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Background: Previous studies have provided conflicting results regarding the effect of drospirenone-containing oral contraceptive pills (OCPs) on the risk of venous and arterial thrombosis., Objectives: To conduct a systematic review to assess the risk of venous thromboembolism (VTE), myocardial infarction (MI), and stroke in individuals taking drospirenone-containing OCPs., Search Strategy: We systematically searched CINAHL, the Cochrane Library, Dissertation & Abstracts, EMBASE, HealthStar, Medline, and the Science Citation Index from inception to November 2012., Selection Criteria: We included all case reports, observational studies, and experimental studies assessing the risk of venous and arterial thrombosis of drospirenone-containing OCPs., Data Collection and Analysis: Data were collected independently by two reviewers., Main Results: A total of 22 studies [six case reports, three case series (including 26 cases), and 13 comparative studies] were included in our systematic review. The 32 identified cases suggest a possible link between drospirenone-containing OCPs and venous and arterial thrombosis. Incidence rates of VTE among drospirenone-containing OCP users ranged from 23.0 to 136.7 per 100 000 woman-years, whereas those among levonorgestrel-containing OCP users ranged from 6.64 to 92.1 per 100 000 woman-years. The rate ratio for VTE among drospirenone-containing OCP users ranged from 4.0 to 6.3 compared with non-users of OCPs, and from 1.0 to 3.3 compared with levonorgestrel-containing OCP users. The arterial effects of drospirenone-containing OCPs were inconclusive., Author's Conclusions: Our systematic review suggests that drospirenone-containing OCP use is associated with a higher risk for VTE than both no OCP use and levonorgestrel-containing OCP use., (© 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.)

Introduction: Meta-analyses of randomized controlled trials (RCT) showed that glycoprotein IIb/IIIa inhibitors (GPI) are associated with reduced adverse events following primary percutaneous coronary revascularization (PCI). However, the external validity of RCTs is generally limited due to their restricted inclusion of patients. The objective of this study is to evaluate the effectiveness and safety of GPI, as adjuvant therapy for primary PCI in real-life patients with myocardial infarction with ST segment elevation (STEMI) from the general population., Methods: We identified all published peer-reviewed observational studies enrolling STEMI patients who underwent primary PCI. We performed random-effect meta-analyses to determine the association of GPI with major adverse events., Results: A total of 11 studies, enrolling 12,253 patients, were retained for this meta-analysis. GPI was associated with approximately 53% reduction in short-term mortality (odds ratio (OR): 0.47, 95% confidence intervals (CI): 0.32-0.68). There was a 62% reduction in long-term mortality associated with GPI (OR: 0.38, 95% CI: 0.30-0.50). GPI was associated with a 62% reduction in 30-day re-infarction (OR: 0.38, 95% CI: 0.24-0.60) and 42% reduction in 30-day repeat PCI (OR: 0.58, 95% CI: 0.36-0.94). A non-significant increase in major bleeding with GPI was observed with an OR of 1.55 (95% CI: 0.92-2.62)., Conclusions: GPI is associated with significant reductions in short-term mortality, re-infarction and repeat PCI, long-term mortality and an inconclusive increase in major bleeding. These results provide evidence for the safety and effectiveness of GPI as adjuvant therapy for primary PCI in real-life STEMI patients., (Copyright © 2010. Published by Elsevier Ireland Ltd.)

Background: Facilitated percutaneous coronary intervention (PCI) is defined as the administration of fibrinolytic therapy and/or glycoprotein (GP) IIb/IIIa inhibitors to minimize myocardial ischemia time while waiting for PCI. A pooled meta-analysis suggested that facilitated PCI was associated with higher rates of mortality and morbidity compared with nonfacilitated PCI., Objective: The heterogeneous and complex trials of facilitated PCI were systematically reviewed to identify where this strategy may be beneficial and deserving of further research., Methods: MEDLINE, EMBASE, the Cochrane database, the Internet and conference proceedings were searched to obtain relevant trials. Human studies that randomly assigned patients to fibrinolytic-facilitated PCI (administration of fibrinolytic therapy alone or in combination with GP IIb/IIIa inhibitors before angiography) versus nonfacilitated PCI were included., Results: Nine trials encompassing 3836 patients were reviewed. The facilitated PCI strategy was fibrinolytic therapy alone in seven trials and half-dose fibrinolytic therapy plus GP IIb/IIIa inhibitors in two trials. In patients who had fibrinolysis less than 2 h after symptom onset (mainly in the prehospital setting) and/or slightly delayed PCI 3 h to 24 h after fibrinolysis, facilitated PCI was associated with the greatest Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow and a trend toward reduced mortality. Overall, facilitated PCI was associated with increased intracranial hemorrhage and reinfarction. Combining half-dose fibrinolytic therapy and GP IIb/IIIa inhibitors reduced reinfarction but increased major bleeding., Conclusions: Facilitated PCI cannot be recommended outside of experimental protocols at this time. Further research should focus on selecting patients with higher benefit-to-risk ratios and performing prehospital fibrinolysis with optimal antiplatelet or antithrombin therapy, as well as slightly delayed PCI in patients who are stable or geographically removed from PCI facilities.

Background: Early treatment can reduce mortality from heart attacks. However, patient delay, especially among the elderly, has slowed progress in this area. One of the reasons for delay may be because of a lack of knowledge about symptoms of acute myocardial infarction (AMI) and treatment benefits. The Internet is a new and promising source of heart health information, but we know little about how elderly people use this medium., Methods: This study investigates the demographic and psychosocial variables that are related to Internet access, health information seeking, and information seeking about heart attacks from the Internet among seniors. We interviewed seniors (N = 323) aged more than 65 years and asked them questions about Internet access, health information seeking, and information seeking on heart attacks, as well as demographic information, risk perceptions for AMI, and personal experience with AMI., Results: The results showed that several demographic variables were related to access to the Internet. Only 7% of the seniors who reported access to the Internet had sought information on heart attacks from the Internet. Age, history of AMI, and family history of AMI were significant predictors of information seeking on heart attacks. This suggests that to date only a very small, high-risk group of seniors actually seeks information on heart attack emergencies from the Internet.

