Childhood exposure to external ionising radiation and solid cancer risk.

The increasing use of ionising radiation for diagnostic purposes has raised concern about potential iatrogenic damage, especially in children. In this review, we discuss some aspects of radiation-induced cancer in relation to age at exposure and measures that should be taken for limiting exposure in this sensitive population.

Improved prognosis of patients presenting with clinical markers of spontaneous reperfusion during acute myocardial infarction.

OBJECTIVE: To describe the clinical features, management, and prognosis of patients presenting with clinical markers of spontaneous reperfusion (SR) during acute myocardial infarction (AMI). DESIGN: Cohort study. SETTING: National registry of 26 coronary care units. PATIENTS: 2382 consecutive patients with AMI. MAIN OUTCOME MEASURES: Patient characteristics, management, and mortality. RESULTS: The incidence of SR was 4% of patients (n = 98) compared with thrombolytic treatment (n = 1163, 49%), primary angioplasty (n = 102, 4%), and non-reperfusion (n = 1019, 43%). SR patients were more likely to develop less or no myocardial damage as indicated by a higher percentage of non-Q wave AMI (58% v 32%, 47%, and 44%, respectively, p < 0.0001), aborted AMI (25% v 9%, 8%, and 12%, p < 0.001), and lower peak creatine kinase (503 v 1384, 1519, and 751 IU, p < 0.0001). SR patients, however, were more likely to develop recurrent ischaemic events (35% v 17%, 12%, and 16%, respectively; p < 0.001) and subsequently were more likely to be referred to coronary angiography (67%), angioplasty (41%), or bypass surgery (16%, p < 0.001). Mortality at 30 days (1% v 8%, 7%, and 13%, respectively, p < 0.0001) and one year (6% v 11%, 12%, and 19%, p < 0.0001) was significantly lower for SR patients than for the other subgroups. By multivariate analysis, SR remained a strong determinant of 30 day survival (odds ratio (OR) 0.16, 95% confidence interval (CI) 0.01 to 0.74). At one year, the association between SR and survival decreased (OR 0.49, 95% CI 0.18 to 1.13). CONCLUSIONS: Clinical markers of SR are associated with greater myocardial salvage and favourable prognosis. The vulnerability of SR patients to recurrent ischaemic events suggests that they need close surveillance and may benefit from early intervention.

A prospective study of plasma fibrinogen levels and the risk of stroke among participants in the bezafibrate infarction prevention study.

PURPOSE: Plasma fibrinogen has emerged as an important predictor of cardiovascular disease, but few data are available on its association with stroke. We sought to determine if plasma fibrinogen is a marker of increased risk or a direct causative risk factor for stroke. SUBJECTS AND METHODS: Patients from the Bezafibrate Infarction Prevention Study, a placebo-controlled, randomized clinical trial of secondary prevention of coronary heart disease by lipid modification with bezafibrate retard (400 mg daily), were studied. Plasma fibrinogen levels were measured at baseline and yearly thereafter. Stroke, a prospectively monitored endpoint, was systematically assessed regarding stroke type, subtype, and functional outcome. RESULTS: Mean baseline fibrinogen levels were significantly higher in patients subsequently having a cerebrovascular event (140 strokes, 36 transient ischemic attacks; mean follow-up, 6.2 years) than in patients who did not (375 vs. 349 mg/dL, P <0.0001). Fibrinogen levels did not differ significantly by the type, subtype, or severity of the cerebrovascular event. Risk of ischemic stroke increased from 3.3% in the lowest tertile (baseline fibrinogen <314 mg/dL) to 7.% in the middle tertile (fibrinogen 314 to 373 mg/dL) to 10% in the upper tertile (fibrinogen >373 mg/dL, P <0.001). Adjusting for age, blood pressure, and other covariates, fibrinogen levels in the upper tertile were associated with more than a twofold increase in risk of ischemic stroke compared with in the lowest tertile (hazard ratio = 2.6; 95% confidence interval: 1.5 to 4.3). We did not find fibrinogen change from baseline to be related to subsequent ischemic stroke events. CONCLUSION: Plasma fibrinogen is a strong predictor of, rather than a direct causative factor for, subsequent stroke among patients at increased risk owing to manifest coronary heart disease.

