Margareta Sjölin

Ten-year mortality amongst patients with a very small or unconfirmed acute myocardial infarction in relation to clinical history, metabolic screening and signs of myocardial ischaemia

Abstract. Karlson BW, Wiklund O, Hallgren P, Sjölin M, Lindqvist J, Herlitz J (Sahlgrenska University Hospital, Göteborg, Sweden). Ten‐year mortality amongst patients with a very small or unconfirmed acute myocardial infarction in relation to clinical history, metabolic screening and signs of myocardial ischaemia. J Intern Med 2000; 247: 449–456.

Rate and mode of death during five years of follow-up among patients with acute chest pain with and without a history of diabetes mellitus

In order to determine the effect of diabetes on the mortality rate and mode of death during 5 years of follow‐up among patients who came to the emergency department with acute chest pain or other symptoms suggestive of acute myocardial infarction (AMI), all patients thus presenting to one single hospital during a period of 21 months were followed for 5 years. In total 5230 patients were included, of whom 402 (8 %) had a history of diabetes. Patients with diabetes differed from those without by being older, having a higher prevalence of previously diagnosed cardiovascular diseases, having less symptoms of chest pain and more symptoms of acute severe heart failure, and more electrocardiographic (ECG) abnormalities on admission. Diabetic patients had a 5‐year mortality of 53.5 % as compared with 23.3 % among non‐diabetic patients (p < 0.001; adjusted risk ratio 1.60; 95% confidence limits 1.35–1.90). Among diabetic patients the following appeared as independent predictors of death: age (p < 0.001), ST‐segment elevation on admission (p < 0.001), a history of myocardial infarction (p < 0.05), and a non‐pathological ECG on admission (p < 0.001). We conclude that among diabetic patients admitted to the emergency department with acute chest pain or other symptoms suggestive of AMI more than 50 % are dead 5 years later. Future research should focus on interventions in order to reduce their mortality.

Ten year mortality in subsets of patients with an acute coronary syndrome

OBJECTIVE To describe the mortality during the subsequent 10 years for subsets of patients hospitalised for suspected acute coronary syndrome. PATIENTS AND METHODS All patients who were admitted to the emergency department in one hospital during 21 months for chest pain or other symptoms raising suspicion of an acute coronary syndrome were registered. From this baseline population three subgroups were defined among those being hospitalised: patients who developed a Q wave acute myocardial infarction (AMI) (n = 306); patients who developed a non-Q wave AMI (n = 527); and patients who developed confirmed or possible myocardial ischaemia (unstable angina pectoris) (n = 1274). These three groups were compared in terms of 10 year mortality. RESULTS Patients who developed a non-Q wave AMI had the highest 10 year mortality (70.3%), significantly higher than those who developed a Q wave AMI (60.1%; p = 0.004) and those who had confirmed or possible myocardial ischaemia (50.1%; p < 0.0001). There was no difference between patients with confirmed and those with possible myocardial ischaemia (50.0% and 50.1%, respectively). After correction for dissimilarities in age, sex, and history the adjusted risk ratio for death in patients with a non-Q wave AMI compared with Q wave AMI was 1.01 (95% confidence interval (CI) 0.82 to 1.25). The corresponding risk ratio for death in patients with a non-Q wave AMI compared with confirmed or possible myocardial ischaemia was 1.91 (95% CI 1.64 to 2.23). There was also an imbalance in drug regimens among groups. CONCLUSION This study shows that in a non-selected population of patients hospitalised with a suspected acute coronary syndrome, the highest risk of death is found in those with a non-Q wave AMI and the lowest in those with confirmed or possible myocardial ischaemia. Thus, patients with a Q wave AMI have a long term mortality risk intermediate between the two fractions defined as having unstable coronary artery disease. However, adjusting these results for age and history of cardiovascular disease eliminated the observed difference in mortality between non-Q wave and Q wave AMI. Furthermore, an imbalance in drug regimens might have affected the outcome.

Predictors of death during 5 years after hospital discharge among patients with a suspected acute coronary syndrome with particular emphasis on whether an infarction was developed.

