Long-term prognosis after coronary artery bypass surgery.

OBJECTIVE: To analyse the risk of coronary heart disease (CHD) events and total mortality among patients who had coronary artery bypass graft (CABG) surgery during 1988-1992. METHODS: A population-based myocardial infarction (MI) register included data on invasive cardiac procedures among residents of the study area. The subjects aged 35-64 years were followed-up for 12 years for non-fatal and fatal CHD events and all-cause mortality, excluding events within 30 days of the CABG operation. CABG was performed on 1158 men and 215 women. RESULTS: The overall survival of men who underwent CABG was similar to the survival of the corresponding background population for about ten years but started to worsen after that. At twelve years of follow-up, 23% (n=266, 95% CI 234-298) of the men who had undergone the operation had died, while the expected proportion, based on mortality in the background population, was 20% (n=231, 95% CI 226-237). The CHD mortality of men who had undergone the operation was clearly higher than in the background population. Among women, the mortality after CABG was about twice the expected mortality in the corresponding background population. In Cox proportional hazards models age, smoking, history of MI, body mass index and diabetes were significant predictors of mortality. CONCLUSIONS: The prognosis of male CABG patients did not differ from the prognosis of the corresponding background population for about ten years, but started to deteriorate after that. History of MI prior to CABG and major cardiovascular risk factors was a predictor of an adverse outcome.

Myocardial infarction in diabetic and non-diabetic persons with and without prior myocardial infarction: the FINAMI Study.

AIMS/HYPOTHESIS: We compared the risk of acute coronary events in diabetic and non-diabetic persons with and without prior myocardial infarction (MI), stratified by age and sex. METHODS: A Finnish MI-register study known as FINAMI recorded incident MIs and coronary deaths (n=6988) among people aged 45 to 74 years in four areas of Finland between 1993 and 2002. The population-based FINRISK surveys were used to estimate the numbers of persons with prior diabetes and prior MI in the population. RESULTS: Persons with diabetes but no prior MI and persons with prior MI but no diabetes had a markedly greater risk of a coronary event than persons without diabetes and without prior MI. The rate of recurrent MI among non-diabetic men with prior MI was higher than the incidence of first MI among diabetic men aged 45 to 54 years. The rate ratio was 2.14 (95% CI 1.40-3.27) among men aged 50. Among elderly men, diabetes conferred a higher risk than prior MI. Diabetic women had a similar risk of suffering a first MI as non-diabetic women with a prior MI had for suffering a recurrent MI. CONCLUSIONS/INTERPRETATION: Both persons with diabetes but no prior MI, and persons with a prior MI but no diabetes are high-risk individuals. Among men, a prior MI conferred a higher risk of a coronary event than diabetes in the 45-54 year age group, but the situation was reversed in the elderly. Among diabetic women, the risk of suffering a first MI was similar to the risk that non-diabetic women with prior MI had of suffering a recurrent MI.

Five-year risk of developing clinical diabetes after first myocardial infarction; the FINAMI study.

AIM: To investigate the incidence of clinical diabetes as determined by the incidence of diabetes drug reimbursements within a 5-year period after the first myocardial infarction (MI) in patients who were non-diabetic at the time of their first MI. RESEARCH DESIGN AND METHODS: A population-based MI register, FINMONICA/FINAMI, recorded all coronary events in persons of 35-64 years of age between 1988 and 2002 in four study areas in Finland. These records were used to identify subjects sustaining their first MI (n = 2632). Participants of the population-based risk factor survey FINRISK (surveys 1987, 1992, 1997 and 2002), who did not have diabetes or a history of MI, served as the control group (n = 7774). The FINMONICA/FINAMI study records were linked with the National Social Security Institute's drug reimbursement records, which include diabetes medications, using personal identification codes. The records were used to identify subjects who developed diabetes during the 5-year follow-up period (n = 98 in the MI group and n = 79 in the control group). RESULTS: Sixteen per cent of men and 20% of women sustaining their first MI were known to have diabetes and thus were excluded from this analysis. Non-diabetic men having a first MI were at more than twofold {hazard ratio (HR) 2.3 [95% confidence interval (CI) 1.6-3.4]}, and women fourfold [HR 4.3 (95% CI 2.4-7.5)], risk of developing diabetes mellitus during the next 5 years compared with the control population without MI. CONCLUSIONS: Many patients who do not have diabetes at the time of their first MI develop diabetes in the following 5 years.