Effect on survival of acute myocardial infarction in Killip classes II or III patients undergoing invasive coronary procedures.

The purpose of the present study was to determine whether patients with acute myocardial infarction (AMI) in Killip class II or III are likely to benefit from catheterization and coronary revascularization performed within 30 days of AMI. The study population was drawn from 2 national surveys performed during 1996 and 1998 in 26 coronary care units operating in Israel. Our analysis included 3,113 patients with AMI who were divided into 2 groups according to their admission Killip class: 2,484 patients (80%) in Killip class I, of whom 1,408 (57%) underwent cardiac catheterization and 1,076 were treated noninvasively; and 629 patients in Killip class II or III, of whom 314 (50%) underwent cardiac catheterization and 315 were managed conservatively. Patients in Killip class II or III who were treated invasively had lower mortality rates than their counterparts who were treated noninvasively at 30 days: 7.6% versus 15.6%, respectively (adjusted odds ratio [OR] 0.52, 95% confidence interval [CI] 0.28 to 0.92), and thereafter from 30 days to 6 months, 4.3% versus 13.6%, respectively (OR 0.34, 95% CI 0.16 to 0.68). In Killip class I patients, an invasive versus noninvasive management was not associated with a better outcome at 30 days: 1.6% versus 3.2%, respectively (OR 0.58, 95% CI 0.32 to 1.05), but with similar mortality rates at 30 days to 6 months, 1.9% versus 2.0%, respectively (OR 1.46, 95% CI 0.79 to 2.74). Thus, the present study suggests that patients with AMI in Killip class II or III on admission may benefit from cardiac catheterization and revascularization performed within 30 days from admission, whereas patients with AMI in Killip class I are less likely to benefit from this approach.

The prognostic significance of intermediate QRS prolongation in acute myocardial infarction.

Complete right and left bundle branch block and advanced atrioventricular block present on admission electrocardiograms of patients with acute myocardial infarction, are associated with poor short and long-term outcome. Little is known about the impact of intermediate QRS prolongation (0.09-0.11 s) on the prognosis of acute myocardial infarction. In this study, among 1100 consecutive patients with acute myocardial infarction treated with thrombolysis, the QRS duration on admission electrocardiogram was <0.09 s in 536 (48%) patients, between 0.09 and 0.11 s in 496 (45%) patients and >0.11 s in 78 (7%) patients. QRS duration was strongly associated with 7-day (0.6%, 6%,18%, P<0.001), 30-day (1%, 8%, 22%, P<0.001) and 1-year (3%, 11%, 26%, P<0.001) all-cause mortality. After adjustment for significant variables associated with 1-year mortality, including age, female gender, diabetes mellitus, systemic hypertension, previous myocardial infarction, anterior myocardial infarction and Killip class> or =2 on admission, both levels of QRS prolongation remained significant independent predictors of short and long-term all-cause mortality.

Prognosis of patients with a recurrent acute myocardial infarction before and in the reperfusion era--a national study.

