Acute coronary events in general practice: the Imminent Myocardial Infarction Rotterdam Study

With the advent of coronary care units in the early sixties, the first concentrated effort was made to reduce mortality from myocardial infarction. Subsequent experience has demonstrated that in-hospital deaths, particularly those from arrhythmias, have decreased from some thirty-five per cent to below ten per cent. However, several studies had indicated that up to 60% of the total mortality from acu· te coronary events, i.e. sudden cardiac death and acute myocardial infarction, took place in pre-hospital phase 1-6 and as early as the late sixties, both clinicians and epidemiologists began to realize that the greatest further gains had to be achieved by decreasing mortality in that particular phase. In 1969, Bondurant7 stated: "the pre-hospital mortality due to ischaemic heart disease is greater than the total mortality due to any other single cause of death" and also: "the pre-hospital phase of acute myocardial infarction poses the greatest single medical problem of our nation in terms of loss of potential salvageable life". This seems to apply to the U.S.A. as well to the entire western world of today. Fulton et al. from Edinburgh, Scotland, concluded also in 1969: "The majority of deaths occur before patients with acute myocardial infarction reach hospital. Most of these are sudden and unattended medically. In many, symptoms of ischaemic heart disease have been present, but often they have passed unnoticed or at least undeclared. It is difficult to conceive of any system which would allow effective treatment of these patients. Therefore, reliable identification of those prone to sudden death and the development of prophylactlcmeasures would do as much or more to combat the problem of acute coronary attacks as any other approach. Thus, the emphasis began to swing away from further intra-hospital efforts at reducing death from coronary atherosclerotic heart disease (C.A.H.D.) to the out-of-hospital pre-coronary phase. For instance, Lown and Wolf stated in 1971: "Coronary care units, while effective in lowering hospital mortality, can not significantly reduce sudden cardiac death, which occurs primarily out-of-hospital and accounts for the majority of deaths from coronary heart disease

Safety of nifedipine GITS in stable angina: The ACTION trial

Aim: We describe the safety profile of nifedipine GITS as assessed from adverse events reported in the ACTION trial in which 7,665 patients with stable, symptomatic coronary artery disease were randomly assigned nifedipine GITS or placebo and followed for a mean of 4.9 years. Methods: All adverse events were coded using the COSTART coding dictionary. The incidence rate for each event was calculated as the number of patients with the event concerned divided by the total time 'at risk'. Hazard ratios comparing nifedipine with placebo and their 95% confidence intervals were obtained by Cox proportional-hazards analysis. Results: As reported previously, nifedipine significantly reduced the incidence of cardiovascular events and procedures [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.83-0.95]. Apart from the known side effects of nifedipine, which include peripheral oedema, vasodilatation, hypotension, asthenia, constipation, leg cramps, non-specific respiratory complaints, impotence and polyuria, and which were reported more frequently in patients assigned nifedipine, the incidence rates of most other adverse events were similar. There were no differences in the occurrence of gastrointestinal haemorrhage, myocardial infarction and suicide. The rate of occurrence of death or new cancer excluding non-melanoma skin cancer for patients with no history of cancer at baseline was 2.53/100 patient years for patients assigned nifedipine and 2.37/100 patient years for patients assigned placebo (HR 1.06, 95% CI 0.93-1.22). Conclusion: Overall nifedipine GITS was well tolerated by patients with stable symptomatic angina

Effects of early intracoronary streptokinase on infarct size estimated from cumulative enzyme release and on enzyme release rate: A randomized trial of 533 patients with acute myocardial infarction

The effects of early intracoronary streptokinase (SK) on enzymatic infarct size and rate of enzyme release were studied in a randomized multicenter trial. A total of 533 patients with acute myocardial infarction (AMI) were allocated to either the SK treatment group (n = 269) or the conventional (control) treatment group (n = 264). Enzymatic infarct size was represented by the cumulative quantity of alpha-hydroxybutyrate dehydrogenase (HBDH) released by the heart per liter of plasma in the first 72 hours. Rate of enzyme release was represented by the ratio of HBDH quantities released in 24 hours and 72 hours. On an "intention to treat" basis, the SK group had a smaller (by 30%; p = 0.0001) median enzymatic infarct size and a higher (by 35%; p = 0.0001) median rate of enzyme release than the control group. Limitation of infarct size was less apparent in patients tre

Thrombolysis with tissue plasminogen activator in acute myocardial infarction: no additional benefit from immediate percutaneous coronary angioplasty

A randomised trial of 367 patients with acute myocardial infarction was performed to determine whether an invasive strategy combining thrombolysis with recombinant tissue-type plasminogen activator (rTPA), heparin, and acetylsalicylic acid, and immediate percutaneous transluminal coronary angioplasty (PTCA) would be superior to a noninvasive strategy with the same medical treatment but without immediate angiography and PTCA. Intravenous infusion of 100 mg rTPA was started within 5 h after onset of symptoms (median 156 min). Angiography was performed 6-165 min later in 180 out of 183 patients allocated to the invasive strategy; 184 patients were allocated to the non-invasive strategy. Immediate PTCA reduced the percentage stenosis of the infarc

Epidemiologie als wegwijzer bij medisch handelen

Inaugurele rede, uitgesproken bij de aanvaarding van het ambt van buitengewoon hoogleraar in de klinische epidemiologie van ischemische hartziekten aan het Interuniversitair Cardiologisch Instituut te Utrecht en aan de Faculteit der Geneeskunde van de Erasmus Universiteit te Rotterdam op donderdag 13 november 198