The Heart Attack Survival Kit (HASK) project is a prospective, randomized trial, testing the effectiveness of an intervention delivered door-to-door by firefighters to increase use of 911 and ingestion of aspirin for symptoms of acute myocardial infarction (AMI) among seniors in King County, Washington. Firefighters visited 24,582 seniors in King County, Washington and delivered a Heart Attack Survival Kit. Another 24,191 senior households served as the control group. Outcomes of the program were measured by tracking 911 calls as well as survey data. This study reports on the results of the telephone survey with a random sample of seniors (N = 323) to assess their knowledge of and intentions to act during a heart emergency. Results of a logistic regression analysis showed that being female, being younger, and remembering the kit was significantly related to intentions to act appropriately to AMI symptoms. The results are discussed in terms of public education around AMI.

Background: Volume of procedures has been associated with short-term outcome after percutaneous transluminal coronary angioplasty. However, the effect of hospital procedural volume on long-term outcome after PTCA is unknown., Methods and Results: We analyzed the physician claims and discharge data of 6635 patients who underwent PTCA after acute myocardial infarction (AMI) between 1991 and 1995 in the province of Quebec, Canada. For each administrative year, hospitals in which PTCA was performed were classified into 3 groups: low-volume, <200 procedures per year; medium-volume, 200 to 399 procedures per year; and high-volume, > or =400 procedures per year. Compared with patients in medium-volume and high-volume hospitals, patients in low-volume hospitals were older, had more recent AMI, and were less likely to have been transferred for PTCA. After adjustment for baseline differences, patients in the low-volume and medium-volume groups were more likely to undergo CABG within 6 months compared with patients in the high-volume group (odds ratio [OR] 2.1, 95% CI 1.3-3.3, and OR 1.5, 95% CI 1.2-1.9, respectively). In contrast, patients in the low-volume and medium-volume groups were less likely than patients in the high-volume group to undergo repeat PTCA within 6 months (OR 0.37, 95% CI 0.24-0.58, and OR 0.8, 95% CI 0.70-0.92, respectively). At 6 months, adjusted rates of repeat revascularization, recurrent AMI, or death did not differ between the 3 groups., Conclusion: Overall adverse event rates at 6 months after PTCA do not differ between hospital volume groups. The higher rate of CABG in low-volume hospitals and the higher rate of repeat PTCA in high-volume hospitals may represent different physician preferences for the treatment of failed PTCA rather than higher complication rates.

Background: A number of studies have documented myocardial ischemia and infarction associated with cocaine use. Mismatch between myocardial oxygen supply and demand from cocaine-induced vasoconstriction and increased myocardial workload are often invoked as the major postulated mechanism by which cocaine induces myocardial ischemia. This article reviews the literature studying the effects produced by cocaine on the coronary arteries to provide insight into the various pathophysiologic mechanisms by which cocaine triggers acute cardiac ischemia or infarction., Methods: We reviewed the published literature describing the effects of cocaine on the coronary arteries. A MEDLINE search of English language articles published between 1985 and 2000 was performed. Key words included coronary arteries, coronary vasoconstriction, vasospasm, coronary vasodilation, cardiac vasculature, myocardial ischemia, platelets, thrombosis, and cocaine. Both animal and human studies were included. The bibliographies of identified articles were also explored for additional sources of information., Results: A recreational dose of cocaine increases the heart rate by approximately 30 beats/min. It also increases the blood pressure by 20/10 mm Hg. These increases are modest, are equivalent to mild exercise, and are not believed to be sufficient to result in myocardial ischemia in the majority of cases. Animal and human studies have documented cocaine-induced early coronary artery vasodilation as shown by a decrease in coronary perfusion pressure ranging from 13% to 68%. This was followed by a more sustained vasoconstriction demonstrated by a decrease in epicardial coronary artery diameter ranging from 5% to 30% with various doses of cocaine by various methods of administration. These changes alone are also an unlikely explanation for cocaine-induced myocardial ischemia. Therefore neither increases in myocardial workload nor hemodynamic changes are sufficient to explain cocaine-induced myocardial ischemia. However, evidence also exists that cocaine activates platelets and promotes thrombosis, resulting in intracoronary thrombus formation. Cocaine may also promote premature and more severe coronary atherosclerosis., Conclusion: The etiology of cocaine-induced myocardial ischemia is complex and is likely to be multifactorial. It appears to be the result of coronary artery vasoconstriction, intracoronary thrombosis, and accelerated atherosclerosis.