BACKGROUND: Patients with recurrent acute myocardial infarction (AMI) are at increased risk for morbidity and mortality. We compared the outcome of patients with recurrent AMI hospitalized in coronary care units in the prereperfusion and reperfusion eras. METHODS: The study population comprised 2 large-scale cohorts with recurrent AMI: (1) 1415 (24%) of 5839 consecutive patients with AMI hospitalized in 1981 to 1983 (Secondary Prevention Reinfarction Israeli Nifedipine Trial [SPRINT] Registry) and (2) 1093 (25%) of 4317 patients with AMI from three national surveys performed in 1992 to 1996. RESULTS: Patients in the 1990s had significantly lower rates of heart failure and cardiogenic shock. The 7-day mortality declined from 18% in 1981-1983 to 10% in 1992-1996 (adjusted odds ratio [OR] 0.57 [0.44-0.75]), the 30-day mortality rate from 26% to 16% (OR 0.56 [0.44-0.71]), and the 1-year mortality rate from 39% to 26% (adjusted hazard ratio [HR] 0.64 [0.54-0.75]), respectively. In the 1992-1996 cohort, the adjusted risk of 7-day, 30-day, and 1-year mortality for patients with recurrent AMI treated with thrombolysis in comparison to patients without thrombolysis was OR 1.69 (1.07-2.65), 1.52 (1.03-2.23), and HR 1.18 (0.90-1.55), respectively. The mortality rate among patients treated with early percutaneous transluminal coronary angioplasty/coronary artery bypass grafting was 3% versus 12% at 7 days (OR 0.36 [0.16-0.73]), 7% versus 18% at 30 days (OR 0.45 [0.25-0.77]), and 16% versus 29% at 1 year (HR 0.64 [0.46-0.96]), in comparison to patients without revascularization. CONCLUSION: The prognosis of patients with recurrent AMI improved significantly during the reperfusion era. Although thrombolysis may have a limited therapeutic effect among patients with recurrent AMI, an interventional approach seems more appropriate when indicated. A randomized trial of thrombolysis versus early revascularization is needed in patients with recurrent AMI.

Impaired fasting glucose concentrations in nondiabetic patients with ischemic heart disease: a marker for a worse prognosis.

BACKGROUND: The issue of whether glucose concentrations below the diabetic threshold may be predictive of increased cardiovascular risk has not yet been fully elucidated. The current study evaluates the prognosis of nondiabetic patients with ischemic heart disease (IHD) and impaired fasting glucose (IFG) over a 7.7-year follow-up period. METHODS: A total of 11,853 patients with documented coronary artery disease aged between 45 and 74 years were examined. Patients were divided into 3 groups on the basis of their fasting blood glucose levels at screening: nondiabetic individuals, patients with IFG, and undiagnosed diabetic patients. Patients who were on any type of pharmacologic antidiabetic treatment were excluded from the study. Mortality rates were assessed separately for each group. RESULTS: The population comprised 9773 nondiabetic patients (82.4%, glucose up to 109 mg/dL), 1258 patients with IFG levels (10.6%, glucose 110-125 mg/dL), and 822 diabetic subjects (7%, glucose > or =126 mg/dL). Patients were followed up from 6.2 to 9.0 years (mean follow-up period 7.7 +/- 1.5 years). Crude mortality was lower in the nondiabetic subjects than in the 2 other groups. All-cause mortality in the nondiabetic group was 14.3% compared to 20.1% in patients with IFG and 24.3% in the undiagnosed (P <.001). Multivariate adjustment showed the lowest mortality in nondiabetic subjects, who exhibited a survival rate of 0.86 at the end of the follow-up, whereas the lowest survival-0.75-was seen among undiagnosed diabetic patients (P =.0001). An intermediate value of 0.78 was documented for patients with IFG (P <.01). After multivariate analysis, with nondiabetic patients as the reference group, IFG was identified as a consistent predictor of increased all-cause and IHD mortality with hazard ratios of 1.39 (95% confidence interval 1.21-1.59) and 1.29 (95% confidence interval 1.01-1.64), respectively. CONCLUSIONS: The main finding of this study is the substantially increased mortality rate among nondiabetic coronary patients with IFG, who had fasting glucose levels markedly lower than hitherto acknowledged as defining overt diabetes.

Improved survival of patients with acute myocardial infarction with significant left ventricular dysfunction undergoing invasive coronary procedures.

