Medical and surgical management of early Q wave myocardial infarction. I. Effects of surgical reperfusion on survival, recurrent myocardial infarction, sudden death and functional class at 10 or more years of follow-up.

To define the outcome of patients given medical or surgical therapy for Q wave myocardial infarction, 387 patients were followed up for 10 to 13 years (mean 11.4). On study entry the groups had similar distributions for variables such as mean age, gender, previous myocardial infarction, abnormal creatine kinase activity, area of infarction, number of vessels diseased and clinical classification. The hospital mortality rate of the medical versus surgical group was 11.5% (23 of 200) versus 5.8% (11 of 187) (p = 0.07). Early reperfusion (that is, less than or equal to 6 h) resulted in a lower mortality rate than did medical therapy--2% (2 of 100) versus 11.5% (23 of 200) (p less than 0.05)--whereas the hospital mortality rate with late reperfusion was 10.3% (9 of 87). The long-term mortality rate of the medical and surgical groups was 41% (82 of 200) versus 27% (51 of 187) (p = 0.0007) with use of an adjusted Cox proportional hazards model. In the survivors, the differences between medical and surgical groups in recurrent myocardial infarction, mortality associated with reinfarction and sudden death were prospectively followed and evaluated by the life table method. Recurrent myocardial infarction was not prevented by surgical reperfusion or medical therapy (23% in both groups), however, the mortality rate in patients with recurrent infarction was higher in the medical therapy group--36.6% (15 of 41) versus 17.5% (7 of 40) (p = 0.04). The mortality difference did not depend on early or late surgical reperfusion. In the in-hospital survivors, the incidence of sudden death was 17.5% in the medical (31 of 177) versus 7.4% (13 of 176) in the surgical group (p = 0.01). This difference was much more pronounced in the early reperfusion group. Functional class was significantly lower than that for medical therapy in the early reperfusion but not the late reperfusion group. Thus, in comparable groups given medical and surgical therapy for acute myocardial infarction and followed up for greater than or equal to 10 years, surgical reperfusion appears to offer improved longevity in selected cases (when implemented early) but does not prevent recurrent myocardial infarction. The associated mortality with recurrent myocardial infarction is less as is the incidence of sudden death. Finally, lower functional class occurs most often in patients given early reperfusion.

Intraaortic balloon counterpulsation with and without reperfusion for myocardial infarction shock.

Forty patients were treated for cardiogenic shock secondary to acute myocardial infarction. Twenty-one (group 1) were treated with intraaortic balloon counterpulsation and 19 (group 2) were treated with counterpulsation and coronary artery bypass grafting. The groups were similar in age, incidence of previous infarction, initial hemodynamics and coronary anatomy. The in-hospital mortality between group 1 (52.4%) and group 2 (42.1%) was not significantly different. The difference in long-term mortality between group 1 and group 2 was substantially different (71.4% vs 47.3%). The subset of group 2 (n = 12) that underwent reperfusion and counterpulsation within 16 hours from the onset of symptoms of infarction had a lower mortality (25.0%) than the subset (n = 7) that underwent operation more than 18 hours after the onset of symptoms (71.4%). The long-term mortality in the subset of group 2 patients operated on within 16 hours after the onset of infarction was significantly different from that in group 1 (25.0% vs 71.4%, p less than 0.03). The data suggest that reperfusion with counterpulsation is more effective when carried out early. Patients who develop shock more than 18 hours after the onset of symptoms of infarction appear to benefit most if treated with counterpulsation alone.

Surgical treatment for ventricular aneurysm.

The results of 110 patients with ventricular aneurysm treated surgically are discussed. The overall mortality in this group was 11.8 per cent. Since the use of coronary bypass operation and the intra-aortic balloon pump, the mortality has been significantly reduced.

Acute myocardial infarction: a surgical emergency.

Preservation of viable myocardium is the primary goal of coronary artery surgery. Our total experience with coronary artery bypass grafting is 1,612 patients, operated upon from March 13, 1969, through Jan. 31, 1975 (2.85 per cent over-all mortality rate). Four hundred thirteen patients were operated upon on an emergency basis. Of this group, 96 were having acute myocardial infarctions and 317 were in the preinfarction syndrome. Emergency coronary artery bypass surgery was performed with 5 deaths (5.2 per cent) in the acute myocardial infarction group and 4 deaths in the preinfarction group (1.26 per cent). These patients had a much lower mortality rate than that of medically treated patients in the acute myocardial infarction group. Postoperative catheterization studies on the acute myocardial infarction group showed a 96 per cent rate of primary graft patency. Follow-up studies through 3 years, 10 months show only 1 late death (4 months after the operation). The in-hospital and the first year mortality rates in a medically treated group with acute myocardial infarction were compared with the surgically treated group. The result was a mortality rate of 30 per cent with medical treatment and 6.3 per cent with surgical treatment. Actuarial analysis demonstrated a greater than 20 per cent difference in mortality rate at 1 year, in favor of surgical treatment. The lower surgical mortality coupled with the early and late clinical results prove that emergency coronary bypass is superior therapy in selected patients with acute myocardial infarction.