[Show abstract][Hide abstract] ABSTRACT: Little is known concerning late outcome and prognostic factors after acute myocardial infarction in the very elderly (greater than 75 years of age). Accordingly, this study compared the clinical course and mortality rate for up to 1 year in a large multicenter data base that included 702 patients greater than 75 years of age (mean +/- SD 81 +/- 4 years), with a less elderly subset of 1,321 patients between 65 and 75 years of age (mean 70 +/- 3 years). The postdischarge 1 year cardiac mortality rate was 17.6% for those greater than 75 years of age compared with 12.0% for patients between 65 and 75 years of age (p less than 0.01). There were differences in the prevalence of several factors, including female gender, history of angina pectoris, history of congestive heart failure, smoking habits and incidence of congestive heart failure during hospitalization. Multivariate analyses of predictors of cardiac death in hospital survivors selected different factors as important in the two age subgroups; age was selected in the 65 to 75 year age group but was not an independent predictor in the very elderly. The survival curves beginning at day 10 for patients 65 to 75 and in those greater than 75 years old were similar for up to 90 days but diverged later. In the very elderly, 63% of late cardiac deaths were sudden or due to new myocardial infarction, similar to the causes of 67% of deaths in the younger age group.(ABSTRACT TRUNCATED AT 250 WORDS)
Journal of the American College of Cardiology 11/1990; 16(4):784-92. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study examines patients with a first myocardial infarction (MI) (about 70% of the population, n = 2089), and identifies factors associated with 1-year cardiac mortality in patients discharged alive. With the use of multivarate analysis of variables observed at hospital discharge in patients with a first MI, age was the most important predictor, followed by left ventricular ejection fraction (LVEF) (determined in 56%) and other variables. Based on this finding, age subsets (less than or equal to 50, 51 to 70, greater than 70 years) were related to LVEF groups (less than or equal to 0.40, 0.41 to 0.50, greater than 0.50). Patients with a first MI who were less than 50 years of age with LVEF greater than 0.40 and patients between 51 and 70 years of age with LVEF greater than 0.50 had a very low risk for 1-year cardiac death, 1.2 +/- 1.1% (95% confidence interval). Such patients comprised 47% of individuals with a first MI having an LVEF determination. Mortality in the remaining patients less than 70 years was 7.4 +/- 3.5%. Mortality for patients greater than 70 years was high, 22.2 +/- 6.6%. Thus with LVEF as the only predischarge test, a sizable low risk group can be identified among patients with a first MI.
American Heart Journal 11/1988; 116(4):925-32. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The left ventricular (LV) ejection fraction (EF) is known to be an independent predictor of late prognosis after acute myocardial infarction. Despite a previous report that early heart failure (evidenced only by advanced pulmonary rales in the hospital) can predict prognosis in the absence of severe depression of the LVEF at hospital discharge, the potentially strong influence of various measures of in-hospital heart failure on the predictive ability of LVEF has not been generally appreciated. Accordingly, in 972 patients with acute myocardial infarction the effect on late mortality of the presence or absence in-hospital of both clinical and radiographic signs of LV failure in subgroups of patients with normal, moderately or severely depressed LVEF was examined and measured close to hospital discharge. Patients were divided into 3 groups according to LVEF: group I LVEF less than or equal to 40, n = 265; group II LVEF 0.41 to 0.50, n = 241 and group III LVEF greater than or equal to 0.51, n = 466. When clinical signs of LV failure were present at any time during the coronary care unit period, the 1-year mortality rate after hospital discharge in groups I, II and III was 26, 19 and 8%, compared with 12% (p less than 0.01), 6% (p less than 0.01) and 3% (p less than 0.02), respectively, when signs of LV failure were absent.(ABSTRACT TRUNCATED AT 250 WORDS)
The American Journal of Cardiology 07/1988; 61(15):1165-71. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate the influence of an exercise program on spatial and left precordial R-wave amplitude among patients with coronary artery disease, computerized electrocardiogram (ECG) data were acquired during maximal treadmill testing before and after 1 yr in 89 patients randomized to either exercise (n = 40) or control (n = 49) groups. Spatial and lateral R-wave amplitudes were derived from the orthogonal Frank (XYZ) lead system. The exercise group significantly increased maximal O2 consumption (0.17 l/min), whereas controls decreased significantly (0.12 l/min, P less than 0.01 between groups). No significant changes in electrocardiographic R-wave voltage measurements occurred within or between groups during the year. It is concluded that exercise training does not result in increases in R-wave voltage in patients with coronary artery disease.