BACKGROUND: Acute myocardial infarction (AMI) associated with significant left ventricular dysfunction (LVD) indicates a poor prognosis. Previous studies suggested that revascularization improves survival of patients with AMI complicated by cardiogenic shock. However, other studies that suggested that revascularization improves survival of stable patients with significant LVD did not specifically address patients who had recently had an AMI. OBJECTIVES: Our purpose was to determine whether patients with thrombolysis-treated AMI associated with significant LVD are likely to incur a survival advantage from catheterization and coronary revascularization performed within 30 days after AMI. METHODS: The study population was drawn from the Argatroban in Acute Myocardial Infarction-2 (ARGAMI-2) trial, which included 1200 patients with AMI, all of whom received thrombolytic therapy. Our analysis included 737 patients for whom LV function was estimated by echocardiography. Two hundred two patients had significant LVD; of them, 117 (58%) underwent cardiac catheterization and 85 were treated noninvasively. Among 535 patients without significant LVD, 291 (54%) underwent cardiac catheterization and 244 were treated noninvasively. RESULTS: Compared with a noninvasive approach, an invasive approach resulted in reduced 30-day and 6-month mortality rates in patients with significant LVD: 4.3% versus 10.6%, adjusted odds ratio (OR) 0.26, 95% confidence interval (CI) 0.04 to 1.18, and 6.1% versus 15.5%, OR 0.27, 95% CI 0.06 to 0.98, respectively. A similar comparison in patients without significant LVD resulted in comparable 30-day and 6-month mortality rates for both patient groups: invasively versus noninvasively treated, 0.7% versus 0.8%, OR 1.04, 95% CI 0.04 to 12.7, and 1.4% versus 1.7%, adjusted OR 1.60, 95% CI 0.20 to 9.87. CONCLUSIONS: The current study suggests that AMI patients with significant LVD may benefit from cardiac catheterization and revascularization performed early after AMI, whereas in patients without significant LVD the outcome of those treated invasively or conservatively was similar.

Clinical impact of borderline and undiagnosed diabetes mellitus in patients with coronary artery disease.

The present study was aimed to evaluate the prevalence and prognostic significance of unrecognized and newly defined borderline diabetes (with fasting blood sugar 126 to 139 mg/dl) by the American Diabetes Association criteria in coronary patients over a 7.7-year follow-up. Both undiagnosed and newly diagnosed borderline diabetes were associated with an unfavorable metabolic profile. The mortality of the borderline diabetics tended to be higher than in their nondiabetic counterparts. but this tendency did not reach statistical significance. A significant excess in long-term mortality was observed among the undiagnosed diabetes group.

Sex differences in management and outcome after acute myocardial infarction in the 1990s: A prospective observational community-based study. Israeli Thrombolytic Survey Group.

BACKGROUND: Previous studies have suggested that women with acute myocardial infarction (AMI) are less aggressively managed than are men. The aim of this study was to assess sex differences in medical and invasive coronary procedures (angiography, PTCA, and CABG) in AMI patients admitted to cardiac care units (CCUs) in Israel in the mid 1990s and their association with early and 1-year prognosis. METHODS AND RESULTS: We studied 2867 consecutive AMI patients (2125 men, 74%) hospitalized in all 25 CCUs in Israel from 3 prospective nationwide surveys conducted in 1992, 1994, and 1996. Women were, on average, older than men (69 versus 61 years, P:<0.0001) and had a higher prevalence of hypertension, diabetes, Killip class >/=II on admission, and in-hospital complications. Women received aspirin and beta-blockers less often than did men, but these differences were not significant after age adjustment. The unadjusted rates of thrombolysis, angiography, and PTCA/CABG use were lower in women than in men but not after covariate adjustment: 42% versus 48% (adjusted odds ratio [OR] 0.92, 95% CI 0.77 to 1.11), 23% versus 31% (OR 0.88, 95% CI 0.70 to 1.09), and 15% versus 19% (OR 0.93, 95% CI 0.72 to 1.19), respectively. The 30-day mortality was higher in women than in men (17.6% versus 9.6%, respectively; OR 1.39, 95% CI 1.06 to 1.82), but the 30-day to 1-year mortality rate was not (9.1% versus 5.6%, respectively; hazard ratio 1.18, 95% CI 0.84 to 1.66). CONCLUSIONS: This prospective nationwide observational community-based study of consecutive AMI patients hospitalized in the CCUs in the mid 1990s indicates that women fare significantly worse than do men at 30 days but not thereafter at 1-year. The difference in 30-day outcome was not influenced by the use of different therapeutic modalities, including thrombolysis and invasive coronary procedures, but was rather due to the older age and greater comorbidity of women; these findings seem also to explain the less frequent use of invasive procedures in women.

Prognostic significance of mild mitral regurgitation by color Doppler echocardiography in acute myocardial infarction.