Background: Many physicians are not adhering to the recommendations found in evidence-based guidelines for the treatment of acute myocardial infarction (AMI). Physicians who practise in tertiary care settings may show better adherence to guideline recommendations than physicians who practise in other settings., Objective: To determine whether there is an association between the practice setting of admission for AMI and discharge prescriptions for cardiac drugs recommended in evidence-based guidelines., Patients and Methods: Discharge prescription data from a prospective cohort of patients with AMI admitted at five tertiary care (n=250) and five community hospitals (n=331) in Quebec from December 1996 to November 1998 were examined., Results: The proportions of patients who were prescribed recommended drugs at tertiary care hospitals compared with those at community hospitals were as follows: beta-blockers (78% versus 74%, respectively; 95% CI around the difference - 4% to 11%), lipid-lowering drugs (45% versus 39%, respectively; 95% CI - 2% to 15%) and angiotensin-converting enzyme (ACE) inhibitors (44% versus 57%, respectively; 95% CI - 22% to - 5%). In adjusted analyses, practice setting was not associated with the prescription of beta-blockers (odds ratio [OR] for tertiary care 1.36; 95% CI 0.82 to 2.24) or lipid-lowering drugs (OR for tertiary care 1.06; 95% CI 0.67 to 1.68). However, tertiary care admission reduced the likelihood of ACE inhibitor prescription (OR 0.50; 95% CI 0.32 to 0.77). This association may have been due to the increased likelihood of ACE inhibitor prescription for patients with hypertension at community hospitals (OR 2.13; 95% CI 1.23 to 3.67). The results also showed that older patients were less likely to be prescribed beta-blockers or lipid-lowering drugs, women were less likely to be prescribed beta-blockers and patients with diabetes mellitus were less likely to be prescribed lipid-lowering drugs (OR 0.45; 95% CI 0.23 to 0.89)., Conclusion: No strong association was found between the practice setting of admission for AMI and discharge prescriptions for cardiac drugs recommended in evidence-based guidelines. Prescription rates for recommended drugs were high, yet results suggest that there is room for improvement with regard to patients with diabetes, women and older patients.

Background: Reperfusion therapy for acute myocardial infarction (AMI) is a time-dependent intervention that can reduce infarct-related morbidity and mortality. Out-of-hospital patient delay from symptom onset until emergency department (ED) presentation may reduce the expected benefit of reperfusion therapy., Objective: To determine the impact of a community educational intervention to reduce patient delay time on the use of reperfusion therapy for AMI., Methods: This was a randomized, controlled community-based trial to enhance patient recognition of AMI symptoms and encourage early ED presentation with resultant increased reperfusion therapy rates for AMI. The study took place in 44 hospitals in 20 pair-matched communities in five U.S. geographic regions. Eligible study subjects were non-institutionalized patients without chest injury (aged > or =30 years) who were admitted to participating hospitals and who received a hospital discharge diagnosis of AMI (ICD 410); n = 4,885. For outcome assessment, patients were excluded if they were without survival data (n = 402), enrolled in thrombolytic trials (n = 61), receiving reperfusion therapy >12 hours after ED arrival (n = 628), or missing symptom onset or reperfusion times (n = 781). The applied intervention was an educational program targeting community organizations and the general public, high-risk patients, and health professionals in target communities. The primary outcome was a change in the proportion of AMI patients receiving early reperfusion therapy (i.e., within one hour of ED arrival or within six hours of symptom onset). Trends in reperfusion therapy rates were determined after adjustment for patient demographics, presenting blood pressure, cardiac history, and insurance status. Four-month baseline was compared with the 18-month intervention period., Results: Of 3,013 selected AMI patients, 40% received reperfusion therapy. Eighteen percent received therapy within one hour of ED arrival (46% of treated patients), and 32% within six hours of symptom onset (80% of treated patients). No significant difference in the trends in reperfusion therapy rates was attributable to the intervention, although increases in early reperfusion therapy rates were noted during the first six months of the intervention. A significant association of early reperfusion therapy use with ambulance use was identified., Conclusions: Community-wide educational efforts to enhance patient response to AMI symptoms may not translate into sustained changes in reperfusion practices. However, an increased odds for early reperfusion therapy use during the initiation of the intervention and the association of early therapy with ambulance use suggest that reperfusion therapy rates can be enhanced.

Background: Few studies have reported population-based information on the treatment trends and outcomes of patients who have had an acute myocardial infarction (AMI). We therefore examined patterns of care and outcomes for AMI patients in Quebec, Canada, between 1988 and 1995., Methods: Longitudinal data files of hospital admissions in Quebec (Med-Echo database) and inpatient and outpatient services (Régie de l'Assurance Maladie du Québec database) were used to construct cohorts of all AMI patients in the province between 1988 and 1995. Temporal trends in the use of cardiac procedures after an AMI, discharge prescriptions and mortality rates were examined., Results: Between 1988 and 1995 the age- and sex-adjusted rates of AMI in the Quebec population declined (148 per 100,000 in 1988 to 137 per 100,000 in 1995). The use of intensive cardiac procedures increased in the same period; the 1-year cumulative incidence rate of catheterization increased from 28% in 1988 to 31% in 1994, that of angioplasty rose from 8% to 15% and that of coronary artery bypass surgery from 6% to 8%. Prescriptions for ASA, beta-blockers, lipid-lowering agents and angiotensin-converting enzyme inhibitors increased, and prescriptions for nitrates and calcium antagonists decreased. These temporal changes were paralleled by a decrease in mortality rates post-AMI. All-cause 1-year cumulative incidence mortality rates decreased from 23% in 1988 to 19% in 1994., Interpretation: The decrease in AMI-related mortality in Quebec between 1988 and 1995 may be linked to changes in treatment strategies (i.e., increased use of cardiac surgical procedures and medications shown to increase survival).