AIM To describe predictors of death after hospital discharge during 5 years of follow-up in a consecutive series of patients surviving hospitalization for symptoms and signs of a confirmed or suspected acute coronary syndrome. PATIENTS AND METHODS All patients who between February 15, 1986 and November 9, 1987, were hospitalized at Sahlgrenska University Hospital in Göteborg, Sweden, and fulfilled the above given criteria. RESULTS In all, 1948 patients were included of whom 731 (38%) had a confirmed acute myocardial infarction (AMI). Independent risk indicators for death were: age (P=0.0001); male sex (P=0.005); a history of previous AMI (P=0.0001), diabetes mellitus (P=0.003) and smoking (P=0.0001); development of AMI during first 3 days in hospital (P=0.0001); in-hospital signs of congestive heart failure (P=0.0001); prescription of digitalis (P=0.001) and diuretics (P=0.02) at hospital discharge. A history of smoking interacted significantly (P=0.02) with the relationship between development of AMI and prognosis. Thus, the difference between patients who did and who did not develop an AMI was more pronounced among non-smokers than smokers. Other factors which interacted significantly with this relationship were a history of angina pectoris, and development of ventricular fibrillation and hypotension while in hospital. CONCLUSION Among hospital survivors of a confirmed or suspected acute coronary syndrome predictors of death during 5 years were: age, male sex, history of AMI, diabetes mellitus and smoking, development of AMI and congestive heart failure while in hospital and prescription of digitalis and diuretics at hospital discharge. A history of smoking and angina pectoris as well as development of hypotension and ventricular fibrillation while in hospital interacted significantly with the relationship between development of AMI and prognosis.

Predictors and mode of death over 5 years amongst patients admitted to the emergency department with acute chest pain or other symptoms raising suspicion of acute myocardial infarction.

Herlitz J, Karlson BW, Lindqvist J, Sjölin M (Sahlgrenska University Hospital, Göteborg, Sweden). Predictors and mode of death over 5 years amongst patients admitted to the emergency department with acute chest pain or other symptoms raising suspicion of acute myocardial infarction. J Intern Med 1998; 243: 41–48.

Survival, Mode of Death, Reinfarction and Use of Medication during a Period of 5 Years after Acute Myocardial Infarction in Different Age Groups

We describe the prognosis during 5 years of follow-up among consecutive patients hospitalized in a single hospital due to acute myocardial infarction in various age groups. When considering various aspects of clinical history, age was the strongest independent predictor of total 5-year mortality and of 5-year mortality after discharge from hospital. The overall 5-year mortality was: age < 65, 23%; age 65-75, 49%; age > 75, 79% (p < 0.001). The relationship between age and death appeared to be similar regardless of the development of Q waves, infarct size and infarct site. Among patients who died, younger patients more frequently died a sudden death associated with ventricular fibrillation, whereas the elderly more frequently died in association with congestive heart failure.

Characteristics and long-term outcome of patients with acute chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to whether they were hospitalized or directly discharged from the emergency department

AimTo describe the characteristics and outcome of patients who came to the emergency department due to chest pain or other symptoms raising suspicion of acute myocardial infarction (AMI) in relation to whether they were hospitalized or directly discharged from the emergency department. MethodsAll patients arriving to the emergency department in one single hospital due to chest pain or other symptoms raising suspicion of AMI during a period of 21 months were followed for 10 years. ResultsIn all, 5362 patients fulfilled the given criteria on 7157 occasions; 3381 (63%) were hospitalized and 1981 (37%) were directly discharged. Patients who were hospitalized were older and had a higher prevalence of previous cardiovascular diseases. The mortality during the subsequent 10 years was 52.1% among those hospitalized and 22.3% among those discharged (P  < 0.0001). Risk indicators for death were similar in the two cohorts. However, many of these risk indicators including age, a history of myocardial infarction, angina pectoris, congestive heart failure, hypertension, initial degree of suspicion of AMI, a pathologic electrocardiogram on admission and a confirmed AMI as underlying etiology were more strongly associated with the prognosis among patients directly discharged than among those hospitalized. Ten (0.5%) of the patients who were directly discharged from the emergency department were found to have a diagnosis of confirmed or possible AMI, making up 1% of all patients given such a diagnosis. These patients had a 10-year mortality of 80.0% compared with 65.7% among patients with a confirmed or possible AMI who were hospitalized. ConclusionOf patients who came to the emergency department with acute chest pain or other symptoms suggestive of AMI about a third were directly discharged. Their mortality during the subsequent 10 years was half that of patients hospitalized. Various risk indicators for death were more strongly associated with prognosis in the patients who were directly discharged from the emergency department compared to those hospitalized. Of all patients given a diagnosis of confirmed or possible AMI, 1% were discharged from the emergency department. Their long-term mortality was high, maybe even higher than among AMI patients hospitalized.

Prognosis during five years of follow-up among patients admitted to the emergency department with acute chest pain in relation to a history of hypertension.