Mitral regurgitation (MR) complicating acute myocardial infarction (AMI) is associated with increased mortality. The prognostic significance of only mild MR detected by echocardiography in patients with AMI is unknown. This study assessed the long-term risk associated with mild MR detected by color Doppler echocardiography within the first 48 hours of admission in 417 consecutive patients with AMI. No MR was detected in 271 patients (65%), mild MR was seen in 121 patients (29%), and moderate or severe MR was noted in 25 patients (6%). One-year mortality rates were 4.8%, 12.4%, and 24%, respectively (p<0.001). Multivariate analysis revealed that mild MR was independently associated with increased 1-year mortality (p<0.05) after adjustment for age, gender, previous myocardial infarction, diabetes mellitus, systemic hypertension, Killip grade > or =2 on admission, and left ventricular ejection fraction < or =40%. The hazard ratio for 1-year mortality was 2.31 (95% confidence interval 1.03 to 5.20) for mild MR and 2.85 (95% confidence interval 0.95 to 8.51) for moderate or severe MR. Thus, mild MR detected by color Doppler echocardiography within the first 2 days of admission in patients with AMI is a significant independent risk predictor for 1-year all-cause mortality.

Mortality trends in men and women with acute myocardial infarction in coronary care units in Israel. A comparison between 1981-1983 and 1992-1994. For the SPRINT and the Israeli Thrombolytic Survey Groups.

AIMS: To assess trends in the management and subsequent outcome in men and women in two cohorts of consecutive patients with acute myocardial infarction hospitalized in coronary care units in Israel, in the pre-reperfusion and the reperfusion eras. METHODS AND RESULTS: We compared trends in the in-hospital management, and 30-day and 1-year mortality in men and women in two cohorts of patients hospitalized with acute myocardial infarction in coronary care units in Israel, in the pre-reperfusion and the reperfusion eras. The first cohort of 5839 consecutive patients (4315 men, 74%) was from the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT) registry of 1981-1983; the second cohort of 1940 patients (1429 males, 74%) derived from two prospective nationwide surveys conducted in all coronary care units in Israel in January/February 1992 and 1994. The demographic and clinical characteristics of patients with acute myocardial infarction in both periods were comparable. Patients in 1992-94 received aspirin, angiotensin-converting enzyme inhibitors, beta-blockers and nitrates more frequently than in 1981-83. Thrombolysis, coronary angiography, angioplasty and bypass grafting were not used in 1981-83, whereas in 1992-94 these procedures were used in 45%, 28%, 11% and 4% of men, respectively, and in 39%, 20%, 9% and 3% of women, respectively. The 30-day age-adjusted mortality declined, in men, from 17.0% in 1981-83 to 10.8% in 1992-94 (multivariate-adjusted odds ratio [OR]=0. 69; 95% confidence interval [CI] 0.55 to 0.87), and the cumulative 1-year age-adjusted mortality declined from 24.6% to 16.9% (adjusted hazard ratio [HR]=0.70%; 95% CI 0.60 to 0.81). In women, the decline in mortality rates were of similar magnitude, from 24.0% to 15.1% (OR=0.70; 95% CI 0.52 to 0.94), and from 33.6% to 21.0% (HR=0.67; 95% CI 0.55 to 0.81), respectively. In both sexes, the decline in mortality was more marked in patients reperfused by thrombolysis and/or mechanical revascularization, but was also evident in non-reperfused patients. CONCLUSIONS: Despite higher mortality in both periods in women compared to men, the prognosis of men and women with acute myocardial infarction improved considerably during the last decade, with a similar decline in 1-year mortality of approximately 30%. The implementation in daily practice of new therapeutic modalities proven to be effective in clinical trials after acute myocardial infarction, probably played a major role in this favourable outcome in both sexes.

Long-term (three-year) prognosis of patients treated with reperfusion or conservatively after acute myocardial infarction. Israeli Thrombolytic Survey Group.