Context: Delayed access to medical care in patients with acute myocardial infarction (AMI) is common and increases myocardial damage and mortality., Objective: To evaluate a community intervention to reduce patient delay from symptom onset to hospital presentation and increase emergency medical service (EMS) use., Design and Setting: The Rapid Early Action for Coronary Treatment Trial, a randomized trial conducted from 1995 to 1997 in 20 US cities (10 matched pairs; population range, 55,777-238,912) in 10 states., Participants: A total of 59,944 adults aged 30 years or older presenting to hospital emergency departments (EDs) with chest pain, of whom 20,364 met the primary population criteria of suspected acute coronary heart disease on admission and were discharged with a coronary heart disease-related diagnosis., Intervention: One city in each pair was randomly assigned to an 18-month intervention that targeted mass media, community organizations, and professional, public, and patient education to increase appropriate patient actions for AMI symptoms (primary population, n=10,563). The other city in each pair was randomly assigned to reference status (primary population, n=9801)., Main Outcome Measures: Time from symptom onset to ED arrival and EMS use, compared between intervention and reference city pairs., Results: General population surveys provided evidence of increased public awareness and knowledge of program messages. Patient delay from symptom onset to hospital arrival at baseline (median, 140 minutes) was identical in the intervention and reference communities. Delay time decreased in intervention communities by -4.7% per year (95% confidence interval [CI], -8.6% to -0.6%), but the change did not differ significantly from that observed in reference communities (-6. 8% per year; 95% CI, -14.5% to 1.6%; P=.54). EMS use by the primary study population increased significantly in intervention communities compared with reference communities, with a net effect of 20% (95% CI, 7%-34%; P<.005). Total numbers of ED presentations for chest pain and patients with chest pain discharged from the ED, as well as EMS use among patients with chest pain released from the ED, did not change significantly., Conclusions: In this study, despite an 18-month intervention, time from symptom onset to hospital arrival for patients with chest pain did not change differentially between groups, although increased appropriate EMS use occurred in intervention communities. New strategies are needed if delay time from symptom onset to hospital presentation is to be decreased further in patients with suspected AMI. JAMA. 2000;284:60-67

The purpose of this study was to test the effectiveness of a 'Heart Attack Survival Kit', disseminated via two different delivery methods, designed to increase seniors' intentions to call 911 and take an aspirin in response to a cardiac emergency. Twelve-hundred seniors were randomly assigned to (1) receiving a Kit via a home visit by an Emergency Medical Technician (EMT), (2) receiving a Kit via direct mail or (3) a control group. All participants were telephoned and asked how they would respond to a cardiac emergency. Results showed that respondents in the intervention group (EMT and direct mail group combined) reported a greater frequency of the recommended coping response to AMI (39%) than respondents in the control group (10%) (P < 0.000). Within intervention groups, 47% in the EMT group and 30% in the direct mail group (P < 0.000) reported intentions to take the appropriate response to AMI. The results suggest that a Heart Attack Survival Kit, especially when delivered door-to-door by EMTs, can be an effective way of educating seniors about cardiac emergencies.

A retrospective observational study using database registry of consecutive patients admitted to 16 King County hospital Coronary Care Units (CCU) was conducted to assess gender differences in symptom presentation for acute myocardial infarction (AMI) and investigate how symptom presentation relates to prehospital delay time interval from acute symptom onset to emergency department (ED) presentation. Between January 1991 and February 1993, 4,497 patients were admitted to the CCUs with diagnosed AMI. Accredited record technicians abstracted age, gender, race, transport method, symptom presentation (chest pain, sweating, nausea, shortness of breath, epigastric pain, and fainting), delay time interval between acute symptom onset and presentation to hospital ED, and discharge diagnosis from the patients' medical records. After adjusting for age and history of diabetes, no gender differences remained for frequencies of chest pain, fainting, or epigastric pain. Women reported more nausea and shortness of breath but less sweating than men as symptoms of AMI. Chest pain, sweating, and fainting were associated with decreasing delay time intervals. Age, gender, histories of AMI and diabetes, and transport choice were also significantly related to delay time interval. These results show that gender differences occur in AMI symptom experience. However, how symptoms relate to the gender gap in delay time interval is not clear. These findings suggest that health care professionals need to tailor information about possible symptoms of AMI to the patient's gender, age, and medical history.

Objective: Early reperfusion for acute myocardial infarction (AMI) can reduce morbidity and mortality, yet there is often delay in accessing medical care after symptom onset. This report describes the design and baseline characteristics of the Rapid Early Action for Coronary Treatment (REACT) community trial, which is testing community intervention to reduce delay., Methods: Twenty U.S. communities were pair-matched and randomly assigned within pairs to intervention or comparison. Four months of baseline data collection was followed by an 18-month intervention of community organization and public, patient, and health professional education. Primary cases were community residents seen in the ED with chest pain, admitted with suspected acute cardiac ischemia, and discharged with a diagnosis related to coronary heart disease. The primary outcome was delay time from symptom onset to ED arrival. Secondary outcomes included delay time in patients with MI/unstable angina, hospital case-fatality rate and length of stay, receipt of reperfusion, and ED/emergency medical services utilization. Impact on public and patient knowledge, attitudes, and intentions was measured by telephone interviews. Characteristics of communities and cases and comparability of paired communities at baseline were assessed., Results: Baseline cases are 46% female, 14% minorities, and 73% aged > or =55 years, and paired communities have similar demographics characteristics. Median delay time (available for 72% of cases) is 2.3 hours and does not vary between treatment conditions (p > 0.86)., Conclusions: REACT communities approximate the demographic distribution of the United States and there is baseline comparability between the intervention and comparison groups. The REACT trial will provide valuable information for community educational programs to reduce patient delay for AMI symptoms.

Objectives: A 10-month direct mail campaign was implemented to increase use of emergency medical services via 911 calls and to reduce prehospital delay for individuals experiencing acute myocardial infarction symptoms., Methods: This prospective, randomized, controlled trial involved three intervention groups (receiving brochures with informational, emotional, or social messages) and a control group., Results: Intervention effects were not observed except for individuals who had a history of acute myocardial infarction and who were discharged with a diagnosis of acute myocardial infarction; their 911 use was meaningfully higher in each intervention group than in the control group., Conclusions: The mailings affected only the individuals at greatest risk.