Journal of Applied Physiology 04/1987; 62(3):1231-5. · 3.48 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Existing studies suggest that exercise-induced ischemia produces an increase in left ventricular end-diastolic volume; however, all of these studies have included patients with previous myocardial infarction. To test whether the end-diastolic volume response to exercise is related to the extent of myocardial scar, the results of gated radionuclide supine exercise tests performed on 130 subjects were reviewed. The patient group comprised 130 subjects were reviewed. The patient group comprised 130 men aged 35 to 65 years (mean +/- SD 52 +/- 5) with documented coronary heart disease. The extent of myocardial ischemia and scar formation was assessed by stress electrocardiography and thallium-201 scintigraphy. Patients were classified into three groups on the basis of left ventricular end-diastolic volume response at peak exercise: group 1 (n = 72) had an increase of end-diastolic volume greater than 10%, group 2 (n = 41) had a change in end-diastolic volume less than 10% and group 3 (n = 17) had a decrease in end-diastolic volume greater than 10% (n = 17). At rest there was no significant difference among groups in heart rate, systolic blood pressure, end-diastolic (EDVrest) or end-systolic volumes or ejection fraction (p greater than 0.05); however, at peak exercise the end-systolic volume response was significantly greater for group 1 (p less than 0.002).(ABSTRACT TRUNCATED AT 250 WORDS)
Journal of the American College of Cardiology 02/1987; 9(1):26-34. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The effect of exercise training on myocardial perfusion was assessed using initial and 1-year thallium-201 (Tl-201) exercise studies in 56 patients with stable coronary artery disease (CAD). Subjects had been randomized into a trained group participating in supervised exercise three times per week and a control group. Indices (non-dimensional units) based on computer-analyzed circumferential count profile from nine regions of the heart, assessed in three projections, were used to eliminate observer bias and more accurately quantitate Tl-201 distribution and 4-hour washout. There was serial improvement of the global distribution count profiles in 21 of 27 (77.8%) of the trained and in 9 of 29 (31.0%) of the control subjects (p less than 0.001). The mean interval change in global initial distribution over the year period was 5 +/- 13 (mean +/- SD) in the trained and -6 +/- 14 in the control groups (p less than 0.003). The mean initial distribution of the trained group had improvement in all nine regions (significant in three), while the control group showed mean improvement in only one of nine regions. Additionally, the trained group showed improvement in the mean washout in five of nine regions (significant in three), while no mean regional washout improvement occurred in the control group. Thus, in this group of patients with stable CAD, exercise training resulted in apparently improved cardiac perfusion evidenced by enhance Tl-201 uptake and washout.
American Heart Journal 12/1986; 112(6):1217-26. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Left ventricular (LV) ejection fraction (EF) is known to be related to prognosis after acute myocardial infarction (AMI), but its role alone and in combination with other factors in the definition of a high-risk group has not been adequately specified. Several recent multicenter studies emphasize that LVEF together with features of ventricular ectopic activity during ambulatory electrocardiography define a group at high risk for death for up to 3 years. However, these high-risk groups comprised only a small fraction of the population (less than 7.5%) and failed to include 75% or more (less than 25% specificity) of observed events. In our study, LVEF was determined close to the time of hospital discharge in 750 patients with AMI enrolled in a collaborative study. Used alone, an LVEF of less than 0.45 best defined a high-risk group (39% of the population) yielding 62% sensitivity and 64% specificity for total cardiac mortality by 1 year; it was 77% sensitive for sudden death alone. In a multivariate analysis together with other factors, LVEF was an independent predictor, but other markers of LV dysfunction entered before LVEF with similar sensitivity for total cardiac deaths, but with increased specificity (75%). When an LVEF of less than 0.45 was used together with the presence of complex arrhythmias to define a high-risk group (19% of the population), sensitivity decreased to 39% and specificity increased to 84%. Thus, LVEF is a simple and effective alternative to multivariate analysis for risk assessment after AMI.(ABSTRACT TRUNCATED AT 250 WORDS)
The American Journal of Cardiology 12/1986; 58(10):872-8. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study was performed in order to determine whether exercise-induced myocardial ischemia demonstrated by thallium-201 imaging could be detected by ST segment shifts in patients with abnormal Q waves at rest. Fifty-four patients with coronary artery disease and exercise-induced thallium-201 defects were compared to 22 patients with similar Q wave patterns but without thallium-201 exercise defects and to 14 normal subjects. Exercise data were analyzed visually in the 12-lead ECG and for spatial ST vector shifts. Both ST segment depression observed on the 12-lead ECG and spatial criteria were reasonably sensitive and specific for ischemia when the resting ECG showed no Q waves or inferior Q waves (range 69% to 93%). However, when anterior Q waves were present, ST segment shifts could not distinguish patients with ischemia from those with normal perfusion as determined by thallium imaging.
