Steven Borzak

Decline in the rate of hospital mortality from acute myocardial infarction: Impact of changing management strategies

This study examined the profile and management of acute myocardial infarction in patients hospitalized in the coronary care unit of Henry Ford Hospital to determine risk factors or treatments that best explained a decline in in-hospital mortality rates. During the 1980s and early 1990s, many therapeutic advances occurred in management of acute infarction. Overall and in-hospital mortality were observed also to decline, but little is known about the relation of newer treatments to clinical outcome. The study population consisted of 1798 patients with a confirmed diagnosis of myocardial infarction. Of these, 982 consecutive patients were hospitalized in the coronary care unit of Henry Ford Hospital from January 1981 through December 1984 and compared with the 816 consecutive patients hospitalized from January 1990 through October 1992. Data on baseline demographics, initial clinical features, in-hospital management, and in-hospital outcome were compared for the two groups. Logistic regression was used to define independent predictors of the improved outcome of the two groups. Demographic features of the earlier group were similar to those of the later cohort, with the exception of a greater incidence of diabetes and hypertension and a lesser incidence of angina and prior heart failure. The occurrence of non-Q wave infarction increased from 27% in the earlier to 39% in the later group, whereas the magnitude of peak creatine kinase elevation in serum was higher in the later group. Medical management differed significantly, with increased use of aspirin, thrombolytics, heparin, warfarin, nitrates, and beta-blockers and decreased use of antiarrhythmic agents, digoxin, and vasopressors in the later group. Coronary revascularization was performed during hospitalization in 6.4% of the earlier group of patients and 31.6% of the later group. In-hospital mortality was 14.7% in the earlier group and 7.4% in the later group. Multivariate logistic regression analysis showed that the difference in mortality between the two groups was best accounted for by increased use of beta-blockers, angioplasty, and thrombolytics, decreased incidence of cardiogenic shock and asystole, and decreased use of lidocaine. In conclusion, the presentation and in-hospital management of patients with acute myocardial infarction has changed from the early 1980s to the early 1990s. The improved hospital mortality rate may be associated with both the expanded use of effective therapies and a more favorable in-hospital course, although these are not mutually exclusive.

Short-term Hemodynamic Effects of Endothelin Receptor Blockade in Dogs With Chronic Heart Failure

BACKGROUNDnPlasma endothelin levels are increased in heart failure and may contribute to the increased peripheral vasoconstriction that characterizes this disease state. In the present study, we examined the effects of intravenous bosentan, a nonpeptide, competitive endothelin-1 receptor antagonist, on hemodynamics in dogs with chronic heart failure.nnnMETHODS AND RESULTSnChronic heart failure was produced in 11 dogs by multiple sequential intracoronary microembolization. At the time of study, left ventricular (LV) ejection fraction was 25 +/- 2%. Hemodynamic and echocardiographic measurements were made at baseline and at 15, 30, and 60 minutes after a bolus injection of bosentan (10 mg/kg). Bosentan had no significant effect on heart rate or mean aortic blood pressure. At 60 minutes, bosentan reduced LV end-diastolic pressure (17 +/- 2 versus 11 +/- 2 mm Hg; P < .05) and systemic vascular resistance (3891 +/- 379 versus 3071 +/- 346 dyne .s. cm-5; P < .05) compared with baseline and increased cardiac output (2.63 +/- 0.29 versus 3.33 +/- 0.46 L/min; P < .05), peak rate of change of LV pressure during isovolumic contraction and relaxation (1751 +/- 92 versus 2197 +/- 170 mm Hg/s; P < .05), and LV fractional shortening determined by echocardiography (30 +/- 2% versus 36 +/- 2%; P < .05).nnnCONCLUSIONSnShort-term intravenous bosentan reduced systemic vascular resistance and improved overall LV performance in dogs with chronic heart failure. These results suggest that endothelin-1 receptor antagonists may be useful therapeutic agents in the treatment of heart failure.

Bleeding associated with eptifibatide targeting higher risk patients with acute coronary syndromes: incidence and multivariate risk factors.

