Search

Immediate reperfusion therapy to restore coronary blood flow is recommended for all eligible patients with acute myocardial infarction. However, reperfusion therapy is reportedly underutilized among African Americans, even when they are eligible. Reasons for the lack of use have not been fully explored.We examined the demographic, clinical, and treatment data of 10,469 African Americans with acute myocardial infarction who were eligible for reperfusion therapy, enrolled in the National Registry of Myocardial Infarction-2 from June 1994 through March 1998.The mean age was 62.58 (+/-14.4) years, and 44.7% were female. Although eligible, 47% of the African Americans in this study did not receive reperfusion therapy. In a multivariate analysis, the absence of chest pain at presentation (odds ratio [OR] 0.31, 95% CI 0.26-0.37) and initial admission diagnoses other than definite myocardial infarction (OR for receipt of reperfusion0.12) were the strongest predictors of lack of early reperfusion therapy. Progressive delays in hospital arrival and hospital evaluation predicted a lower likelihood of early reperfusion. Prior stroke (OR 0.63, 95% CI 0.50-0.78), myocardial infarction (OR 0.75, 95% CI 0.65-0.86), and congestive heart failure (OR 0.49, 95% CI 0.40-0.60) were all associated with lack of reperfusion therapy.Almost half of eligible African American patients with myocardial infarction did not receive reperfusion therapy. Potential reasons may include atypical presentation, patient and institutional delay, and underappreciation of myocardial infarction by care providers. Strategies to address these factors may improve the rate of use of reperfusion therapy.

Psychological factors are linked to outcomes in coronary artery disease (CAD) pts but the mechanisms are obscure. The PIMI is a NIH multicenter study designed to test the overall hypothesis that manifestations and expressions of ischemia are influenced by specific psycho-physiologic mechanisms. Accordingly, 200 pts, mean age 62, with CAD and ischemia responses on treadmill were studied. Ambulatory ECG (AECG) monitoring, psychological instrument batteries and plasma biochemical tests were applied to identify mechanisms associated with ischemia during daily life, exercise and mental stress without influence of cardiac medications. Daily life ischemia (AECG) occurred in 41% of pts (95% with ischemia were asymptomatic) and was associated with lower hostility (p l 0.01) and anger expression (p l 0.03) scores compared with those without daily life ischemia. An inverse association between magnitude of daily life ischemia and these scores was observed. No differences were found for depression (Beck) or anxiety scores. On treadmill all pts had ischemia (ST segment depression) but 44% had angina. Angina expression was associated with higher depression (p =0.002), anxiety (State, p = 0.002 and Trait, p = 0.01) and autonomic perception (p = 0.05) scores than no angina. Depression best predicted time to angina (Cox model, p = 0.007). During mental stress (Stroop and speech tasks) ischemia (radionuclide ventriculogram (RVG) or ST segment abnormalities) occurred in 79% of pts (95% with ischemia were asymptomatic) and associated with higher Reward, Dependence, (Temperament and Character Inventory, p l 0.02) and level of irritation during Stroop task (p l 0.01). Plasma norepinephrine remained low, but epinephrine doubled and systolic pressure increased. No associations were found for medical or demographic factors examined. During bicycle exercise ischemia (RVG abnormality) occurred in 94% of pts (64% with ischemia were asymptomatic) yet norepinephrine increased three-fold. In summary, daily life ischemia (usually asymptomatic) is associated with suppressed hostility, anger and emotion but not depression or anxiety. Mental stress ischemia (mostly asymptomatic and with epinephrine release) is related to temperament characteristics. Exercise stress ischemia, on the other hand, more often evokes symptoms and marked norepinephrine release but symptom expression seems dependent upon depression, anxiety and autonomic perception. Mechanisms responsible for ischemia evoked in different settings and its symptomatic expression involve complex interactions of behavioral, physiological and psychophysiological factors.