Trial of early nifedipine in acute myocardial infarction: the Trent study.

Abstract

The difference between the mean operative delays in the two groups was therefore 43 hours (95% confidence interval 41-35 to 44-45 h; t=6 0 143 df; p<O-OOOl). Despite a slight difference in the median ages for groups A and B (80 (range 47-%) and 82 (range 69-93), respectively) age distributions were similar. Typical reasons for delay included operator fatigue, delay in diagnosis, lack of theatre time, industrial action, and lack of patient's consent. DiscussionThis retrospective -study suggests that the longer an otherwise fit patient has to wait for her hip fracture to be treated the less she will progress after discharge, regardless of her social circumstances. Many hospitals use trauma list systems, patients admitted one day being held over to the-next before undergoing surgery. Previous work has shown that delays of 1348 hours are not necessarily detrimental to patients' wellbeing.2 Such work, however, emphasises the delay between admission and surgery rather than between injury and operation, the two observations often being widely different. Some of our patients had languished at home for several days before being admitted to hospital; thus in these cases there was a-short interval between admission and surgery but an unacceptable delay between injury and surgery.Loss of independence is perhaps the most important social problem relating to patients with fractures of the femoral neck, resulting in blocked beds and overloading ofsocial and pnrmary care services. What then should be done to avoid this for the elderly patient who arrives in the accident and emergency department with a hip fracture? We believe that if she is otherwise fit every effort should be made for her to undergo surgery at the earliest opportunity. To include such patients in a standard trauma listsystem, however convenient it may be for surgeons, anaesthetists, and administrators, is to exacerbate a situation that is already out of control. Over 30 months 9292 consecutive patients admitted to nine coronary care units with suspected myocardial infarction were considered for admission to a randomised double blind study comparing the effect on mortality ofnifedipine 10 mg four times a day with that ofplacebo. Among the 4801 patients excluded from the study the overall one month fatality rate was 18-2% and the one month fatality rate in those with definite myocardial infarction 2688%. A total of4491 patients fulfilled the entry criteria and were randomly allocated to nifedipine or placebo immediately after assessment in the coronary care unit. Roughly 64% of patients in both treatment groups sustained an acute myocardial infarction. The overall one month fatalty rates were 6-3% in the placebo treated group and 677% in the nifedipine treated group. Most of the deaths occurred in patients with an in hospital References

Amelioration of Hypertensive Heart Failure by Amlodipine May Occur via Antioxidative Effects

“…Calcium channel blockers (CCBs) are widely used to treat patients with hypertension (6), but treatment with short-acting CCBs has been reported to increase the risk of cardiovascular death, at least partly due to activation of the sympathetic nervous system (7)(8)(9). However, CCBs with an intrinsically long duration of activity have been shown to significantly reduce vascular resistance properties without significant effects on myocardial contractility (10).…”

The prognostic significance of a history of systemic hypertension in patients randomised to either placebo or ramipril following acute myocardial infarction: evidence from the AIRE study

“…10 Lowering of blood pressure per se might also be advantageous in these patients, though experience with vasodilating calcium antagonists suggests that such a mechanism is not dominant. 11 The AIRE study was one of the landmark studies to demonstrate the value of ACE inhibition in patients with AMI and some evidence of LV dysfunction. In the current investigation we evaluated the prognostic value of a history of hypertension in the placebo and ramipril treated cohorts of patients.…”

Pharmacological Therapy for Myocardial Infarction in the Elderly: An 8-year Analysis

“…The use of nifedipine was significantly lower, while a proportional increase in the use of diltiazem, usually indicated as a substitute for the beta-blocker or after transluminal coronary angioplasty, was observed. The studies assessing the use of calcium antagonists in the treatment of acute myocardial infarction showed no benefits, and, in some cases, even showed a deleterious effect [41][42][43][44] . The ACC/AHA Guidelines for the Management of Patients with Acute Myocardial Infarction and the guidelines of the Brazilian Society of Cardiology (SBC) do not recommend the routine use of those drugs after acute myocardial infarction.…”