OBJECTIVES: This survey sought to assess the frequency of the use of thrombolytic therapy, invasive coronary procedures (ICP) (angiography, percutaneous transluminal coronary angioplasty and coronary artery bypass grafting [CABG]), variables associated with their use, and their impact on early (30-day) and long-term (3-year) mortality after acute myocardial infarction (AMI). BACKGROUND: Few data are available regarding the implementation in daily practice of the results of clinical trials of treatments for AMI and their impact on early and long-term prognosis in unselected patients after AMI. METHODS: A prospective community-based national survey was conducted during January-February 1994 in all 25 coronary care units operating in Israel. RESULTS: Among 999 consecutive patients with an AMI (72% men; mean age 63+/-12 years) acute reperfusion therapy (ART) was used in 455 patients (46%; thrombolysis in 435 patients [44%] and primary angioplasty in 20 [2%]). Its use was independently associated with anterior AMI location and hospitals with on-site angioplasty facilities, whereas advancing age, prior myocardial infarction (MI) and prior angioplasty or CABG were independently associated with its lower use. The three-year mortality of patients treated with ART was lower than in counterpart patients (22.0% vs. 31.4%, p = 0.0008), mainly as the result of 30-day to 3-year outcome (12.4% vs. 21.1%; hazard ratio = 0.73, 95% confidence interval [CI] 0.52 to 1.03). Independent predictors of long-term mortality were: age, heart failure on admission or during the hospitalization, ventricular tachycardia or fibrillation and diabetes. The outcome of patients not treated with ART differed according to the reason for the exclusion, where patients with contraindications experienced the highest three-year (50%) mortality rate. After ART, coronary angiography, angioplasty and CABG were performed in-hospital in 28%, 12% and 5% of patients, respectively. Their use was independently associated with recurrent infarction or ischemia, on-site catheterization or CABG facilities, non-Q-wave AMI and anterior infarct location. In the entire study population, and in patients with a non-Q-wave AMI, performance of ICP was associated with lower 30-day mortality (odds ratio [OR] = 0.53, 95% CI 0.25 to 0.98, and OR = 0.21, 0.03 to 0.84, respectively), but not thereafter. CONCLUSIONS: This survey demonstrates the extent of implementation in daily practice of ART and ICP and their impact on early and long-term prognosis in an unselected population after AMI.

Does the coronary care unit improve prognosis of patients with acute myocardial infarction? A thrombolytic era study.

AIMS: The purpose of our study was to examine and compare the prognosis of acute myocardial infarction patients hospitalized in an intensive coronary care unit and in an internal medicine ward, in the era of reperfusion therapy, and to identify factors associated with the observed outcomes. METHODS AND RESULTS: Patients hospitalized for acute myocardial infarction during the period 1994-1997 at the Sheba Medical Center, Tel Hashomer, Israel (n=2114), were grouped according to the hospital department in which they were treated: the intensive coronary care unit (n=1443, 68.3%) or an internal medicine ward (n=671, 31.7%). Baseline characteristics, comorbidity, hospital course, use of procedures and 30-day mortality were compared between the groups. Stepwise logistic regression was used to identify the factors associated with 30-day mortality. Crude 30-day mortality rates were 5.4% among all patients hospitalized in the intensive coronary care unit compared with 15.9% for all patients in an internal medicine ward (P<0.001); in a subgroup of patients aged 70 years and above these rates were 11.0% and 21.0%, respectively (P<0. 001). Among the independent predictors of the 30-day mortality identified in multivariate analysis was treatment only in an internal medicine ward (odds ratio: 1.48; 95% confidence interval: 1. 00-2.18). Reperfusion therapy was independently associated with a 53% reduction in 30-day mortality. CONCLUSIONS: Our findings emphasize the importance of the treatment of acute myocardial infarction in the setting of intensive coronary care units in the thrombolytic era, in order to ensure early access to advanced diagnostic and therapeutic options for all patients, including the elderly.

Prognosis of patients with a first non-Q-wave myocardial infarction before and in the reperfusion era. SPRINT and the Israeli Thrombolytic Survey Groups. Secondary Prevention Reinfarction Israeli Nifedipine Trial.