Decline in out-of-hospital coronary heart disease deaths has contributed the main part to the overall decline in coronary heart disease mortality rates among persons 35 to 64 years of age in Finland: the FINAMI study.

BACKGROUND: Out-of-hospital deaths constitute the majority of all coronary heart disease (CHD) deaths and are therefore of considerable public health significance. METHODS AND RESULTS: We used population-based myocardial infarction register data to examine trends in out-of-hospital CHD deaths in Finland during 1983 to 1997. We included in out-of-hospital deaths also deaths in the emergency room and all deaths within 1 hour after the onset of symptoms. Altogether, 3494 such events were included in the analyses. The proportion of out-of-hospital deaths of all CHD deaths depended on age and gender. In the age group 35 to 64 years, it was 73% among men and 60% among women. These proportions did not change during the study. The annual average decline in the age-standardized out-of-hospital CHD death rate was 6.1% (95% CI, -7.3, -5.0%) among men and 7.0% (-10.0, -4.0%) among women. These declines contributed among men 70% and among women 58% to the overall decline in CHD mortality rate. In all, 58% of the male and 52% of the female victims of out-of-hospital CHD death had a history of symptomatic CHD. Among men with a prior history of myocardial infarction, the annual average decline in out-of-hospital CHD deaths was 5.3% (-7.2, -3.2%), and among men without such history the decline was 2.9% (-4.4, -1.5%). Among women, the corresponding changes were -7.8% (-14.2, -1.5%) and -4.5% (-8.0, -1.0%). CONCLUSIONS: The decline in out-of-hospital CHD deaths has contributed the main part to the overall decline in CHD mortality rates among persons 35 to 64 years of age in Finland.

Trends in coronary events in Finland during 1983-1997. The FINAMI study.

AIMS: To analyse the trends in incidence, recurrence, case fatality, and treatments of acute coronary events in Finland during the 15-year period 1983-97. METHODS AND RESULTS: Population-based MI registration has been carried out in defined geographical areas, first as a part of the FINMONICA Project and then continued as the FINAMI register. During the study period, 6501 coronary heart disease (CHD) events were recorded among men and 1778 among women aged 35-64 years. The CHD mortality declined on average 6.4%/year (95% confidence interval -5.4, -7.4%) among men and 7.0%/year (-4.7, -9.3%) among women. The mortality from recurrent events declined even more steeply, 9.9%/year (-8.3, -11.4%) among men and 9.3%/year (-5.1, -13.4%) among women. The proportion of recurrent events of all CHD events also declined significantly in both sexes. Of all coronary deaths, 74% among men and 61% among women took place out-of-hospital. The decline in 28-day case fatality was 1.3%/year (-0.3, -2.3%) among men and 3.1%/year (-0.7, -5.5%) among women. CONCLUSIONS: The study period was characterized by a marked reduction in the occurrence of recurrent CHD events and a relatively modest reduction in the 28-day case fatality. The findings suggest that primary and secondary prevention have played the main roles in the decline in CHD mortality in Finland.

Serum and plasma as alternative sample types in analysis of cardiac markers in the clinical routine.

