Triggers and Timing of Acute Coronary Syndromes Tofler, Geoffrey H., MD; Kopel, Eran, MD; Klempfner, Robert, MD ...
The American journal of cardiology,
05/2017, Letnik:
119, Številka:
10
Journal Article
Recenzirano
Abstract Prior studies have shown that an acute coronary syndrome (ACS) may be triggered by external activities, however their frequency, predictors and significance are uncertain. We evaluated data ...from The National Israel Survey of Acute Coronary Syndromes, which was conducted in 2004 (February-March) in all 25 coronary care units and cardiac wards in Israel. Demographic and clinical data were recorded for consecutive participants, including potential triggers and time of symptom onset of ACS. Among the 1849 patients who completed the trigger question, one quarter (25.9%) reported a possible trigger, comprising heavy physical exertion (15.2%), emotional stress (8.3%), anger (1.1%), heavy meal (1.3%) and sexual activity (0.5%). Predictors of a triggered ACS were age <65 years, prior angina, no prior ACE / AT2 inhibitors, impaired functional class, not having typical chest pain on admission, and a final diagnosis of unstable angina. The highest proportion of triggered ACS was between noon- 6pm. Physical exertion as a trigger was associated with reduced in-hospital mortality (0.4 versus 2.8%, p <0.05) and 1-year mortality. Emotional stress as a trigger did not influence in-hospital or 1-year mortality, however among those discharged from hospital, it was associated with increased 30-day rehospitalisation (27.6 versus 19.3%, p <0.05) and a trend towards increased mortality (4.1 versus 2.0%, p=0.10).
Abstract Background Although there is evidence that anxiety and anger are associated with a higher risk of cardiovascular events, studies examining the relationship between these stressors and ...prognosis following myocardial infarction have been mixed. Methods We conducted a prospective cohort study of 1968 participants (average age 60.2 years, 30.6% women) in the Determinants of Myocardial Infarction Onset Study recruited at the time of admission for myocardial infarction between 1989 and 1996. We used the state anxiety and anger subscales of the State-Trait Personality Inventory. Participants were followed for all-cause mortality through December 31, 2007 using the National Death Index. We constructed multivariable Cox proportional hazards models adjusted for demographic, behavioral, and clinical confounders and calculated hazard ratios (HR) and 95% confidence intervals (CI) to examine the relationship between high levels of anxiety and anger and all-cause mortality. Results Over 10 years of follow-up, 525 participants died. Compared with those scoring lower, an anxiety score >90th percentile was associated with a 1.31-times (95% CI, 0.93-1.84) higher mortality rate. The association was apparent in the first 3 years (HR 1.78; 95% CI 1.08-2.93), but not thereafter. Likewise, an anger score >90th percentile was associated with a 1.25-times (95% CI, 0.87-1.80) higher mortality rate. The association was higher in the first 3 years (HR 1.58; 95% CI, 0.91-2.74) than in subsequent years, but it was not statistically significant during either follow-up period. Conclusions In this study of myocardial infarction survivors, a high level of anxiety was associated with all-cause mortality, with the strongest association in the first 3 years of follow-up.
The aim of the present study was to explore the association between outbursts of anger and acute myocardial infarction (AMI) risk. Outbursts of anger are associated with an abrupt increase in ...cardiovascular events; however, it remains unknown whether greater levels of anger intensity are associated with greater levels of AMI risk or whether potentially modifiable factors can mitigate the short-term risk of AMI. We conducted a case-crossover analysis of 3,886 participants from the multicenter Determinants of Myocardial Infarction Onset Study, who were interviewed during the index hospitalization for AMI from 1989 to 1996. We compared the observed number and intensity of anger outbursts in the 2 hours preceding AMI symptom onset with its expected frequency according to each patient's control information, defined as the number of anger outbursts in the previous year. Of the 3,886 participants in the Determinants of Myocardial Infarction Onset Study, 1,484 (38%) reported outbursts of anger in the previous year. The incidence rate of AMI onset was elevated 2.43-fold (95% confidence interval 2.01 to 2.90) within 2 hours of an outburst of anger. The association was consistently stronger with increasing anger intensities (p trend <0.001). In conclusion, the risk of experiencing AMI was more than twofold greater after outbursts of anger compared with at other times, and greater intensities of anger were associated with greater relative risks. Compared with nonusers, regular β-blocker users had a lower susceptibility to heart attacks triggered by anger, suggesting that some drugs might lower the risk from each anger episode.
