese women, possibly involving a stressful weekend burden for women. Confirmation of this finding in other communities may help identify triggers of acute myocardial infarction and be useful in prevention.

Joint effects of Chlamydia pneumoniae infection and classic coronary risk factors on risk of acute myocardial infarction.

BACKGROUND Although not in itself strongly predictive of coronary heart disease, Chlamydia pneumoniae infection could interact with classic risk factors in determining risk of acute myocardial infarction (AMI). METHODS We assessed C pneumoniae immunoglobulin (Ig) G and IgA titers and classic risk factors in 618 patients with AMI and in 967 controls. RESULTS IgG titers were not related to AMI, but a significant association was seen between IgA titers and AMI. Excess risk of AMI was noted mainly among patients with the highest IgA titers, such as those beyond 2.88 (the 95th percentile cutoff point in control subjects), showing a 1.8-fold increase in risk (odds ratio 1.75, 95% CI 1.04-2.92). Classic risk factors did not differ between subjects with IgA titers above and below the 95th percentile cutoff. However, in multivariate analyses, models incorporating both IgA titers and a classic risk factor such as obesity, hypercholesterolemia, or smoking predicted risk more effectively than single-parameter models. For example, the odds ratio for AMI among subjects with the highest IgA titers plus hypercholesterolemia was greater than the product of individual risks associated with these high IgA titers and with hypercholesterolemia. CONCLUSIONS Interactions with classic risk factors (ie, obesity, hypercholesterolemia, and smoking), increased the predictive value of C pneumoniae IgA antibody titers in determining risk of AMI.

Rationale and Design of the OACIS-LIPID Study That Evaluates Early Use of Pravastatin in Acute Myocardial Infarction

We conduct a prospective randomized study, the OACIS-LIPID, to determine whether early use of pravastatin can prevent secondary cardiac events in patients with acute myocardial infarction (AMI) and hyperlipidemia (HL). Three hundred and fifty Japanese patients with AMI and mild to moderate HL are randomly assigned to receive or not to receive pravastatin in an open-labeled fashion. The primary dose of pravastatin is 10 mg per day, which is a standard dose for the Japanese population. Both groups receive dietary counseling. Over a 9-month follow-up period, the combination of the endpoints (death, nonfetal myocardial infarction, unstable angina, noncardiac rehospitalization, revascularization and nonfetal stroke) will be evaluated. The results of the OACIS-LIPID study will determine the utility of a practical dose of hydroxymethylglutaryl coenzyme A reductase as an early intervention in AMI.