There is an increasing demand for the results of cardiac markers (troponin I or T, creatine kinase MB mass and myoglobin) to be made available promptly after sample-taking. In order to shorten the turnaround time, the possibility of using EDTA- or heparin-plasma instead of serum was investigated. The study population comprised 391 patients with acute chest pain. Four different instruments and systems routinely used in Finland giving quantitative results were studied for the assays of creatine kinase isoenzyme MB mass, myoglobin, and troponin I or troponin T. In addition to serum samples, heparin-plasma seems to be useful for all three assays using the Access and Immulite systems, while EDTA-plasma seems to be useful for all three assays with the Access and Elecsys systems. For the AxSYM assays, serum samples seem to be the best alternative. In conclusion, it is possible to use a single EDTA- or heparin-plasma sample for Access, Elecsys and Immulite analysers, and thereby to shorten the turnaround time. In this way the quantitative analyses from plasma can be performed 30 min after taking the sample.

Differences in the diagnosis of myocardial infarction by troponin T compared with clinical and epidemiologic criteria.

We investigated the difference in the number of myocardial infarction (MI) diagnoses based on troponin T compared with clinical and epidemiologic (modified FINnish Multinational MONItoring of trends and determinants in CArdiovascular diseases) diagnoses, and the prognosis of patients with discordant diagnoses. Five hundred fifty-nine consecutive patients (315 men and 244 women, median age 69 years) were admitted to the hospital with a suspected acute coronary syndrome. Median follow-up time was 17 months. Of the 559 patients, 127 had a clinical and 137 an epidemiologic diagnosis of MI. When a diagnosis of MI was primarily based on troponin T (>0.10 microg/L), the number of MIs was 169, which increased by 33% compared with the number of MIs by clinical diagnosis, and by 23% compared with those by epidemiologic diagnosis. However, troponin T was not elevated in 13% of the 127 patients with the clinical diagnosis and in 14% of the 137 patients with the epidemiologic diagnosis of MI. Among patients in whom clinical diagnosis of MI was not made, the prognosis with regard to coronary death or nonfatal MI was not significantly worse in patients with troponin T >0.10 microg/L than < or =0.10 microg/L (hazard ratio 1.07; 95% confidence interval 0.62 to 1.84). In patients with a suspected acute coronary syndrome, troponin T-based diagnostics leads to an increase in the number of patients diagnosed with MI compared with clinical or epidemiologic diagnosis. The prognostic impact of troponin T in patients without clinical diagnosis of MI based on elevations in conventional enzyme activities needs further study in larger series of patients.

C-reactive protein, fibrinogen, interleukin-6 and tumour necrosis factor-alpha in the prognostic classification of unstable angina pectoris.

BACKGROUND: Inflammatory process has been found to play an important role in the pathogenesis of coronary heart disease (CHD) and in the prognosis of CHD patients. AIM. The aim of this study was to investigate the prognostic value of C-reactive protein (CRP), fibrinogen, interleukin (IL)-6 and tumour necrosis factor-alpha (TNF-alpha) in patients with unstable angina pectoris (UAP), including factor analysis to assess their joint effects. METHODS: The study comprised 263 consecutive patients (159 men, 104 women; median age 68 years) with UAP. Blood samples for the acute-phase protein and cytokine determinations were drawn on admission. RESULTS: Coronary mortality during the median follow-up time of 17 months was 6-fold higher in the highest tertile for CRP and IL-6 and 3.5-fold higher in the highest tertile for fibrinogen and TNF-alpha than in the respective combined lower tertiles. Factor analysis produced two underlying factors, ie the 'inflammation' factor, including CRP, fibrinogen and IL-6, and the 'injury' factor, including troponin T, creatine kinase MB mass and TNF-alpha. In Cox models, both of these factors were independent predictors of the risk of coronary death and major coronary events (coronary death or nonfatal myocardial infarction). CONCLUSIONS: Elevated levels of acute-phase proteins and cytokines, particularly CRP and IL-6, are strong predictors of the risk of serious coronary events in patients with UAP.

Ruling out myocardial infarction with troponin T and creatine kinase MB mass: diagnostic and prognostic aspects.