The objective of this study was to determine the safety of the glycoprotein Ilb/IIa receptor inhibitor eptifibatide in patients at high risk for adverse clinical outcomes and to determine risk factors for eptifibatide‐associated bleeding. Consecutive patients (n =175) who presented with an acute coronary syndrome and who were at high risk for adverse clinical outcomes were prospectively observed for eptifibatide‐associated bleeding, which was classified according to Thrombolysis in Myocardial Infarction (TIMI) and Global Use of Strategies to Open Occluded arteries (GUSTO) criteria. High risk was defined as unstable angina or non‐Q‐wave myocardial infarction with at least one of the following: left ventricular ejection fraction < 40%, diabetes mellitus, ST segment depression or transient ST segment elevation, serum [troponin I] > 2.5 ng/mL, and recurrent angina symptoms after initiation of conventional antianginal therapy Bleeding incidences in thepatients in this study were compared with those in the 4722 eptifibatide‐treated patients in the Platelet Glycoprotein IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial. Compared to PURSUIT patients, the population in this study was similar in age but had a higher proportion of females, African Americans, hypertension, diabetes, prior myocardial infarction, heart failure, and revascularization. Bleeding incidences in this studys patients were similar to or lower than those in the PURSUIT population: TIMI major 1.1% versus 10.8%, TIMI minor 12.6% versus 13.1%, GUSTO severe 1.7% versus 1.5%, GUSTO moderate 3.9% versus 11.3%, and GUSTO mild 19.7% versus 26.1%. Renal dysfunction was an independent risk factor for TIMI (odds ratio = 9.1 [95% CI= 1.6–52.5]) and GUSTO (odds ratio = 6.1 [95% CI = 1.2–30.0]) bleeding. In conclusion, despite being at higher risk for adverse outcomes, patients administered eptifibatide according to this studys institutional guidelines had comparable or lower bleeding rates than in the PURSUIT trial. Renal dysfunction is an independent risk factor for eptifibatide‐induced bleeding.

Sex and Outcome After Myocardial Infarction A Case of Sexual Politics

The concluding decades of the last millennium have brought about a dramatic transformation in the role of women in Western society. Along with a growth in equality in the social and political landscape, there has been an increased awareness of the manifestations of diseases and their diagnosis, management, and outcome in women.nnThe treatment of women with coronary disease has received particularly intense scrutiny. A multitude of studies have been published from administrative databases, patient registries, clinical trials, and population-based surveys. These have evaluated findings in women with diagnoses of chest pain, stable coronary disease, ST elevation myocardial infarction (MI), and non-ST elevation acute ischemic syndromes. Although the anatomic biological differences are incompletely understood,1 the following 3 key questions have been posed: (1) does the outcome of women with coronary artery disease differ from that of men? (2) Do treatment and management strategies differ between the sexes? (3) Is the effect of treatment and outcome similar for both sexes? The findings in studies have been inconsistent, but nonetheless, several areas of agreement and consensus exist (Table⇓).nnThe report by Gottlieb et al2 advances our understanding of the relationship between treatment and outcome in the setting of acute MI. This study was derived from a comprehensive national registry of all coronary care units in Israel, and it reports data on hospitalized patients with a diagnosis of acute MI over 2 months during 3 different years. A particular …

Hemodynamic effects of a novel sodium channel activator in dogs with chronic heart failure

The use of positive inotropic agents, such as sympathomimetics and phosphodiesterase inhibitors, in heart failure (HF) is limited by proarrhythmic and positive chronotropic effects. In the present study, we compared the hemodynamic effects of intravenous LY366634 (LY), a Na+ channel enhancer, with dobutamine (DOB), in eight dogs with HF produced by intracoronary microembolizations. We also determined whether intravenous LY has synergistic effects when combined with digoxin. After baseline measurements, infusion of DOB was initiated at a dose of 2 µg/kg/min and increased until an increase of heart rate (HR) >30% of baseline or ventricular arrhythmias developed. Once hemodynamics returned to baseline, LY was infused at a dose of 2 µg/kg/min and increased until the LV fractional area of shortening (FAS), determined echocardiographically, reached a similar level as with DOB. Both drugs increased FAS equivalently compared to baseline (DOB, 24 ± 3 to 47 ± 2; LY, 27 ± 2 to 46 ± 2%). DOB increased HR from 78 ± 4 min-1 at baseline to 107 ± 7 min-1 at maximal dose (p < 0.05) and provoked serious arrhythmias in one dog. In contrast, LY infusion did not increase HR (82 ± 7 vs. 80 ± 8 min-1) or elicit arrhythmias. After 1 week of oral digoxin, dogs were infused again with LY. A lower dose of LY was needed to achieve the same increase in FAS compared to LY alone, but this was not statistically significant. The combination of LY with digoxin did not increase HR or evoke arrhythmias. We conclude that in dogs with HF, intravenous LY improves LV function to the same extent as DOB without increasing HR or evoking ventricular arrhythmias. The combination of LY with digoxin elicits a safe positive inotropic response.