BACKGROUND: The reported incidence of non-Q-wave acute myocardial infarction (AMI) has increased in the thrombolytic era. Data comparing prognosis among these patients before and after the advent of the thrombolytic era are scarce. METHODS: We compared the early and late prognosis among 2 cohorts of consecutive patients with a first non-Q-wave AMI hospitalized in the coronary care units operating in Israel: 610 patients from 1981 to 1983 and 225 patients in 1994. RESULTS: The proportion of patients with non-Q-wave AMI increased from 14% in 1981 to 1983 to 32% in 1994. Baseline characteristics in both periods were comparable. In-hospital management of patients differed during the last decade. Patients in 1994 received aspirin, angiotensin-converting enzyme inhibitors, beta-blockers, and nitrates more frequently than in the period 1981 to 1983. Thrombolytic therapy, coronary angiography, and percutaneous transluminal coronary angioplasty or coronary artery bypass grafting were not used during the index hospitalization in the early 1980s, whereas in 1994 these procedures were used in 28%, 38%, 19%, and 6% of patients, respectively. In-hospital complications, including arrhythmias, conduction disturbances, and heart failure, were less frequent in 1994 compared with the period 1981 to 1983. The 7- and 30-day crude mortality rates were significantly lower in 1994 compared with the early 1980s (5% vs 9% and 5% vs 13%, respectively, P < .05 for both), whereas the 1-year crude mortality rate decreased slightly (15% vs 19%, P = .13). Multivariate analyses adjusting for pertinent variables revealed a decreased risk for death in 1994 versus 1981 to 1983; for 7-day (odds ratio = 0.49, 95% confidence interval 0.23 to 0.94), 30-day (odds ratio = 0.36, 95% confidence interval 0.18 to 0.69) and for 1-year (odds ratio = 0.65, 95% confidence interval 0.44 to 0.96). CONCLUSION: The prognosis of patients with a first non-Q-wave AMI has improved considerably during the last decade. The introduction of new therapeutic modalities, including invasive cardiac procedures and new medications, probably played a major role in the favorable outcome of these patients.

Long-term mortality follow-up of hospital survivors of a myocardial infarction randomized to nifedipine in the SPRINT study. Secondary Prevention Reinfarction Israeli Nifedipine Trial.

This study was intended to determine the 5-year mortality of 2138 post-myocardial infarction (MI) patients who took part in the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT). In the framework of the SPRINT study, 1065 patients were randomly assigned 30 mg/d nifedipine therapy, for a mean 10-month follow-up period, and 1073 received placebo. No information is available concerning treatment after the first year. One-year postdischarge mortality was 5.0% in the placebo group and 5.9% among patients receiving nifedipine (P = 0.37). Mortality rates after 5 years of follow-up in patients previously randomized to 1 year of nifedipine therapy and placebo were 18.4% and 18.3%, respectively. The 5-year mortality risk ratio associated with randomization to nifedipine over 1 year, adjusted for age, gender, past MI, angina, diabetes, hypertension, MI location, and therapy, was 1.00 (95% CI: 0.81-1.22). Our results do not support an association between nifedipine therapy and a late harmful effect on long-term mortality.

Nifedipine and cancer mortality: ten-year follow-up of 2607 patients after acute myocardial infarction.

Recent publications contended that the use of short-acting calcium antagonists may double the risk of cancer incidence and possibly increase mortality in hypertensive patients. The purpose of this study was to assess the risk ratio for cancer mortality associated with nifedipine in a large population of patients post-myocardial infarction. Cancer mortality data, over a 10-year period, were obtained on 2607 hospital survivors of acute myocardial infarction who were screened, but not included, in the Secondary Prevention Reinfarction Israeli Nifedipine Trial (SPRINT I) study. In this group of patients, 526 (20%) were on nifedipine, according to their treating physicians' decision. In the cohort of screened patients not included in SPRINT I, there were 22 (4.2%) cancer-related deaths in the patients on nifedipine compared with 114 (5.5%) in the group not treated with nifedipine (P = 0.23). In multivariate analysis, the 10-year cancer mortality risk ratio associated with nifedipine therapy was 1.06 (95% CI 0.52-2.18). The current analysis shows no evidence of an increased risk of cancer mortality in a large number of patients treated at baseline with nifedipine.