Multivariable models were adjusted for covariates selected a priori including demographics (age, sex, age*sex, race, marital status, education, income), health behaviors (smoking status, alcohol ...consumption, body mass index, usual frequency of physical exertion), medical history (history of MI; congestive heart failure; angina; hypertension; diabetes mellitus; noncardiac comorbidities including stroke, cancer, respiratory disease, and renal failure), thrombolytic therapy, peak creatine kinase, and medication use. ...anxiety immediately before MI onset is associated with a higher 10-year all-cause mortality rate.
Heavy physical exertion, emotional stress, heavy meals, and respiratory infection transiently increase the risk of myocardial infarction, sudden cardiac death, and stroke; however, it remains ...uncertain how to use this information for disease prevention. We determined whether it was feasible for those with either risk factors for cardiovascular disease (CVD) or known CVD to take targeted medication for the hazard duration of the triggering activity to reduce their risk. After a run-in of 1 month, 20 subjects (12 women and 8 men) aged 68.6 years (range 58 to 83) recorded for 2 months all episodes of physical and emotional stress, heavy meal consumption, and respiratory infection. For each episode, the subjects were instructed to take either aspirin 100 mg and propranolol 10 mg (for physical exertion and emotional stress) or aspirin 100 mg alone (for respiratory infection and heavy meal consumption) and to record their adherence. Adherence with taking the appropriate medication was 86% according to the diary entries, with 15 of 20 subjects (75%) achieving ≥80% adherence. Propranolol taken before exertion reduced the peak heart rate compared with similar exercise during the run-in period (118 ± 21 vs 132 ± 16 beats/min, p = 0.016). Most subjects (85%) reported that it was feasible to continue taking the medication in this manner. In conclusion, it is feasible for those with increased CVD risk to identify potential triggers of acute CVD and to take targeted therapy at the time of these triggers.
Abstract Background Current data on the influence of sex on the prognosis of heart failure (HF) are conflicting, possibly owing to the use of different end points and a heterogeneous heart failure ...population in earlier studies. We sought to evaluate the effect of sex on the risk of early and late mortality outcomes after hospitalization for acute heart failure. Methods and Results The prospective cohort study population comprised 2,212 hospitalized patients with acute HF enrolled in a multicenter national survey in Israel. Cox proportional-hazards regression modeling was used to evaluate the effect of sex on the risk of early (≤6 months) and late (>6 months to 4 years) mortality after the index hospitalization. Among the study patients, 998 (45%) were women. Women with HF displayed significantly different clinical characteristics compared with men, including older age, higher frequency of HF with preserved ejection fraction and hypertensive heart disease, and lower percentage of coronary artery disease (all P < .001). The fully adjusted multivariable analyses for mortality outcomes showed that women tended toward an increased risk for early (≤6 months) mortality (hazard ratio HR 1.16, 95% confidence interval CI 0.96–1.41; P = .13), whereas men had significantly increased risk for late (>6 months) mortality (HR 1.25, 95% CI 1.09–1.43; P = .001). Conclusions There are important differences in the clinical characteristics and the short- and long-term outcomes between men and women hospitalized with acute HF after adjusting for multiple confounding variables.
Background Bereavement is associated with increased cardiovascular risk, particularly in surviving spouses and parents, however the mechanism is not well understood due to limited studies. The ...purpose of this study was to evaluate haemodynamic changes (blood pressure (BP) and heart rate (HR)), that may contribute to increased cardiac risk in early bereavement. Methods We enrolled 80 bereaved individuals and 80 non-bereaved as a reference group. Twenty-four hour ambulatory blood pressure monitoring was performed within two weeks (acute assessment) and at six months following bereavement. Results Compared to the non-bereaved, the acutely bereaved had higher 24-hour systolic BP (mean (SE) 130.3 (1.5) vs 127.5 (1.4) mm Hg, p = 0.03), higher daytime systolic BP (135.6 (1.5) vs 131.6 (1.4) mm Hg, p = 0.02) and higher daytime systolic load (median % 39.0 vs 29.3, p = 0.02). By six months the BP of the bereaved tended to be lower than acute measures. This difference was significant amongst those not taking BP lowering medications for 24-hour systolic BP (126.5 (2.4) vs 129.7 (2.3) mm Hg, p = 0.04), daytime systolic BP (129.8 (2.1) vs 133.9 (2.0) mm Hg, p = 0.01) and daytime diastolic pressure (76.7 (1.0) vs 78.9 (0.9) mm Hg, p = 0.03). Twenty-four hour heart rate was also higher acutely in the bereaved compared with the reference group (74.0 (1.2) vs 71.7 (0.9) b/min, p = 0.02); at six months heart rate in the bereaved had fallen to non-bereaved levels (70.4 (0.09), p = 0.02). Conclusion Early bereavement is associated with increased systolic blood pressure and heart rate. These haemodynamic changes may contribute to a time-limited increase in cardiovascular risk.
