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Biomedical subjects

J S Alpert

Publications and source records attributed to J S Alpert.

At least 19 recordsLinked to original sources
PubMed1992

Patient delay and receipt of thrombolytic therapy among patients with acute myocardial infarction from a community-wide perspective.

The duration of patient delay from the time of onset of symptoms of acute myocardial infarction (AMI) to hospital presentation, and the relation of delay time and various patient characteristics to receipt of thrombolytic therapy were examined as part of a community-based study of patients hospitalized with AMI in the Worcester, Massachusetts, metropolitan area. In all, 800 patients with validated AMI hospitalized at 16 hospitals in the Worcester metropolitan area in 1986 and 1988 constituted the study sample. Patients delayed on average 4 hours between noting symptoms suggestive of AMI and presenting to area-wide emergency departments with no significant change observed between 1986 and 1988. The shorter the time interval of delay, the greater the likelihood of receiving thrombolytic therapy; patients arriving at the emergency department within 1 hour of the onset of acute symptoms were approximately 2.5 and 6.5 times more likely to receive thrombolytic agents than were those presenting to the hospital between 4 and 6, and greater than 6 hours, respectively, after the onset of symptoms. Results of a multivariate analysis showed increasing length of delay, older age, history of hypertension or AMI and non-Q-wave AMI to be significantly associated with failure to receive thrombolytic therapy.

Adolescent↗
PubMed1992

Prognosis of acute myocardial infarction complicated by complete heart block (the Worcester Heart Attack Study).

As part of a community-based study of patients hospitalized with acute myocardial infarction (AMI) in the Worcester, Massachusetts, metropolitan area, changes over time in the incidence rates of complete heart block (CHB) complicating AMI, and the prognostic impact of CHB on the in-hospital and long-term survival of these patients were examined. In all, 4,762 patients with validated AMI hospitalized at 16 hospitals in the Worcester metropolitan area during 1975, 1978, 1981, 1984, 1986 and 1988 constituted the study sample. The incidence rates of CHB complicating AMI remained relatively stable at 5.8% over the 13-year (1975 to 1988) period studied. The incidence rates of CHB were approximately twice as high in patients with inferior/posterior wall AMI (7.7%) as in those with anterior wall AMI (3.9%). Use of a multivariate regression analysis to control for factors affecting the incidence rates of CHB revealed that patients were at highest risk for developing CHB during the latter 2 study years (1986 and 1988). Patients with AMI developing CHB had higher in-hospital case fatality rates than did those without CHB overall, as well as during each of the 6 periods studied. The in-hospital survival associated with CHB did not improve over time. After use of a multivariate regression analysis to control for additional prognostic factors, the independent effect of CHB on in-hospital prognosis remained (adjusted risk of dying = 2.10; 95% confidence intervals = 1.37, 3.21). Patients with inferior wall AMI complicated by CHB were at significantly increased risk of dying during hospitalization compared with those without CHB (adjusted risk of dying = 2.71; 95% confidence intervals = 1.60, 4.59).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Beta-blocker therapy in acute myocardial infarction: evidence for underutilization in the elderly.

PURPOSE: To assess the impact of patient age on the use of beta-blocker therapy in the management of acute myocardial infarction. PATIENTS AND METHODS: The population studied consisted of 4,762 patients hospitalized with validated acute myocardial infarction in 16 hospitals in the Worcester, Massachusetts, Standard Metropolitan Statistical Area during the years 1975, 1978, 1981, 1984, 1986, and 1988. Logistic regression analysis was employed to control for relevant demographic and clinical variables in evaluating the independent effect of patient age as a determinant of receipt of beta-blocker therapy during the hospitalization. RESULTS: A consistent trend toward reduced use of beta-blocker therapy in older patients was demonstrated. After adjustment for demographic and clinical variables (gender; prior history of angina, hypertension, or diabetes mellitus; myocardial infarction characteristics; complications including congestive heart failure and shock; and use of digoxin and diuretics), odds ratios for receipt of beta-blocker therapy relative to patients less than 55 years of age were 0.61 for those 55 to 64; 0.52 for those 65 to 74; 0.36 for those 75 to 84; and 0.26 for those 85 or older. Analyses performed for each study year demonstrated results consistent with those for the overall study population. CONCLUSION: The results of this population-based study suggest that there are substantial opportunities for expanded use of beta-blocker therapy in elderly patients who have sustained an acute myocardial infarction.