Prognostic significance of cerebrovascular disease in 11,526 chronic coronary artery disease patients. Bezafibrate Infarction Prevention (BIP) Study Group.

Patients with chronic CAD and a history of cerebrovascular events were compared with patients without prior cerebrovascular events to assess the effect of these events on 5-year prognosis. Despite adjustment for older age and higher comorbidity among patients who had experienced a cerebrovascular event, a history of such an event was associated with an increased risk of 1.86 for total mortality.

Improved outcome of elderly patients (> or = 75 years of age) with acute myocardial infarction from 1981-1983 to 1992-1994 in Israel. The SPRINT and Thrombolytic Survey Groups. Secondary Prevention Reinfarction Israel Nifedipine Trial.

BACKGROUND: The number of elderly patients experiencing acute myocardial infarction (AMI) is growing rapidly, and their hospital mortality rate remains high, although mortality after AMI declined in the 1990s with the introduction of new therapeutic modalities. METHODS AND RESULTS: We compared the management, in-hospital complications, and 30-day and 1-year mortality rates in two cohorts of elderly (> or = 75 years of age) AMI patients in the coronary care units in Israel before and after the reperfusion era. The first cohort of 789 consecutive patients was from the Secondary Prevention Reinfarction Israel Nifedipine Trial registry in 1981-1983; the second 366 patients came from two prospective nationwide surveys in 1992 and 1994. Reperfusion therapies were not used in 1981-1983 but were used in 1992-1994. The 30-day mortality rate declined from 38% in 1981-1983 to 27% in 1992-1994 (odds ratio, 0.49; 95% confidence interval [CI], 0.34 to 0.71), and the cumulative 1-year mortality rate declined from 52% to 38% (hazard ratio [HR], 0.62; 95% CI, 0.50 to 0.76). In the 1992-1994 cohort, the decline in mortality was most marked in patients reperfused by thrombolysis and/or percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery but was also evident in nonreperfused patients: cumulative 1-year mortality rate was 29% in the former (HR, 0.45; 95% CI, 0.31 to 0.67) and 42% in the latter (HR, 0.60; 95% CI, 0.46 to 0.78). CONCLUSIONS: During the last decade, elderly (> or = 75 years) AMI patients experienced fewer in-hospital complications and lower 30-day and 1-year mortality rates, which declined approximately 30%, most markedly in reperfused patients. The favorable outcome in 1992-1994 was related to changes in patient management. Reperfusion therapy is therefore also advocated in elderly AMI patients, unless specific contraindications are present.

Usefulness of beta-blocker therapy in patients with non-insulin-dependent diabetes mellitus and coronary artery disease. Bezafibrate Infarction Prevention (BIP) Study Group.

The benefit of beta-blocker therapy in patients after myocardial infarction is well established. The use of beta blockers in the high-risk subgroup of patients with combined diabetes mellitus (DM) and coronary artery disease (CAD) remains controversial. From a database of 14,417 patients with chronic CAD who had been screened for participation in the Bezafibrate Infarction Prevention (BIP) study, 2,723 (19%) had non-insulin-dependent DM. Baseline characteristics and 3-year mortality were analyzed in patients with DM receiving (n = 911; 33%) and not receiving (n = 1,812; 67%) beta blockers. Total mortality during a 3-year follow-up was 7.8% in those receiving beta blockers compared with 14.0% in those who were not (a 44% reduction). A reduction in cardiac mortality of 42% between the 2 groups was also noted. Three-year survival curves showed significant differences in mortality with increasing divergence (p = 0.0001). After multiple adjustment, multivariate analysis identified beta-blocker therapy as a significant independent contributor to improved survival (relative risk = 0.58; 90% confidence interval 0.46 to 0.74). Within the diabetic population, the main benefit associated with beta-blocker therapy was observed in older patients, in those with a history of myocardial infarction, those with limited functional capacity, and those at lower risk. Thus, therapy with beta blockers appears to be associated with improved long-term survival in the high-risk subpopulation of patients with DM and CAD.