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      Early Stroke following Acute Myocardial Infarction: Incidence, Predictors and Outcome in Six Middle-Eastern Countries

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          Abstract

          Background and Objectives: Stroke is a potential complication of acute myocardial infarction (AMI). The aim of this study was to identify the incidence, risk factors predisposing to stroke and in-hospital outcome during the index admission with AMI among patients in the Middle East. Methods: For a period of 6 months in 2006 and 2007, 5,833 consecutive AMI patients were enrolled from 64 hospitals in 6 Middle East countries. Results: The incidence of in-hospital stroke following AMI was 0.85%. Most cases were ST segment elevation AMI-related and ischemic in nature. Patients with in-hospital stroke were older than patients without stroke and were more likely to be female (36 vs. 18.6%, p = 0.0033). They were also more likely to have diabetes mellitus, dyslipidemia, prior AMI, or percutaneous/surgical coronary revascularization. Patients with stroke were more likely to present with advanced Killip class II–IV, higher mean heart rate and higher serum creatinine. Independent predictors of stroke were age, prior stroke, prior coronary artery bypass surgery, anterior AMI and systolic blood pressure >190 mm Hg on presentation. Early administration of statins was independently associated with reduced stroke risk (odds ratio, OR, 0.4, 95% confidence interval, CI, 0.19–0.90, p = 0.025). Stroke was fatal in 44% of the cases and was independently associated with in-hospital mortality (adjusted OR 12.5, 95% CI 5.7–27.4, p < 0.01). Conclusion: There is a low incidence of in-hospital stroke in Middle-Eastern patients presenting with AMI but with very high fatality rates. Early statin therapy was associated with a significant reduction in stroke risk. Future work should be focused on reducing the risk and improving the outcome of this devastating complication.

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          Most cited references 35

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          American College of Cardiology key data elements and definitions for measuring the clinical management and outcomes of patients with acute coronary syndromes. A report of the American College of Cardiology Task Force on Clinical Data Standards (Acute Coronary Syndromes Writing Committee).

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            A prospective survey of the characteristics, treatments and outcomes of patients with acute coronary syndromes in Europe and the Mediterranean basin; the Euro Heart Survey of Acute Coronary Syndromes (Euro Heart Survey ACS).

            To better delineate the characteristics, treatments, and outcomes of patients with acute coronary syndromes (ACS) in representative countries across Europe and the Mediterranean basin, and to examine adherence to current guidelines. We performed a prospective survey (103 hospitals, 25 countries) of 10484 patients with a discharge diagnosis of acute coronary syndromes. The initial diagnosis was ST elevation ACS in 42.3%, non-ST elevation ACS in 51.2%, and undetermined electrocardiogram ACS in 6.5%. The discharge diagnosis was Q wave myocardial infarction in 32.8%, non-Q wave myocardial infarction in 25.3%, and unstable angina in 41.9%. The use of aspirin, beta-blockers, angiotensin converting enzyme inhibitors, and heparins for patients with ST elevation ACS were 93.0%, 77.8%, 62.1%, and 86.8%, respectively, with corresponding rates of 88.5%, 76.6%, 55.8%, and 83.9% for non-ST elevation ACS patients. Coronary angiography, percutaneous coronary interventions, and coronary bypass surgery were performed in 56.3%, 40.4%, and 3.4% of ST elevation ACS patients, respectively, with corresponding rates of 52.0%, 25.4%, and 5.4% for non-ST elevation ACS patients. Among patients with ST elevation ACS, 55.8% received reperfusion treatment; 35.1% fibrinolytic therapy and 20.7% primary percutaneous coronary interventions. The in-hospital mortality of patients with ST elevation ACS was 7.0%, for non-ST elevation ACS 2.4%, and for undetermined electrocardiogram ACS 11.8%. At 30 days, mortality was 8.4%, 3.5%, and 13.3%, respectively. This survey demonstrates the discordance between existing guidelines for ACS and current practice across a broad region in Europe and the Mediterranean basin and more extensively reflects the outcomes of ACS in real practice in this region.
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              Ventricular dysfunction and the risk of stroke after myocardial infarction.

              In patients who have had a myocardial infarction, the long-term risk of stroke and its relation to the extent of left ventricular dysfunction have not been determined. We studied whether a reduced left ventricular ejection fraction is associated with an increased risk of stroke after myocardial infarction and whether other factors such as older age and therapy with anticoagulants, thrombolytic agents, or captopril affect long-term rates of stroke. We performed an observational analysis of prospectively collected data on 2231 patients who had left ventricular dysfunction after acute myocardial infarction who were enrolled in the Survival and Ventricular Enlargement trial. The mean follow-up was 42 months. Risk factors for stroke were assessed by both univariate and multivariate Cox proportional-hazards analysis. Among these patients, 103 (4.6 percent) had fatal or nonfatal strokes during the study (rate of stroke per year of follow-up, 1.5 percent). The estimated five-year rate of stroke in all the patients was 8.1 percent. As compared with patients without stroke, patients with stroke were older (mean [+/-SD] age, 63+/-9 years vs. 59+/-11 years; P<0.001) and had lower ejection fractions (29+/-7 percent vs. 31+/-7 percent, P=0.01). Independent risk factors for stroke included a lower ejection fraction (for every decrease of 5 percentage points in the ejection fraction there was an 18 percent increase in the risk of stroke), older age, and the absence of aspirin or anticoagulant therapy. Patients with ejection fractions of < or = 28 percent after myocardial infarction had a relative risk of stroke of 1.86, as compared with patients with ejection fractions of more than 35 percent (P=0.01). The use of thrombolytic agents and captopril had no significant effect on the risk of stroke. During the five years after myocardial infarction, patients have a substantial risk of stroke. A decreased ejection fraction and older age are both independent predictors of an increased risk of stroke. Anticoagulant therapy appears to have a protective effect against stroke after myocardial infarction.
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                Author and article information

                Journal
                CED
                Cerebrovasc Dis
                10.1159/issn.1015-9770
                Cerebrovascular Diseases
                S. Karger AG
                1015-9770
                1421-9786
                2011
                November 2011
                01 November 2011
                : 32
                : 5
                : 471-482
                Affiliations
                aDepartment of Medicine, Faculty of Medicine, Kuwait University, Kuwait, Kuwait; bInstitute of Cardiac Sciences, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates; cDepartment of Medicine, Mubarak Al-Kabeer Hospital, Ministry of Health, Kuwait, Kuwait; dPriority Diseases Control Section, Department of Non-Communicable Diseases Surveillance and Control, Ministry of Health, and eRoyal Hospital, Muscat, Oman; fDepartment of Cardiology and Cardiovascular Surgery, Hamad Medical Corporation, Doha, Qatar; gInstitute for Clinical Research and Health Policy Studies and Department of Medicine, Tufts Medical Center and Tufts University School of Medicine, Boston, Mass., USA
                Author notes
                *Jassim Al Suwaidi, MB, ChB, FACC, FSCAI, FESC, Department of Cardiology and Cardiovascular Surgery, Hamad General Hospital, PO Box 3050, Doha (Qatar), Tel. +974 439 2464, E-Mail Jha01@hmc.org.qa
                Article
                330344 Cerebrovasc Dis 2011;32:471–482
                10.1159/000330344
                22057047
                © 2011 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Tables: 5, Pages: 12
                Categories
                Original Paper

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