Adrenergic beta-Antagonists↗
PubMed1991

Importance of the pharmacological profile of thrombolytic agents in clinical practice.

Three thrombolytic agents are frequently used in the United States for treating patients with acute myocardial infarction: streptokinase, alteplase (tissue plasminogen activator [t-PA]), and anistreplase (anisoylated plasminogen-streptokinase activator complex [APSAC]). A fourth agent, urokinase, is occasionally used but clinical experience is considerably more limited with this agent. Streptokinase, alteplase, and anistreplase differ in a number of pharmacologic properties, which include half-life, enzymatic efficiency, and induction of platelet aggregation; these differences may be clinically important. For example, anistreplase and alteplase have high affinity for fibrin and bind to intravascular thrombi after intravenous administration, which may result in higher clot specificity. Anistreplase has the longest half-life of the 3 agents and, therefore, can be administered conveniently and quickly. Alteplase has a shorter half-life and heparin is generally a necessary adjunctive agent. These differences can be clinically significant in various settings and application of such theoretical advantages is just beginning.

Fibrinolytic Agents↗
PubMed1991

Diagnostic testing in acute myocardial infarction: does patient age influence utilization patterns? The Worcester Heart Attack Study.

To assess the impact of patient age on the use of diagnostic testing in the management of acute myocardial infarction, the authors reviewed the hospital charts of 4,109 patients hospitalized for validated acute myocardial infarction in the Worcester, Massachusetts, metropolitan area during selected years between 1975 and 1986. Older patients were more likely to be female and to have a prior history of angina, hypertension, and diabetes mellitus (p less than 0.001). Acute myocardial infarctions among older patients were more likely to be recurrent, anterior in location, non-Q wave, smaller as reflected by peak creatine kinase levels, and complicated by congestive heart failure, cardiogenic shock, and atrial fibrillation (p less than 0.001). In-hospital mortality was directly related to increasing patient age (p less than 0.001). Patterns of utilization of the following diagnostic tests were examined: Holter monitoring, radionuclide ventriculography, echocardiography, exercise testing, pulmonary artery catheterization, and coronary arteriography. After adjustment for differences in demographic and clinical characteristics and in-hospital mortality, patients aged 65 years and older were significantly less likely to undergo exercise testing than were patients less than age 55. Patients older than age 75 were significantly less likely to undergo radionuclide ventriculography, pulmonary artery catheterization, and coronary arteriography than were younger patients. Sex-specific analyses did not produce results substantially different from those for the overall study population. The results of this community-wide study suggest that among patients hospitalized for acute myocardial infarction, chronologic age may be an independent determinant of utilization patterns of diagnostic testing. These findings suggest the need for a prospective evaluation of this issue, with an additional emphasis placed on the contributions of functional status and noncardiovascular illness to decision-making in the clinical management of acute myocardial infarction patients.

Age Factors↗
PubMed1991

Cardiogenic shock after acute myocardial infarction. Incidence and mortality from a community-wide perspective, 1975 to 1988.