AIM To describe the mortality, mode and place of death and risk indicators of death during 5 years of follow-up among patients admitted to the emergency department (ED) with acute chest pain or other symptoms raising a suspicion of acute myocardial infarction (AMI) in relation to a history of hypertension. METHODS All the patients admitted to the ED at Sahlgrenska University Hospital during a period of 21 months with acute chest pain or other symptoms raising a suspicion of AMI were followed up prospectively for 5 years. RESULTS Of 5,355 patients fulfilling the inclusion criteria, 22% had a history of hypertension. Hypertensive patients differed from non-hypertensive patients in that there were more females, they were older and had a higher prevalence of previous cardiovascular disease. Patients with a history of hypertension had a 5-year mortality rate of 37.4% as compared with 22.2% among non-hypertensive patients (p < 0.001). The difference in mortality appeared to be more marked among patients without a history of cardiovascular disease. A history of hypertension was an independent predictor of death. Risk indicators of death appeared to be relatively similar among patients with and without a history of hypertension. Of the patients who died, those with a history of hypertension were more frequently judged to have suffered a cardiac death and died more frequently in association with an AMI. CONCLUSION Among patients admitted to the ED with acute chest pain and with a history of hypertension, 37% died during the following 5 years. A history of hypertension was an independent predictor of death.

Five-year mortality after acute myocardial infarction in relation to previous history, level of initial care, complications in hospital, and medication at discharge.

SummaryThe purpose of this study was to describe the prognosis during 5 years of follow-up in a consecutive population of patients discharged from hospital after acute myocardial infarction (AMI) in relation to clinical history, level of initial care, complications during hospitalization, and medication at discharge. All patients admitted to a single hospital from February 15, 1986 to November 9, 1987 due to AMI, regardless of age and whether or not they were treated in the coronary care unit, and who were discharged alive from hospital were included in the study. There were 862 patients with AMI, 740 of whom were discharged alive. Information on medication at discharge was available in 713 patients (96%). In a multivariate analysis taking into account age, sex, history of cardiovascular diseases, whether patients were admitted to coronary care unit or not, complications during hospitalization, and medication at discharge, the following factors appeared to be independent predictors of mortality: age (p<0.001), history of AMI (p<0.001), congestive heart failure in hospital (p<0.001), whether beta-blockers had been prescribed at discharge (p<0.01), and a history of diabetes (p<0.01). This study indicates that in consecutive patients surviving the hospital phase of AMI, the development of complications while in hospital and the manner in which medication was prescribed at discharge independently influenced their longterm prognosis, but age was the most important factor in long-term prognosis.

Long-term mortality among patients discharged alive after out-of-hospital cardiac arrest does not differ markedly compared with that of myocardial infarct patients without out-of-hospital cardiac arrest.

The aim of our research was to study the long-term prognosis among patients discharged alive after an out-of-hospital cardiac arrest (OHCA) in comparison with patients discharged alive after acute myocardial infarction (AMI) without OHCA, and also to study the long-term influence of AMI in connection with OHCA. Our research was conducted in the municipality of Göteborg. We retrospectively studied patients discharged from hospital 1990–91 after an OHCA of cardiac aetiology and patients discharged after an AMI without prehospital cardiac arrest. During 1980–98, we studied all patients discharged alive after OHCA of cardiac aetiology, divided into groups of precipitating AMI and no AMI. The study includes 48 patients discharged alive after an OHCA 1990–91, 30 (62%) of whom had a simultaneous AMI and 1425 patients with an AMI without OHCA. Compared with AMI survivors, survivors of an OHCA of cardiac origin were younger but had more frequently a history of congestive heart failure. Their mortality rate during the subsequent 5 years was 46%, compared with 40% among survivors of an AMI (NS). The 5-year mortality rate among patients with an OHCA precipitated by an AMI was 40%. When correcting for differences at baseline, the adjusted risk ratio for death among patients with an OHCA of cardiac origin was 1.2 (95% CI 0.8–1.8) compared with patients with an uncomplicated AMI. During 1980–98, 215 patients were judged as having an OHCA precipitated by an AMI and 115 patients had an OHCA of cardiac aetiology but no simultaneous AMI. Five-year mortality was 54% and 50% respectively (NS). It is concluded that survivors of an OHCA of cardiac origin differed from survivors of an uncomplicated AMI in that they were younger and more frequently had a history of cardiovascular disease. Their 5-year mortality after discharge was similar to that of survivors of an AMI without a prehospital cardiac arrest, even after adjusting for differences at baseline.