Physicians and other health care professionals play an important role in reducing the delay to treatment in patients who have an evolving acute myocardial infarction. A multidisciplinary working group has been convened by the National Heart Attack Alert Program (which is coordinated by the National Heart, Lung, and Blood Institute of the National Institutes of Health) to address this concern. The working group's recommendations target specific groups of patients: those who are known to have coronary heart disease, atherosclerotic disease of the aorta or peripheral arteries, or cerebrovascular disease. The risk for acute myocardial infarction or death in such patients is five to seven times greater than that in the general population. The working group recommends that these high-risk patients be clearly informed about symptoms that they might have during a coronary occlusion, steps that they should take, the importance of contacting emergency medical services, the need to report to an appropriate facility quickly, treatment options that are available if they present early, and rewards of early treatment in terms of improved quality of life. These instructions should be reviewed frequently and reinforced with appropriate written material, and patients should be encouraged to have a plan and to rehearse it periodically. Because of the important role of the bystander in increasing or decreasing delay to treatment, family members and significant others should be included in all instruction. Finally, physicians' offices and clinics should devise systems to quickly assess patients who telephone or present with symptoms of a possible acute myocardial infarction.

Prehospital cardiac care, first established in Belfast, Northern Ireland, in 1966, may be called revolutionary in that it was a radical break from existing practices. The Belfast program "moved" the coronary care unit into the community by treating the early complications of acute myocardial infarcation. The program staffed a mobile coronary care unit with a physician and nurse and demonstrated that patients with out-of-hospital sudden cardiac arrest could be resuscitated. The idea of prehospital cardiac care spread to other countries after publication of the Belfast experience in the Lancet. The first program in the United States, stationed at St Vincent's Hospital in New York, NY, began in 1968 and was modeled after the Belfast program. The physician-staffed model, however, was not widely imitated in the United States. Rather, beginning in 1969, programs using specially trained personnel, know as paramedics, began in Miami, Fla, Seattle, Wash, Columbus, Ohio, Los Angeles, Calif, Portland, Ore, and Nassau County, New York. Paramedic-staffed programs were designed not only to treat early complications of acute myocardial infarction, but also to attempt resuscitation for primary cardiac arrest. Most of the early paramedic programs were based in fire departments. Other programs used private ambulance or police personnel. Prehospital cardiac care has evolved significantly in the past 3 decades. Some notable developments include the tiered response system, training of the general public in cardiopulmonary resuscitation, low-energy defibrillators, automatic external defibrillators, and 12-lead electrocardiographic telemetry. The basic lesson of prehospital cardiac care is that the timely provision of cardiopulmonary resuscitation and defibrillation saves lives.

Both experimental and clinical studies suggest that the prehospital administration of aspirin may be beneficial in patients with unstable angina and acute myocardial infarction. Experimental studies indicate that within 1 hour of aspirin administration, serum levels peak and significant inhibition of platelet aggregation occurs. Clinical studies demonstrate that early treatment with aspirin reduces mortality and reinfarction rates in patients with unstable angina and acute myocardial infarction. However, these same studies also indicate that prolonged delays often occur before in-hospital therapy with aspirin is initiated. Since the potential benefits are great and the risks and costs are low, physicians should encourage the prehospital administration of aspirin in patients with symptoms suggestive of unstable angina or acute myocardial infarction.

Left ventricular (LV) function is an important predictor of morbidity and mortality after myocardial infarction (MI). Changes in LV function have been examined during the early and late phases after MI, but serial measurements of LV function during the subacute period have not been performed. To assess sequential changes in LV function during the subacute period after MI, we used quantitative two-dimensional echocardiography to examine 22 patients over a 1-year period. Twenty-one of the 22 patients had a Q-wave MI. Eleven had an anterior MI and 10 had an inferior MI; their peak creatine phosphokinase (CPK) was 1213 mIU/ml +/- 14. Three weeks after acute MI, LV ejection fraction (LVEF) had increased from 45% to 52%. Seven of 19 patients showed an LVEF < 43% at baseline. In five of these patients, LVEF improved, but in two patients, LVEF was still < 43% in week 3. There was a significant enlargement of LV end-diastolic volume (LVEDV) (94 ml to 112 ml, p < 0.05) across the four observations but no change in LV end-systolic volume (LVESV; 54 ml to 56 ml, p = n.s.). When two groups (G1 [depressed], LVEF < or = 43%; G2 [preserved], LVEF > 43%) were compared, the group with depressed LVEF demonstrated a higher probability of improvement in LVEF (34% to 47%, p < 0.001) and stroke volume (38 ml to 65 ml, p < 0.01).

With the advent of thrombolytic therapy and other coronary reperfusion strategies, rapid identification and treatment of acute myocardial infarction greatly reduces mortality. Unfortunately, many patients delay seeking medical care and miss the benefits afforded by recent advances in treatment. Studies have shown that the median time from onset of symptoms to seeking care ranges from 2 to 61/2 hours, while optimal benefit is derived during the first hour from symptom onset. The phenomenon of delay by AMI patients and those around them needs to be understood prior to the design of education and counseling strategies to reduce delay. In this article the literature is reviewed and variables that increase patient delay are identified. A theoretical model based on the health belief model, a self regulation model of illness cognition, and interactionist role theory is proposed to explain the response of an individual to the signs and symptoms of acute myocardial infarction. Finally, recommendations are made for future research.

Objective: To examine patient characteristics and situational and clinical factors that affect utilization of Emergency Medical Services (EMS) for symptoms of acute myocardial infarction (AMI)., Design: Telephone interview of patients hospitalized with suspected AMI., Setting: Nine hospitals in King County, Washington., Patients: Patients admitted to a coronary or intensive care unit between October 1, 1986, and December 31, 1987, with suspected AMI occurring out of hospital. Spouses of patients who met criteria but died during the hospitalization also participated., Outcome Measures: Patient demographics, coping strategies, situational factors, prior cardiac history, perceived symptom severity, belief about the nature of condition, and method of transportation., Results: Descriptive statistics showed that although few patients called EMS as a "first thing" in response to symptoms, almost half of all patients called EMS before being hospitalized. Stepwise logistic regression analyses revealed that being older, the belief that one was experiencing a heart attack, the presence of other people (including the spouse), and the lack of physical activity at time of symptom onset, were related to both greater and quicker utilization of EMS. Additionally, education, medical history of angina, and severity of symptoms also were related to utilization of EMS., Conclusion: The findings are discussed in a theoretical context, using Leventhal's self-regulatory model to suggest avenues for future research and interventions.