OBJECTIVE: To investigate the time window for ruling out myocardial infarction (MI) with troponin T (TnT) and creatine kinase isoenzyme MB mass (CK-MBm) and the prognosis of patients with ruled-out MI diagnosis. DESIGN: The study was based on 397 patients admitted with a suspected acute coronary syndrome but with relief of symptoms within 24 h. RESULTS: MI diagnosis was confirmed with elevated TnT (>0.10 microg/l) in 108 patients. in 91% within 12-24 h from the onset of symptoms, and in 99% within 12 h from admission. In 94 of these patients CK-MBm became elevated (>5.0 microg/l). in 95% within 10-12 h from the onset of symptoms, and in 99% within 6 h from admission. Among patients with ruled-out MI diagnosis, the 1-year incidence of recurrent coronary events was 29% in those with positive history of coronary heart disease (CHD) but only 7% in those without prior CHD (p < 0.001). CONCLUSION: Using TnT or CK-MBm, MI can be ruled out within 12 h from admission in the majority of patients. Among patients with ruled-out MI diagnosis, positive history of CHD is an important determinant of prognosis.

Depression after coronary heart disease events.

OBJECTIVE: To study the prevalence of depression at least 6 months after various coronary heart disease (CHD) events (bypass grafting, coronary angioplasty, myocardial infarction, myocardial ischaemia without infarction) and the associations between depression and clinical variables. DESIGN: In the course of the study 414 (284 males, 130 females) patients younger than 71 years (mean age for men 60.9 years and for women 63.6 years) were interviewed and examined. Smoking habits, body mass index, lipid levels and diabetic status were recorded. The New York Heart Association (NYHA) class was assessed. Depression was screened using a self-rated depression scale. RESULTS: In the four diagnostic categories, one-sixth of the patients (14-19%) suffered from depression. Depression was associated with smoking (OR 1.7, 95% CI 1.2; 2.4) and poor NYHA class (OR 1.9, 95% CI 1.4; 2.6). CONCLUSION: Depression is common after CHD events, and is associated with smoking and poor NYHA class. The identification and treatment of depression should be one of the elements in the rehabilitation of cardiac patients.

Myoglobin, creatine kinase MB, troponin T, and troponin I - rapid bedside assays in patients with acute chest pain.

Three new rapid, qualitative bedside immunoassays were evaluated in the diagnosis of patients with acute chest pain. The subjects, 122 patients in group 1 (bedside tests for myoglobin, creatine kinase MB) and 233 patients in group 2 (bedside tests for troponin I and sensitive troponin T) were admitted to hospital with acute chest pain for less than 12 h. The bedside tests were performed on admission, and 2, 4, and 6 h later. The correlation between the two parts of the rapid creatine kinase MB/myoglobin test during the first 12 h after the onset of chest pain was moderate in all patients (kappa=0.401, 95% confidence interval 0.321-0.483). The highest correlation was seen with the patients with definite and probable myocardial infarction. The correlations were smaller but significant also in other diagnostic groups (unstable angina pectoris, prolonged chest pain, and non-cardiac chest pain). The correlation between the rapid sensitive test for troponin T and rapid test for troponin I was significant in all groups (kappa=0.776, 95% confidence interval 0.711-0.841). The myoglobin part of the rapid creatine kinase MB/myoglobin test may be too non-specific for clinical diagnostic purposes [in non-infarct patients the myoglobin part was significantly more often positive than creatine kinase MB or troponin tests (P<0.001)].

Troponin T and creatinine kinase isoenzyme MB mass in the diagnosis of myocardial infarction.

