The high risk subset of a non-acute myocardial infarction population can be identified by means of a clinical evaluation and non-invasive cardiac examinations. Among the remainder, pulmonary embolism, gastro-oesophageal diseases and chest-wall syndromes should be paid special attention. A careful physical examination of the chest wall and upper endoscopy seems to be the most cost-beneficial examination to employ in this subset.
The purpose of the study was to describe the prognosis of patients with acute chest pain of different origin, but without myocardial infarction (non-AMI). A total of 204 patients were included. In 56, a definite diagnosis was obtained within 24-48 h of admission. The remaining 148 patients underwent the following examinations: exercise test, myocardial scintigraphy, echocardiography, Holier monitoring, hyperventilation test, oesophago-gastro-duodenoscopy, oesophageal manometry, oesophageal pH monitoring, Bernstein test, physical chest wall examination, bronchial histamine test, chest X-ray and ultrasonic upper abdominal examination. Ischaemic heart disease (IHD) was diagnosed in 64 patients, 81 had gastro-oesophageal disorders, 58 chest wall disorders, 9 pericarditis, 5 pulmonary embolism, 4 pneumonia/pleuritis, 3 pulmonary cancer, 2 dissecting aortic aneurysm, 1 aortic stenosis and 1 herpes zoster. During follow-up of 33 months, 31 of the 64 patients with IHD had a cardiac event (cardiac deaths, non-fatal AMI, bypass surgery or PTCA), whereas only 3 events occurred among the 140 patients without IHD (p < 0.00001). However, the frequency of readmissions and of recurrent episodes of chest pain were similar in the 3 major diagnostic groups (NS). To conclude, the high-risk subset of a non-AMI population can be identified by means of non-invasive cardiac examination. The remainder who have other diagnoses are at low risk. However, the morbidity is high with frequent readmissions and recurrent episodes of chest pain and the need for development of strategies with regard to diagnosis and treatment of these patients are emphasized.
This study prospectively evaluates the long-term prognosis of patients admitted with chest pain under suspicion of acute myocardial infarction (AMI) with and without confirmed diagnosis. All patients below 76 years of age, free of other severe diseases and alive at discharge, who were admitted to a coronary care unit of a well-defined region during 1 year, constituted the study population. In all, 275 patients with and 257 patients without confirmed AMI (non-AMI) were included. During 7 years of follow-up, 122 cardiac events (96 cardiac deaths and 26 nonfatal AMI) occurred in the AMI patients, and 69 (44 cardiac deaths and 25 nonfatal AMI) were observed in the non-AMI patients. Using univariate analysis, the following risk variables were significantly related to an impaired prognosis of non-AMI patients: age, a history of previous AMI, angina pectoris, clinical heart failure, diabetes and ST or T changes in the electrocardiogram (ECG) on admission. By multivariate analysis, the following risk factors contained independent prognostic information for non-AMI patients: (1) a history of angina pectoris and (2) ST and T changes on the ECG on admission. We conclude that a subset of non-AMI patients at high risk for cardiac events even in the long term can be identified from the medical history and the ECG on admission. These patients should be carefully evaluated prior to discharge, whereas patients without signs of ischemic heart disease have an excellent prognosis.
In order to perform risk stratification, 195 consecutive, unselected patients with acute myocardial infarction (AMI) underwent independent echocardiographic and clinical evaluation of their left ventricular function by means of the wall motion index (WMI) and Killip classification 5 days after AMI. The patients were prospectively allocated to a low, medium or high risk class depending on WMI alone, and the 1-year mortality in these classes was 2, 34 and 37%, respectively (p < 0.0001). The 1-year mortality of the patients in Killip class I, II, or III and IV was 6, 26 and 48%, respectively (p < 0.00001). The number of patients allocated to the low risk group by means of WMI was 87, and the number of patients in Killip class I was 86. Since these groups were not identical, a total of 103 patients, i.e. 53% of the study population, could be identified as low risk patients regarding 1-year mortality 5 days after AMI, when WMI and Killip classification were used in combination. We conclude that the combination of echocardiographic and clinical evaluation of left ventricular function after AMI provides a strong and yet very simple procedure to identify low risk patients, which could be easily implemented in the routine work of coronary care units.
urinary tract infection must be suspected, diagnosed, and treated rapidly in infancy and childhood and further infection prevented during follow up. It is also essential to identify vesicoureteric reflux early by investigation with cystography in infants with antenatal dilatation of the urinary tract, infants and young children after a first urinary infection, and siblings and offspring of patients with renal scarring. These measures will reduce the risk in children of the later development of reflux nephropathy and its complications. Main outcome measures-Death and cause of death. Standardised mortality ratio (observed mortality/expected mortality in background population).Results-The estimated 10 year mortalities were 58-80/o 55.5%/ and 428/o in patients with definite, probable, and no infarction, respectively (P < 0 0001). Stratified Cox's analysis identified a hazard ratio for mortality of 1*25 (95% confidence interval 108 to 1.44) for probable infarction compared with no infarction and of 115 (1.00 to 1.32) for definite compared with probable infarction. The standardised mortality ratio in the first year was 7-1 (6 5 to 7.8) for definite infarction, 5.0 (3.6 to 6 3) for probable infarction, and 4-7 (4-2 to 5.2) for no infarction. From the second year and onwards the annual standardised mortality ratio in the three groups did not differ significantly. Cardiac causes of deaths were recorded in 890/o, 84%, and 71% of the deaths in patients with definite, probable, and no infarction, respectively.Conclusions-The 10 year mortality of patients with and without infarction is significantly higher than in the background population. Most deaths are caused by coronary heart disease, and these patients should consequently be further evaluated at the time ofdischarge and followed up closely.
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