This study evaluated a direct mail intervention called the "Call Fast, Call 911" campaign designed to increase use of emergency medical services for symptoms of acute myocardial infarction. The campaign was targeted at individuals over the age of 50. Persons over 50 years of age (N = 130,000) in King County, Washington, were randomly assigned to intervention or control groups. Individuals in the intervention groups received six direct mail pieces over a 1-year period encouraging them to call 911 quickly in response to chest pain. A postintervention telephone survey of a random sample of households (N = 434) assessed the impact of the campaign on knowledge, attitudes, and behavioral intentions regarding use of emergency medical services for symptoms of acute myocardial infarction. The results showed no significant differences between intervention and control groups in terms of knowledge of AMI. However, there were significant differences in beliefs and behavioral intentions to call 911 in a cardiac emergency.

Study Objective: We evaluated the effects of a community public education campaign that encouraged patients to quickly call 911 after the onset of acute myocardial infarction (AMI) symptoms., Setting and Participants: The media campaign focused on residents 50 years of age or older in King County, Washington, which has a population of 1.5 million (1990 census)., Design: We determined 911 responses for chest pain, emergency department visits for AMI symptoms, the number of patients admitted to a CCU with an admitting diagnosis of rule-out MI, and the number of confirmed AMIs before and after the campaign., Results: The number of emergency medical services (EMS) responses (911 runs) for patients 50 years of age or older experiencing AMI symptoms increased significantly during the media campaign. ED visits for chest pain also increased significantly during the campaign, as did the number of patients 50 years of age or older admitted to a King County CCU with an admitting diagnosis of rule-out MI. Each of the above increases tapered--with time after the media campaign but remained above baseline., Conclusion: An intense public education campaign can significantly increase EMS use, ED visits, and CCU admissions for AMI symptoms. However, these effects taper off with time after the campaign.

This study was conducted in 19 hospitals in the metropolitan Seattle area and included 6,270 unselected patients who had acute myocardial infarction (AMI) between January 1988 and April 1991. Hospital mortality was determined and related to patient demographic and clinical characteristics, the use of reperfusion therapies, and to complications after AMI. Thrombolytic therapy or direct coronary angioplasty < 6 hours from symptom onset was used to treat 1,185 (19%) and 524 (9%) patients, respectively. There were 629 (10%) hospital deaths; most occurred during the first 3 days of hospitalization. Factors affecting mortality after admission included: recurrent chest pain, recurrent AMI, development of heart failure, and the occurrence of stroke. After adjustment for age, treatment with thrombolytic therapy or direct angioplasty had no independent effect on reducing the overall mortality rate. Hospital mortality rates for AMI have improved considerably since 1970, although recurrent myocardial ischemic events continue to have an adverse effect on outcome. The current use of reperfusion treatments has had minimal causal impact on overall mortality rates, principally because less than one third of patients, who are relatively "low risk," are eligible and receive these treatments.

Study Objective: To investigate the effect of heart-related medical conditions and demographic variables on patients' tendency to delay contacting emergency medical services for symptoms of acute myocardial infarction., Type of Participants: A sample of 2,947 patients with acute myocardial infarction but no cardiac arrest, transported by paramedics to the coronary care units of 19 hospitals in King County, Washington, between January 1988 and April 1991., Measurements: Patient record abstracts contained information on medical history, age, gender, delay interval, and means of transportation., Results: Multiple regression analyses showed that prehospital delay interval was significantly greater for individuals who were older and female and who had a history of angina, congestive heart failure, or diabetes., Conclusion: It is important to investigate further how people interpret and evaluate their symptoms in light of other medical conditions. It is also critical to find out why women delay longer than men and why older individuals delay longer than younger people before they contact emergency medical services. Interventions need to be developed that are targeted at populations at risk for delaying use of emergency medical services for acute myocardial infarction symptoms. These interventions must legitimize the use of emergency medical services and encourage patients to act quickly when confronted with acute myocardial infarction symptoms.

Objective: To determine the effect of prehospital-initiated vs hospital-initiated treatment of myocardial infarction on clinical outcome., Design: Randomized, controlled clinical trial., Setting: Multicenter study involving 19 hospitals and all paramedic systems in the Seattle, Wash, metropolitan area., Patients: A total of 360 patients with symptoms for 6 hours or less, no risk factors for serious bleeding, and ST-segment elevation were selected by paramedics and a remote physician for inclusion into the trial. They represented 4% of patients with chest pain who were screened and 21% of those with acute infarction., Interventions: Patients were allocated to have aspirin and alteplase treatment initiated before or after hospital arrival. Intravenous sodium heparin was administered to both groups in the hospital., Main Outcome Measure: The primary endpoint was a ranked composite score (combining death, stroke, serious bleeding, and infarct size). The relation between time to treatment and outcome (composite score, infarct size, ejection fraction, and mortality) was also assessed., Results: Initiating treatment before hospital arrival decreased the interval from symptom onset to treatment from 110 to 77 minutes (P < .001). Although more patients whose therapy was initiated before hospital arrival had resolution of pain by admission (23% vs 7%; P < .001), there were no significant differences in the composite score (P = .64), mortality (5.7% vs 8.1%), ejection fraction (53% vs 54%), or infarct size (6.1% vs 6.5%). A secondary analysis of time to treatment and outcome showed that treatment initiated within 70 minutes of symptom onset was associated with better outcome (composite score, P = .009; mortality, 1.2% vs 8.7%, P = .04; infarct size, 4.9% vs 11.2%, P < .001; and ejection fraction, 53% vs 49%, P = .03) than later treatment. Identification of patients eligible for thrombolysis by paramedics reduced the hospital treatment time from 60 minutes (for patients not in the study) to 20 minutes (for study patients allocated to begin treatment in the hospital)., Conclusion: There was no improvement in outcome associated with initiating treatment before hospital arrival; however, treatment within 70 minutes of symptom onset--whether in the hospital or in the field--minimized the infarct process and its complications.