The aim of this study was to compare troponin T (TnT) and creatine kinase isoenzyme MB mass (CK-MBm) with conventional enzymes, ie CK, CK-MB activity and lactate dehydrogenase isoenzyme 1, in the diagnosis of myocardial infarction (MI). 624 patients (351 men and 273 women, median age 69 years) were admitted to hospital with suspicion of an acute coronary heart disease event. TnT was elevated (> 0.10 microg/L) in 100%, CK-MBm (> 5.0 microg/L) in 99%, and both markers in 99% of the 89 patients with the diagnosis of a definite MI according to modified FINMONICA criteria. In the 60 patients with the diagnosis of a probable MI, TnT was elevated in 65%, CK-MBm in 67% and both markers in 60%. In the patients with unstable coronary artery disease (unstable angina or prolonged chest pain attack) and conventional enzymes within normal limits, TnT was elevated in 14%, CK-MBm in 17% and both markers in 9%. The use of TnT and CK-MBm did not lead to a major change in the diagnostics of definite MI. However, TnT and CK-MBm did not confirm the diagnosis of probable MI in one-third of the events. These new markers revealed a myocardial injury in about 15% of those patients who had unstable coronary artery disease and conventional enzymes within normal limits.

Concordance of diet with the recommended cholesterol lowering diet in patients with coronary heart disease.

OBJECTIVE: The aim was to examine the concordance of diet with the recommended cholesterol lowering diet in Coronary Heart Disease (CHD) patients receiving usual care. DESIGN: CHD patients were selected for a survey from hospital records at least six months after hospitalization. Four patient groups divided according to the severity of disease were examined in cross-sectional setting. Food records and fatty acid composition of serum lipids were used to assess dietary intake. SUBJECTS: The study population consisted of 109 patients with coronary bypass grafting, 106 patients with balloon angioplasty, 101 patients with acute myocardial infarction and 99 patients with acute myocardial ischemia. RESULTS: Concordance of the diet with the cholesterol lowering diet was similar in the patient groups. One third of the patients achieved the recommended fat intake and only one fourth achieved the recommended saturated fat intake. Concordance was better in the patients who also used lipid lowering drugs, but previous myocardial infarction did not affect dietary intake of fat and saturated fat. Diabetic or obese patients tended to have a higher intake of saturated fat. Myristic acid in cholesterol esters, triglycerides and phospholipids and also palmitic and linoleic acids in triglycerides were markers of dietary saturated fat intake. CONCLUSIONS: Concordance of the diet with the recommended cholesterol lowering diet in CHD patients was moderate. Concordance was not affected by disease severity or previous myocardial infarction and was slightly worse in CHD patients who had diabetes or were obese or did not use lipid lowering drugs.

Comparison of the troponin T and troponin I ELISA tests, as measured by microplate immunoassay techniques, in diagnosing acute myocardial infarction.

We describe an improved procedure using a standard microplate immunoassay reader to measure the concentration of troponin T in human serum. We also describe an immunoassay for troponin I in serum. Only 160 microliters of serum are needed for a single analysis of each troponin. For comparison, creatine kinase MB mass analysis in serum was performed with a commercial luminometric method. From 95 apparently healthy people the following values were obtained: creatine kinase MB mass 2.6 +/- 1.2 micrograms/l, troponin T 0.027 +/- 0.025 microgram/l and troponin I 0.03 +/- 0.031 microgram/l. We compared the results of troponin T and troponin I methods with each other, as well as with those of creatine kinase MB mass measured in 48 patients with verified acute myocardial infarction and in 60 control patients with non-cardiac chest pain. The correlation between troponin T and troponin I values was 0.91 for the total material and 0.94 for 48 patients with acute myocardial infarction. Troponin I showed better earlier sensitivity than troponin T (p = 0.043). In nine patients in the control group, creatine kinase MB mass exceeded the reference limit of 5.0 micrograms/l, while in two patients the cut-off limit of 10.0 micrograms/l was also surpassed, pointing to non-specificity. In the group of infarct patients, the highest serum creatinine value was 193 mumol/l, whereas in the control group it was 406 mumol/l. The sera of patients with impaired renal function without any cardiac failure showed no increase in troponin T and troponin I values. In conclusion, serum creatine kinase MB mass and troponin I seem to confirm an acute myocardial infarction more rapidly than does troponin T; troponin I has the highest cardiac specificity.