American Heart Journal 06/1986; 111(5):909-16. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Exercise-induced changes in QRS duration were assessed in 25 normal subjects and in 17 patients with stable ischemic heart disease. None had bundle branch block or were taking medications, and all patients had angina pectoris induced during the test. QRS duration and ST60 amplitude were measured by computer during rest while standing, at a heart rate of 100 to 110 bpm during exercise, at peak heart rate for the angina patients (mean of 127 bpm), and at the corresponding matched heart rate and peak heart rate for the normals (mean of 174 bpm). As heart rate increased, the patients showed significant ST60 depression. In normal subjects, the QRS duration tended to increase initially but at the matched heart rate level and at peak heart rate it decreased significantly compared to rest (p less than 0.01). The QRS duration in the angina patients increased significantly at the heart rate level of 100 to 110 bpm (p less than 0.05). Of the eight patients who reached a peak heart rate above 127 bpm, six (75%) during that period further increased QRS duration compared to three (12%) of the 25 normal subjects (p less than 0.001). We conclude that a consistent increase in QRS duration during exercise, although subtle, may be a marker of ischemia and consequently a potential diagnostic tool.
American Heart Journal 06/1986; 111(5):903-8. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined whether or not subsets of patients with complex ventricular arrhythmias after myocardial infarction are at high risk with respect to 1 year mortality after hospital discharge. Based on previous studies showing increased risk for those with non-Q wave infarcts, we hypothesized that complex PVCs (premature ventricular complexes) in this group might be associated with a poorer prognosis than complex PVCs in patients with Q wave infarcts. Seven hundred seventy-seven patients entering our study with acute infarction were followed prospectively for 1 year after undergoing a predischarge 24 hr ambulatory electrocardiographic examination. Patients were classified by electrocardiographic criteria into the following groups: Non-Q wave (n = 191), Q wave anterior (n = 261), and Q wave inferior infarction (n = 325). The following arrhythmias were classified as complex: multiform PVCs, couplets, and ventricular tachycardia. Sixty-two percent of patients with non-Q wave infarcts who did not survive 1 year had complex PVCs, compared with 32% of survivors (p less than .01). No differences were seen in the Q wave subgroup. The survival for patients with Q wave and non-Q wave infarction without complex PVCs were nearly identical at 1 year (93% and 90%), whereas in patients with complex PVCs survival for those with Q wave and non-Q wave infarction was 92% and 76%, respectively (p less than .001). Of those with non-Q wave infarction, only 4% of nonsurvivors were free of any PVCs, as compared with 28% of nonsurvivors in the Q wave group (p less than .02).(ABSTRACT TRUNCATED AT 250 WORDS)
[Show abstract][Hide abstract] ABSTRACT: This study evaluated whether an ischemic exercise test response or functional capacity could be predicted from data available during hospitalization in patients discharged after acute myocardial infarction (AMI). The value of exercise test variables for predicting death and new AMI within 1 year was also examined. Among 1,469 patients, 466 (32%) underwent treadmill exercise testing around the time of discharge. An ischemic exercise test response (ST-segment depression or angina) could not be predicted. Good functional capacity (more than 4 METs) could be predicted from age and ST-segment changes at rest. Among the 60% of the patients who were predicted to have functional capacity of more than 4 METs, only 15% had poor functional capacity at the time of testing. Multivariate analysis for predicting death and new infarction selected only functional capacity (continuous variable in METs), which classified 72% of the patients into a low-risk group with less than a 2% rate of death and new AMI in the first year. The high-risk group (29% of the patients) had an 18% rate of death or new AMI. It is concluded that functional capacity is the most important exercise test variable and that patients likely to have good functional capacity can be identified on the basis of age and ST-segment changes at rest. Further, the level of functional capacity on exercise testing can identify groups of patients with very low and relatively high risk of death or new AMI within 1 year.
