Monty M. Zion

Circadian variation and possible external triggers of onset of myocardial infarction

PURPOSE To determine whether a circadian pattern in onset of symptoms existed and possible external triggers were implicated in the precipitation of acute myocardial infarction (AMI). PATIENTS AND METHODS One thousand eight hundred eighteen consecutive patients with AMI hospitalized in 14 of the 21 existing coronary care units in Israel during the study period were assessed. RESULTS The frequency of onset of symptoms by 6-hour intervals showed a predominant morning peak (6 AM to noon) (32%, p < 0.01) in comparison with the other three 6-hour intervals of the day. The preponderance of the morning peak persisted for subgroup analysis by gender (males 32%, females 31%); age (less than or equal to 65 years--32%; greater than 65 years--33%); diabetes mellitus (present or absent, 32%). However, patients with peripheral vascular disease and those with stroke in the past had a predominant evening peak. Possible external triggers of onset of AMI were present in 10% of patients. Exceptional heavy physical work, violent quarrel at work or at home, and unusual mental stress were the three most frequent possible external triggers reported immediately before or within the 24 hours preceding pain onset. Patients with possible external triggers were more likely to be males (85%) and were somewhat but not significantly younger (63.1 years) in comparison with patients without external triggers (73% and 64.3 years respectively). CONCLUSIONS In a large group of consecutive patients with AMI, a predominant cyclic morning peak of pain onset was found in comparison with the other hours of the day. Possible external triggers precipitating AMI were involved in a minority of cases, suggesting that endogenous changes occurring in the morning hours are generally responsible for the increased rate of myocardial infarction occurring after awakening.

Cerebrovascular accident complicating acute myocardial infarction: Incidence, clinical significance, and short-long-term mortality rates

Abstract purpose: The purpose of this study was to report the incidence, the antecedents, and the clinical significance of clinically recognized cerebrovascular accidents or transient ischemic attacks (CVA-TIA) complicating acute myocardial infarction. patients and methods: During 1981 to 1983, a secondary prevention study with nifedipine (SPRINT) was conducted in 14 hospitals in Israel among 2,276 survivors of acute myocardial infarction. During the study, demographic, historical, and medical data were collected on special forms for all patients with diagnosed acute myocardial infarction in 13 of these 14 hospitals (the SPRINT registry, n=5,839). Mortality followup was completed for 99% of hospital survivors for a mean follow-up of 5.5 years (range: 4.5 to 7 years). results: The incidence of CVA-TIA was 0.9% (54 of 5,839). The latter rate increased significantly only with age, from 0.4% among patients up to 59 years old to 1.6% among those aged greater than or equal to 70 years. Multivariate analysis identified age, congestive heart failure, and history of stroke as predictors of CVA-TIA during the acute phase of myocardial infarction. Patients with CVA-TIA exhibited a complicated hospital course, with a 15-day mortality rate of 41%. Subsequent mortality rates in survivors at 1 and 5 years were 34% and 59%, respectively. Rates at the same time points in patients without CVA-TIA were 16%,11%, and 29% (p conclusion: In this large cohort of consecutive patients with myocardial infarction, CVATIA was a relatively infrequent complication of acute myocardial infarction. Factors independently favoring the occurrence of CVA-TIA were old age, previous CVA, and congestive heart failure. CVA-TIA occurring during acute myocardial infarction independently increased the risk of early death threefold as well as the risk of long-term mortality in early-phase survivors (2.5-fold).

Heart disease in Africa, with particular reference to southern Africa

Abstract 1. 1. Racial differences of heart disease in Africa are discussed together with apparent differences in standards of normality of electrocardiograms and serum lipid patterns. 2. 2. The high incidence of ischemic heart disease in white South Africans and its virtual absence in the Bantu has been stressed. 3. 3. Heart diseases peculiar to Africa, such as idiopathic cardiac hypertrophy and endomyocardial fibrosis, are described. 4. 4. The difference in altitude found in two South African cities is shown to result in a different incidence of patent ductus arteriosus and in various differences in blood findings. The possibility of these blood differences causing different incidences of myocardial infarction is discussed. 5. 5. The general pattern of heart disease and its relationship to the pattern of other diseases in South Africa receives brief mention.

Effects of Enalapril on Lymphocyte Sodium, Potassium, Magnesium and Calcium Levels in Patients with Severe Congestive Heart Failure

Fifteen patients (median age 73 years) with severe congestive heart failure were treated with Enalapril for a total of 12 weeks with a significant improvement in their right atrial pressures and in their functional state. Renal function, serum potassium, magnesium and calcium levels were unchanged. Lymphocyte sodium, potassium and calcium levels were generally lower than control values throughout the study but these differences were only statistically significant early in the study. Lymphocyte magnesium levels were unchanged. These findings are in contrast to those previously reported in the literature for such patients treated with conventional diuretics.

Randomized Trials vs Data Banking

bound to improve the composition, and therefore the long-term results, of the surgical cohort. 3. All significant hemodynamic differences between the cohorts showed the medical cohort to be the more severely affected. Thus, the medical group had more patients with cardiomegaly, diffuse left ventricular dysfunction, mitral insufficiency, elevated left ventricular end-diastolic pressure and a low ejection fraction. Furthermore, although the difference did not achieve statistical significance, 55% of the medical patients had three vessel disease compared to 48% of the surgical group. These differences are far more meaningful than the lack of differences found in many of the other parameters tested. 4. Finally, and perhaps most fundamental, is the question of how the decision was made regarding surgical or medical therapy. In many centers the condition of the run-off vessels is a major factor in this decision, and in fact, in the final paragraph of the Data and Analysis section, the authors state that the distal run-off was specifically re-evaluated among the patients of subgroup F. Nevertheless, the results of this analysis do not appear within the text of the article and the reader cannot help feeling that such an analysis would show a considerable difference between the entire medical and surgical cohorts with the latter having superior distal vessels. The condition of the distal run-off vessels may itself be an important prognostic indicator. Unfortunately, the data are lacking to evaluate this point. Therefore, although one cannot fail to be impressed with the exhaustive data analysis provided in this retrospective study, it is important to recognize that the findings, no matter how statistically significant, cannot be used as a replacement for a properly designed, randomized prospective study. LEONARD J. LYON, M. D. Bergen Pines County Hospital Paramus, New Jersey 07652