Background: During the past decade the use of coronary angiography after acute myocardial infarction has substantially increased. Among the possible contributing factors, the increasing availability of cardiac catheterization facilities was the focus of our investigation., Methods: We investigated whether the availability of cardiac catheterization facilities at an admitting hospital was associated with the likelihood that a patient would undergo coronary angiography. After adjusting for age, sex, cardiac history, and cardiac complications during hospitalization, we evaluated this association in 5867 consecutive patients with acute myocardial infarction admitted to 19 Seattle-area hospitals. We also assessed the association between the presence of on-site cardiac catheterization facilities and in-hospital mortality., Results: Patients admitted to hospitals with on-site cardiac catheterization facilities were far more likely to undergo coronary angiography (odds ratio, 3.21; 95 percent confidence interval, 2.81 to 3.67) than patients admitted to hospitals where transfer to another institution would be required to perform cardiac catheterization. Admission to a hospital with on-site facilities was more strongly associated with the use of coronary angiography than any characteristic of the patient. Although our study had limited power to detect differences in mortality, the availability of coronary angiography had no discernible association with in-hospital mortality rates (odds ratio for mortality among patients admitted to hospitals with on-site facilities vs. patients admitted to hospitals without such facilities, 0.88; 95 percent confidence interval, 0.71 to 1.09)., Conclusions: In this community-wide study, the availability of on-site cardiac catheterization facilities was associated with a higher likelihood that a patient would undergo coronary angiography. However, admission to hospitals with these facilities did not appear to be associated with lower short-term mortality.

All patients with symptoms and ECG findings suggestive of acute myocardial infarction (AMI) should be considered for treatment with thrombolytic agents. The decision to use thrombolytic therapy is a clinical judgment based upon a weighing of the potential benefits versus the possible risks. The physician must take into account relative contraindications, age of the patient, area of jeopardized myocardium, and duration of symptoms. Health professionals involved in the care of AMI patients should develop written plans and protocols addressing the following matters: identification of patients with chest pain in the prehospital setting (this applies to hospitals that receive patients from emergency medical services systems), triage of patients in the emergency department, obtaining the 12-lead electrocardiogram, determination of contraindications, authority for ordering thrombolytic therapy, and consultation for atypical cases. There also should be agreed standards for the time interval from arrival in the ED to administration of the thrombolytic agent, as well as a commitment to the prospective monitoring of procedures and times to assure continuous improvement. A time interval for treatment (arrival in ED to administration of drug) of 30 to 60 minutes should be achievable for patients who present with typical symptoms and ECG findings.

The findings in 3,256 consecutive patients hospitalized for acute myocardial infarction were tabulated to assess the history, treatments and outcome in the elderly; 1,848 patients (56%) were greater than 65 years of age, including 28% who were aged greater than or equal to 75 years. The incidence of prior angina, hypertension and heart failure (only 3% of patients less than 55 years of age had a history of heart failure compared with 24% greater than or equal to 75 years old) was found to increase with age. Twenty-nine percent of patients less than 75 years of age were treated with a systemic thrombolytic drug compared with only 5% of patients older than 75 years. Mortality rates increased strikingly with advanced age (less than 2% in patients less than or equal to 55, 4.6% in those 55 to 64, 12.3% in those 65 to 74 and 17.8% in those greater than or equal to 75 years). Both the incidence of complicating illness and a nondiagnostic electrocardiogram (ECG) increased with age. In a multivariate analysis of outcome in older patients (greater than or equal to 65 years), adverse events were related to both prior history of heart failure (odds ratio 3.9) and increasing age (odds ratio 1.4 per each decade of age). Outcome was not improved by treatment with thrombolytic drugs, but these agents were prescribed to only 12% of patients greater than 65 years of age, thereby reducing the power for detecting such an effect.(ABSTRACT TRUNCATED AT 250 WORDS)

A prehospital computer-interpreted electrocardiogram (ECG) was obtained in 1,189 patients with chest pain of suspected cardiac origin during an ongoing trial of prehospital thrombolytic therapy in acute myocardial infarction. Electrocardiograms were performed by paramedics 1.5 +/- 1.2 h after the onset of symptoms. Of 391 patients with evidence of acute myocardial infarction, 202 (52%) were identified as having ST segment elevation (acute injury) by the computer-interpreted ECG compared with 259 (66%) by an electrocardiographer (p less than 0.001). Of 798 patients with chest pain but no infarction, 785 (98%) were appropriately excluded by computer compared with 757 (95%) by an electrocardiographer (p less than 0.001). The positive predictive value of the computer- and physician-interpreted ECG was, respectively, 94% and 86% and the negative predictive value was 81% and 85%. Prehospital screening of possible candidates for thrombolytic therapy with the aid of a computerized ECG is feasible, highly specific and with further enhancement can speed the care of all patients with acute myocardial infarction.