Smoking remains a major public health problem. Experiencing a myocardial infarction (MI) can be a teachable moment that results in smoking cessation when previous efforts have failed. We tested the ...feasibility of providing a simulated and personalized experience of an MI to facilitate quitting smoking. Smokers, who were recruited from the community, had photographs taken of themselves, their partner, and family. These photographs were inserted into a video depicting the subject as a smoker experiencing an MI with potential consequences to themselves (death or disability) and their family. The subject watched the video and a psychologist used motivational interviewing to reinforce quitting efficacy. Thirteen subjects (11 men, 2 women) 45 ± 12 years of age with no smoking-related illness and a nonsmoking partner were studied. At week 1, 7 of 13 subjects (54%) reported stopping smoking, and the other 6 had decreased consumption. Daily cigarette consumption at week 1 decreased from 17.3 ± 9.3 at baseline to 2.7 ± 4.9 (p <0.005) and expired carbon monoxide levels from 15.7 ± 9 to 3.1 ± 3.2 parts per million (p <0.005). Seven subjects had observable responses to the video including “looking uncomfortable” and “red eyes, difficulty speaking.” Self-reports included “made me aware of the important things” and “it felt very real.” At 6 months, 7 of 13 subjects (54%) were still abstinent. Five of the 7 nonsmoking subjects used an additional antismoking aid. In conclusion, it is feasible to create a simulated and personalized teachable moment and these findings provide encouragement for evaluating this novel method for smoking cessation and other behavior modifications.
Background Heavy physical exertion, emotional stress, heavy meals and respiratory infection transiently increase the risk of myocardial infarction, sudden death and stroke, however it remains ...uncertain how to use this information for disease prevention. Aims We determined the feasibility of taking targeted medication for the hazard duration of a triggering activity to reduce risk. Methods After a run-in training period over 1 month, 17 healthy subjects recorded for 1 month all episodes of physical and emotional stress, heavy meal and respiratory infection. For each episode, they were instructed to take either aspirin 100 mg and propranolol 10 mg (for physical exertion and emotional stress) or aspirin 100 mg alone (for respiratory infection and heavy meal) and record adherence with taking medication. Subjects performed exertion while wearing a heart rate monitor, once during the run-in period, and once 30 min after taking propranolol and aspirin. Results Based on study diary subjects reliably documented triggers with 94% adherence. Designated medication was also reliably taken, with 88% adherence. Propranolol taken prior to exertion resulted in a lower peak heart rate (128 ± 38 versus 149 ± 21, p < 0.01) compared to similar exercise during the run-in period. Over two-thirds (71%) of subjects considered that it was feasible to continue taking medication in this manner. Conclusions The study indicates that potential triggers of acute cardiovascular disease can be reliably identified, and it is feasible and acceptable to take targeted medication at the time of these triggers. These findings encourage further investigation of the potential role of this therapeutic strategy.
Introduction Although anaemia is associated with an adverse prognosis in congestive heart failure (HF), the cause of the anaemia and its relationship to non-cardiac and cardiac complications needs to ...be better defined, particularly in a general community population. Methods Clinical data were collected prospectively from 959 patients hospitalised with HF. Results Thirty-eight percent ( n = 369) had anaemia (Hb < 120 g/L), which was normochromic normocytic in 87.8%. Of those who had haematinic studies, 15.5% had a confirmed haematinic deficiency. Anaemic patients were of similar age to non-anaemic (79 vs 77 years) but were more likely to have elevated creatinine (48 vs 29%, p < 0.001), hyponatremia (20 vs 15%, p = 0.05), and LVEF > 40% (49 vs 39%, p = 0.004), and less likely to receive ACE inhibitors (72 vs 78%, p = 0.04). At 12 months, anaemic patients had higher HF readmission rates (22.4 vs 15.7%, p = 0.01), more multiple non-HF readmissions (12.4 vs 6.3%, p = 0.001) and a higher mortality (16.4% vs 10.5%, p = 0.01). Conclusion Anaemia is common (38%) in community patients hospitalised with HF, and is associated with increased HF and non-HF readmissions, and increased mortality. A haematinic deficiency was identified in 15.5% of patients. Anaemia is a common, multifactorial, but potentially treatable cause of adverse outcome in HF.
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