BACKGROUND: Cardiogenic shock resulting from acute myocardial infarction is a serious complication with a high mortality rate, but little is known about whether its incidence or outcome has changed over time. As part of an ongoing population-based study of acute myocardial infarction, we examined trends over time in the incidence and mortality rate of cardiogenic shock after acute myocardial infarction. METHODS: We studied 4762 patients with acute myocardial infarction who were admitted to 16 hospitals in the Worcester, Massachusetts, metropolitan area between 1975 and 1988. We determined the incidence of and short-term and long-term mortality due to cardiogenic shock in each of six years during this study period. RESULTS: The incidence of cardiogenic shock complicating acute myocardial infarction remained relatively constant, averaging 7.5 percent. Multivariate regression analysis that controlled for variables affecting incidence revealed significant though inconsistent temporal trends in the incidence of cardiogenic shock. As compared with the risk in 1975, the adjusted relative risk (with 95 percent confidence interval) was 0.83 (0.54 to 1.28) in 1978, 0.96 (0.63 to 1.48) in 1981, 0.68 (0.42 to 1.12) in 1984, 1.16 (0.70 to 1.92) in 1986, and 1.65 (0.99 to 2.77) in 1988. The overall in-hospital mortality rate among patients with cardiogenic shock was significantly higher than that among patients without this complication (77.7 percent vs. 13.5 percent, P less than 0.001). The in-hospital mortality among the patients with shock did not improve between 1975 (73.7 percent) and 1988 (81.7 percent). Long-term survival during the 14-year follow-up period was significantly worse among patients who survived cardiogenic shock during hospitalization than among patients who did not have shock (P less than 0.001). CONCLUSIONS: The results of this observational, community-wide study suggest that neither the incidence nor the prognosis of cardiogenic shock resulting from acute myocardial infarction has improved over time. Both in-hospital and long-term survival remain poor for patients with this complication.

Aged↗
PubMed1991

Coronary flow reserve.

The ability of the coronary circulation to autoregulate is essential for the heart to respond to metabolic demands. Several alterations in function may limit maximal coronary perfusion including atherosclerosis, structural abnormalities of small coronary vessels, extravascular compressive forces, thrombosis, abnormal endothelial regulatory function, and the effect of abnormal myocardium on the coronary circulation. Coronary flow reserve is a unifying concept that examines the limitation in myocardial perfusion that certain disease states impose. At present, even with state-of-the-art technology, the measurement of coronary flow reserve is difficult in routine clinical situations. As the ability to measure regional myocardial perfusion improves, coronary flow reserve may gain more widespread clinical use with perhaps as yet undiscovered therapeutic implications.

Angioplasty, Balloon, Coronary↗
PubMed1991

Heart disease in native Americans.

Cardiovascular disease is one of the major causes of death among native Americans. Ischemic heart disease has been relatively uncommon in the past, but this entity is rapidly becoming more frequent among Indians as a result of Western acculturation (Western high-fat diet, smoking, sedentary lifestyle). Hypertension remains a major problem in native American populations. Hypertension is often inadequately detected and treated in Indians. Rheumatic fever and rheumatic heart disease are moderately common and apparently in decline among native Americans. Finally, the fetal alcohol syndrome with its accompanying cardiac malformations is all too common among North American Indians. The amount of information available concerning cardiovascular disease in native Americans is rather small. Considerably more attention should be paid to this area in the future.

Coronary Disease↗
PubMed1991

Relation of left atrial size to pulmonary capillary wedge pressure in severe mitral regurgitation.

4,071 consecutive cardiac catheterizations were reviewed retrospectively to obtain 56 cases of pure mitral regurgitation among whom chest X-ray, electrocardiography and echocardiography had been performed within 10 days of catheterization. Mitral regurgitation was mild to moderate (1-2+) in 7 of the 56 cases while 49 had more severe regurgitation (3-4+). Left atrial size as measured by echocardiography was found to be enlarged in all but 2 cases. A positive correlation between left atrial size and severity of mitral regurgitation, irrespective of the height of the pulmonary capillary wedge pressure V wave was demonstrated. There was no demonstrable, predictive relationship between left atrial size and pulmonary capillary wedge pressure or electrocardiographic or chest X-ray findings. We conclude that knowledge of left atrial size is predictive of the severity of mitral regurgitation; however, it is not possible to predict the pulmonary capillary wedge pressure or height of the V waves based on a knowledge of left atrial dilatation in patients with pure mitral regurgitation.