The timing of Q-wave evolution and its prognostic significance was studied in 201 patients who received thrombolytic therapy for a first acute myocardial infarction (AMI). One hundred forty-one patients (70%) had evidence of a Q-wave AMI within 3 hours of the initiation of thrombolytic therapy, 31 (16%) developed Q waves after 3 hours but before hospital discharge, and 29 (14%) were discharged with a non-Q-wave AMI. Laboratory indicators of myocardial damage and in-hospital morbidity and mortality were greater among patients with Q-wave AMIs than with non-Q-wave AMIs. When these indexes were examined with respect to the timing of Q-wave evolution, the prognosis of patients with delayed Q-wave development was similar to that of patients with non-Q-wave AMIs. Thus, compared to patients with early (less than or equal to 3 hours) Q-wave evolution, patients with delayed Q-wave evolution or with a non-Q-wave AMI had a smaller creatine kinase peak (mean 661 to 1,081 vs 1,251 to 1,541 IU; p = 0.005), better preservation of left ventricular function as measured by radionuclide ventriculography before discharge (mean +/- standard deviation 54 +/- 11% vs 47 +/- 13%; p less than 0.01), and a lower incidence of congestive heart failure at discharge (3 vs 15%; p = 0.02). In-hospital mortality was lower among patients with delayed Q-wave evolution or with a non-Q-wave AMI (5 of 141 vs 0 of 60; difference not significant).(ABSTRACT TRUNCATED AT 250 WORDS)

Prehospital initiation of thrombolytic therapy by paramedics, if both feasible and safe, could considerably reduce the time to treatment and possibly decrease the extent of myocardial necrosis in patients with acute coronary thrombosis. Preliminary to a trial of such a treatment strategy, paramedics evaluated the characteristics of 2,472 patients with chest pain of presumed cardiac origin; 677 (27%) had suitable clinical findings consistent with possible acute myocardial infarction and no apparent risk of complication for potential thrombolytic drug treatment. Electrocardiograms (ECGs) of 522 of the 677 patients were transmitted by cellular telephone to a base station physician; 107 (21%) of the tracings showed evidence of ST segment elevation. Of the total 2,472 patients, 453 developed evidence of acute myocardial infarction in the hospital; 163 (36%) of the 453 had met the strict prehospital screening history and examination criteria and 105 (23.9%) showed ST elevation on the ECG and, thus, would have been suitable candidates for prehospital thrombolytic treatment if it had been available. The average time from the onset of chest pain to prehospital diagnosis was 72 +/- 52 min (median 52); this was 73 +/- 44 min (median 62) earlier than the time when thrombolytic treatment was later started in the hospital. Paramedic selection of appropriate patients for potential prehospital initiation of thrombolytic treatment is feasible with use of a directed checklist and cellular-transmitted ECG and saves time. This strategy may reduce the extent and complications of infarction compared with results that can be achieved in a hospital setting.

Thrombolytic therapy for acute myocardial infarction (AMI) is now routinely given in the emergency department and is being considered for pre-hospital care. Its effectiveness is dependent on how early it can be given after the onset of AMI. Maximal benefit, however, is not realized in many patients due to delay in seeking care. The effect of a public media education campaign (message) to shorten patient delay and increase use of emergency medical services (EMS) was evaluated prospectively in King County, Washington. We interviewed 401 patients admitted with possible AMI in the premessage period (4.5 months) and 489 in the postmessage period (4.5 months). The two groups were comparable in all factors except for discharge diagnosis of AMI (premessage, 34%; postmessage, 25%; P less than .01) and history of myocardial infarction or angina (premessage, 52%; postmessage, 43%; P less than .01). The proportion of patients who heard new information on AMI increased significantly in the postmessage period (premessage, 53%; postmessage, 74%; P less than .0001). The campaign, however, did not significantly shorten patient delay in seeking care (median delay: premessage, 2.6 hours; postmessage, 2.3 hours) or alter the distribution of patients in the less-than-two-hour, two-to-four-hour, and more-than-four-hour intervals. The rate of EMS use also was not significantly changed (premessage, 42%; postmessage, 44%). We conclude that a short-duration education campaign may increase AMI knowledge but does not seem to significantly alter patient behavior.

We surveyed all patients admitted to nine community hospital coronary care units to determine what proportion could be candidates for thrombolytic therapy. During the 12-month study period, there were 4,115 admissions for possible acute myocardial infarction, and 1,076 (26%) had a discharge diagnosis of myocardial infarction. Patients with myocardial infarction had the following characteristics: 60% had ST elevation seen on the first ECG, 17% had ST depression without ST elevation, 75% were less than 75 years old, 75% had no contraindications to thrombolytic therapy, 78% arrived at hospital within six hours of onset of symptoms, and 94% arrived within 24 hours of symptoms. Criteria for administration of thrombolytic therapy can be grouped as restrictive (arrival within six hours of symptoms and ST elevation) or liberal (arrival within 24 hours of symptoms and ST elevation or ST depression). Applying these characteristics, 26% met restrictive criteria for treatment with thrombolytic therapy, and 36% met liberal criteria. Until liberal criteria (therapy up to 24 hours and ST depression) are convincingly shown to be of benefit, we believe clinicians should apply restrictive criteria to potential candidates for thrombolytic therapy.

We interviewed 308 survivors of out-of-hospital cardiac arrest and matched controls who had suffered a myocardial infarction. The Sickness Impact Profile (SIP) scores of controls were somewhat lower (better) than those of cases, but responses of cases and controls to additional questions about stair climbing, irritability and mood were virtually identical. Half as many (18 per cent) controls as cases (38 per cent) reported poorer memory function; nevertheless, 63 per cent of cases and 79 per cent of controls who had been working outside the home at the time of the event were employed at the time of the interview.

Presents the summary of the study "Mortality Rates in Elderly Patients Who Take Different Angiotensin-Converting Enzyme Inhibitors After Acute Myocardial Infarction: A Class Effect?," which was published in the July 20, 2004 issue of Annals of Internal Medicine.