The American Journal of Cardiology 12/1985; 56(13):839-45. · 3.21 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Prognostic differences between patients with anterior or inferior myocardial infarction are often related to such variables as previous infarction or the size of the myocardial infarct. We examined the determinants of mortality in 997 hospital survivors of acute Q wave infarction (anterior in 449, inferior in 548) who, although not preselected, were well matched with respect to age, sex and prior infarction or congestive heart failure. Additionally, there was no significant difference in peak serum creatine kinase (CK) between the groups with anterior and inferior infarction (1,459 +/- 1,004 versus 1,357 +/- 1,036). Among the patients with anterior infarction who died during the 1 year follow-up period, 56% died in the first 60 days after hospital discharge compared with 18% of those without inferior infarction (p less than 0.01). Survival curves then became nearly identical at 3 months, and remained so until 1 year when the total mortality rate was 10% for the anterior and 7% for the inferior infarction group (p = NS). Variables associated with heart failure during the hospital phase were more prevalent in anterior infarction, but rales above the scapulae during the hospital stay (p less than 0.0001) and ventricular gallop at the time of discharge (p less than 0.0001) were the top two predictors of 1 year mortality by both univariate and multivariate analysis in inferior infarction. Age (p less than 0.0001) and peripheral edema (p less than 0.0001) were the strongest predictors of mortality in anterior infarction. Previous infarction, although just as common in the group with anterior infarction, was present at 1 year in 48% of nonsurvivors of the group with inferior infarction compared with only 19% of survivors (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)
Journal of the American College of Cardiology 11/1985; 6(4):731-6. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A population of 2955 patients admitted to the hospital with acute myocardial infarction (AMI) was followed for 1 year after AMI or until death. Smokers as compared to nonsmokers were over 10 years younger (p less than 0.001) and had a lower prevalence of hypertension (p less than 0.01), congestive heart failure (p less than 0.0001), angina pectoris (p less than 0.01), and diabetes (p less than 0.0001). They had less severe myocardial infarction evidenced, for example, by lower prevalence of pulmonary congestion on chest x-ray (p less than 0.01). Both early (1 month) and late (6 and 12 months) mortality rates were lower in the smoking population (p less than 0.0001 at 1 month, p less than 0.05 at 6 months, and p less than 0.01 at 1 year). Adjusting for age and other variables reduced but did not reverse the survival differential favoring smokers at 1 month, but adjusting for age alone eliminated the differences in mortality rates at 6 and 12 months. We conclude that while smoking is a risk factor for cardiovascular disease and may contribute to the occurrence of AMI at a younger age, smoking at the time of AMI does not appear to be an independent predictor of death during the first year after AMI.
American Heart Journal 10/1985; 110(3):535-41. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Thirty patients who exhibited increased and 65 patients decreased spatial R wave amplitude during exercise testing were compared for left ventricular function and ischemic variables. Spatial R wave amplitude was derived from the three-dimensional Frank X, Y, Z leads using computerized methods. All patients had stable coronary artery disease and they were classified into two groups: one that attained a higher (n = 48) and one a lower (n = 47) median value of maximal heart rate during exercise (161 beats/min). Within these two groups, patients with increasing or decreasing spatial R wave amplitude during exercise were analyzed for differences in oxygen consumption, exercise-induced changes in spatial R wave amplitude, ST segment depression laterally (ST60, lead X), ST displacement spatially, left ventricular ejection fraction at rest, change in left ventricular ejection fraction with exercise and thallium-201 ischemia during exercise. Significant differences were demonstrated only in exercise-induced spatial R wave amplitude changes (p less than 0.0001). There was no significant correlation between exercise-induced change in heart rate and change in spatial R wave amplitude in either the group with increasing or the group with decreasing spatial R wave amplitude. It is concluded that changes in spatial R wave amplitude during exercise are not related to ischemic electrocardiographic or thallium-201 imaging changes or to left ventricular ejection fraction determined at rest or during exercise.
Journal of the American College of Cardiology 10/1985; 6(3):603-8. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To estimate variations in intra- and interindividual measurements of the corrected QT (QTc) interval, duplicates of 50 twelve lead electrocardiograms (100 photocopies, paper speed 50 mm/s) were given to each of nine investigators in random order. The electrocardiograms were recorded from patients with acute myocardial infarction consecutively admitted to a coronary care unit. Patients receiving drug therapy and those manifesting various arrhythmias were included. Two-way analysis of variance was used to evaluate the results from all 900 QTc measurements. Significant differences in these measurements were registered among investigators and were of major importance (p less than 0.001). This finding illustrates the difficulty in comparing mean values from different studies and emphasizes the difficulties in applying limits for a normal QTc interval to data obtained by different observers. Of less but still significant importance was the interaction between the investigator and electrocardiogram (p less than 0.001). Finally, the random error was calculated and proven to be of no importance (less than 0.5 mm) when more than 11 measurements were performed.