Use of discharge-worksheet enhances compliance with evidence-based myocardial infarction care

AbstractBackground: Prior studies demonstrate that effective secondary prevention therapies are underutilized in patients with myocardial infarction (MI) at hospital discharge. At a US tertiary center, we developed and encouraged providers to complete a simple “Acute MI Discharge Worksheet” (MIDW) designed to educate patients, prompt caregivers, and provide chart documentation regarding evidence-based therapies post-MI.nMethods and Results: The MIDW was introduced in May of 2000 with use encouraged in all surviving patients with MI. We calculated a patient discharge score by summing the number of quality indicators (aspirin use, beta-blocker use, ACE-inhibitor use, smoking cessation, lipid-lowering therapy, cardiac rehabilitation referral) and compared documentation of quality indicators at discharge between patients without (Group I, n = 65) and with (Group II, n = 60) the MIDW. Group II was subdivided into those with an incomplete worksheet (Group IIa, n = 26), and those with a completed worksheet (Group IIb, n = 34). Greater documentation of secondary prevention indicators occurred in patients with incomplete and completed discharge forms present. Mean Discharge scores were significantly higher for Group II vs. Group I (4.98 vs. 3.88, p < 0.0001), and Group IIb vs. Group IIa, (5.47 vs. 4.35, p < 0.001).nConclusion: A simple “Acute MI Discharge Worksheet” was associated with better adherence and documentation of evidence-based post MI care and be a useful component to improve post MI care.

Can vascular surgery be performed soon after myocardial infarction

We undertook the present study to test the hypothesis that in a contemporary setting of high rates of use of effective medical therapy and coronary revascularization, vascular surgery soon after myocardial infarction (MI) may not be prohibitively risky within 1 year. Elective vascular surgery is generally contraindicated within the first six months of MI. However, this principle is based on high complication rates from old case series. Forty six consecutive patients underwent 63 vascular procedures after MI. Thirty major arterial reconstructions, 9 thromboembolectomies, and 22 amputations or revisions were performed. We compared patients who had vascular surgery within six months after MI (Group I, n=30) to patients who had surgery six to 12 months after MI, Group II (n=16). Both groups had similar demographic characteristics, coronary risk factors and Goodman and Cooperman scores of operative risk. The high overall prevalence of coronary revascularizations (37%) and treatment with aspirin (87%), beta-blockers (65%) and ACE-inhibitors (76%), did not differ significantly between both groups. There was no significant difference in the incidence of reinfarction, cardiac mortality, or total mortality in the two groups. Patients undergoing vascular surgical procedures soon after acute MI may not have prohibitively high rates of death and cardiovascular complications. These favorable outcomes may be associated with the use of effective medical therapy and coronary revascularization. Vascular surgery should not be postponed in patients with recent MI.

Immediate revascularization for cardiogenic shock after MI reduced 6-month mortality

Source Citation Hochman JS, Sleeper LA, Webb JG, et al. Early revascularization in acute myocardial infarction complicated by cardiogenic shock. SHOCK Investigators. Should We Emergently Revascular...

Review: β-blockers have outcomes similar to calcium antagonists but cause fewer adverse events in stable angina

Source Citation Heidenreich PA, McDonald KM, Hastie T, et al. Meta-analysis of trials comparing β-blockers, calcium antagonists, and nitrates for stable angina. JAMA. 1999 May 26;281;1927-36.

Antiplatelet therapy reduced cardiac and noncardiac events after placement of coronary artery stents

Source Citation Schomig A, Neumann FJ, Kastrati A, et al. A randomized comparison of antiplatelet and anticoagulant therapy after the placement of coronary-artery stents. N Engl J Med. 1996 Apr 25;...