Angiography↗
PubMed1991

Prognosis following interventional therapy for acute myocardial infarction: utility of dipyridamole thallium scintigraphy.

A variety of methods for risk stratification after acute myocardial infarction have been successfully employed, however, little attention has been focused on patients who have received reperfusion therapy. The present report examines the utility of dipyridamole thallium scintigraphy in the prediction of late cardiac death or recurrent myocardial infarction in patients who have received thrombolytic therapy. Prospectively, 71 patients who presented with myocardial infarction and were treated with recombinant tissue plasminogen activator (and frequently percutaneous transluminal coronary angioplasty) were enrolled in the study. The primary end points during the follow-up period of nearly 2 years were recurrent infarction or death, which occurred in 10 patients. Although cardiac events were significantly related to either the performance of late myocardial revascularization or the presence of a residual coronary artery stenosis at discharge, no scintigraphic variable was found to be predictive of myocardial infarction or death. Thus, this report is the first to suggest limitation of scintigraphic techniques with regard to prognostic value in myocardial infarction survivors treated with reperfusion techniques. This selected population may have physiologic differences as compared with post-infarction studies performed before the advent of thrombolytic agents. Caution is therefore advised in extrapolating results of earlier reports to the ever increasing percentage of patients receiving recannalization therapy.

Adult↗
PubMed1990

Nitrate therapy in the elderly.

Changes in the heart and blood vessels with age alter the response of the cardiovascular system to pharmacologic agents. Nitrate plasma half-life is longer and volume of distribution is larger in older persons. Apparently, these pharmacokinetic differences in older persons lead to increased venous smooth muscle responsivity to nitrates which, in turn, leads to greater reductions in central venous and pulmonary arterial pressures after nitrate administration. This is probably the explanation for the greater frequency of nitrate-induced severe hypotension and bradycardia in elderly patients with myocardial infarction compared with younger patients. Clinicians should be cognizant of the changes in the cardiovascular system which occur with age that sensitize the elderly patient to the action of organic nitrates. Initial dosages of nitrates should accordingly be less than in younger patients.

Aged↗
PubMed1990

Impact of atrial fibrillation on the in-hospital and long-term survival of patients with acute myocardial infarction: a community-wide perspective.

As part of an ongoing community-wide study examining changes over time in the incidence and survival rates of 4108 patients hospitalized with validated acute myocardial infarction (MI) in 16 hospitals in the Worcester, Massachusetts, metropolitan area during calendar years 1975, 1978, 1981, 1984, and 1986, we examined changes over time in the proportion of patients with acute MI developing atrial fibrillation (AF) and the impact of AF on in-hospital and long-term survival for up to a 10-year follow-up period. The overall percentage of patients with AF complicating acute MI was 16.0%; this proportion increased over time from 13.3% in 1975 to 14.8% in 1978, 14.9% in 1981, 20.3% in 1984, and to 17.7% in 1986. Patients with AF experienced consistently higher in-hospital case fatality rates than MI patients without AF overall (27.6% versus 16.6%), as well as during each of the 5 years under study. The independent effect of AF on in-hospital survival was not upheld, however, when a variety of potentially confounding prognostic factors were controlled for in a multivariate analysis resulting in an adjusted odds ratio (OR) of 1.18 (95% confidence interval 0.90, 1.52). Among discharged hospital patients, while the crude long-term survival rate for patients with AF was poorer than that of patients without AF for the combined as well as for individual study periods, similar to the in-hospital findings the independent effect of AF on long-term prognosis was not upheld after use of a multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1990

Percutaneous transluminal coronary angioplasty in women.

Percutaneous transluminal coronary angioplasty (PTCA) for coronary artery disease is currently as successful in women as it is in men. Acute and long-term results are similar for both sexes. Differences in the size of the coronary arteries may have accounted for gender differences in earlier series. However, improved PTCA technology has eliminated gender differences in outcome.

Angioplasty, Balloon, Coronary↗