Journal of the American College of Cardiology 04/1985; 5(3):699-702. · 14.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Out of 156 patients with stable coronary heart disease randomized to either an exercise intervention group or a control group, 41 had complete gas analysis data. Continuous gas exchange data, including the ventilatory threshold, and selected heart rates were determined initially and at 1 year. The mean attendance for the exercise group was 2.2 ± 0.7 days a week at an intensity of 60 ± 9% of estimated peak oxygen uptake for 1 year of the study. Statistically significant differences (p < 0.05) were observed between the exercise group (n = 19) and the control group (n = 22) for peak oxygen uptake (L/min), total treadmill time, and supine rest and submaximal heart rates after 1 year. The most remarkable change was a 16% increase in treadmill time. There was no difference between groups for the ventilatory threshold expressed either as an absolute oxygen uptake or as a percentage of peak oxygen uptake at 1 year. However, there was a significant correlation (r = 0.45; p < 0.05) between the absolute change in peak oxygen uptake and the absolute change in the ventilatory threshold. These results indicate that a moderate exercise program is inadequate to alter the ventilatory threshold in patients with coronary heart disease and that changes in ventilatory threshold do not explain the increase in treadmill time that usually occurs.
American Heart Journal 04/1985; · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We examined whether or not subsets of patients with extension of myocardial infarct were at high risk for early and late mortality. Some data suggest increased risk in patients with non-Q wave infarcts and we hypothesized that infarct extension in this group might be associated with a poorer prognosis than that for patients with extension of Q wave infarcts. A total of 1253 patients with acute myocardial infarction who were included in our data base were followed prospectively. The patients were classified according to electrocardiographic results into the following groups: those with non-Q wave (n = 277) infarcts and those with Q-anterior (n = 462) and Q-inferior (n = 497) infarcts. Extension was diagnosed by two of the following criteria: (1) recurrent chest pain 24 hr or more after admission to the hospital, (2) new persistent electrocardiographic changes, and (3) elevation or reappearance of creatine kinase. By these criteria 85 (6%) patients had extension (8% of non-Q wave infarcts, 6% of Q-anterior infarcts, and 6% of Q-inferior infarcts). Hospital mortality in patients with extension was 15% in those with Q wave infarcts vs 43% in those with non-Q wave infarcts (p less than .01). Nine hundred and fifty-two patients were followed for 1 year. In 24% of those who did not survive 1 year there was extension of infarct; only 6% of survivors had extension (p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)
[Show abstract][Hide abstract] ABSTRACT: We evaluated 229 patients discharged after a definite acute myocardial infarction. Pulmonary venous congestion determined from chest x-ray films during the hospitalization and at discharge and the cardiothoracic ratio at discharge were compared to the left ventricular ejection fraction measured at discharge by a gated radionuclide technique. During hospitalization, pulmonary venous congestion was found on at least one x-ray frame in 94 patients (41%). At discharge 134 patients (59%) had abnormal ejection fraction (less than 0.51) and 35 had pulmonary venous congestion (15%). The sensitivity of the x-ray for detecting an abnormal ejection fraction was 20% when pulmonary venous congestion was observed on the discharge x-ray film (specificity 92% and predictive value 77%), 52% if pulmonary venous congestion was present on any x-ray film during the hospitalization (specificity 74% and predictive value 73%), and 47% if the cardiothoracic ratio was abnormal (greater than or equal to 0.50) on the discharge x-ray film (specificity and predictive value 66%). We conclude that an abnormal x-ray film at discharge or during the hospitalization will identify approximately one-half of the abnormal ejection fractions at the time of hospital discharge. Therefore, to reliably assess left ventricular function, either for prognostic or therapeutic purposes in the individual patient, a more direct measure of left ventricular function such as radionuclide angiography must be obtained.
American Heart Journal 01/1985; 108(6):1431-6. · 4.50 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: As part of a randomized trial of the effects of 1 year of exercise training on patients with stable coronary artery disease, 48 patients who exercised and 59 control patients had computerized exercise electrocardiography performed initially and 1 year later. The patients who had exercise training as an intervention had a 9% increase in measured maximal oxygen consumption and significant decreases in heart rate at rest and during submaximal exercise. ST segment displacement was analyzed 60 ms after the end of the QRS complex in the three-dimensional X, Y and Z leads and utilizing the spatial amplitude derived from them. Statistical analysis by t testing yielded no significant differences between the groups except for less ST segment displacement at a matched work load, but this could be explained by a lowered heart rate. Analysis of variance yielded some minor differences within clinical subgroups, particularly in the spatial analysis. Obvious changes in exercise-induced ST segment depression could not be demonstrated in this heterogeneous group of selected volunteers with coronary artery disease secondary to an exercise program.
Journal of the American College of Cardiology 01/1985; 4(6):1094-102. · 14.09 Impact Factor