One thousand and ten patient years of oral anticoagulant therapy with vitamin-K-antagonists were reviewed with regard to major bleeding complications. The incidence of bleeding that necessitated hospital admission was 2.7% per year (95% confidence limits, 1.7-3.7%). The major source of bleeding was the alimentary tract, whereas no cases of intracranial bleeding were found. Various factors with potential effects on the bleeding risk were evaluated by multivariate statistical analysis, and the following independent risk factors were identified: age greater than 75 years and hypertension increased the bleeding risk by 10.5% and 4.5%, respectively. Each recorded prothrombin value significantly below the therapeutic range increased the bleeding risk by 3.9%, and each year of treatment increased the risk by 2.0%. These figures may be used to estimate the risk of major bleeding in an individual patient. Current treatment with thiazide diuretics was found to increase the bleeding risk by 5.2%. However, this observation requires further documentation and analysis. Although no lethal episodes of bleeding occurred, the developing field of indications for oral anticoagulant therapy should be considered on the basis of a continuous substantial risk of major bleeding.

Echocardiographic estimates of left ventricular ejection fraction (ECHO-LVEF) in acute myocardial infarction (AMI) were obtained by a new approach, using visual analysis of left ventricular wall motion in a nine-segment model. The method was validated in 41 patients using radionuclide ventriculography (RNV) and contrast ventriculography measurements of LVEF for comparison. ECHO-LVEF from the 41 patients correlated well with the reference methods (y = 1.5x – 14.7, r = 0.93; linear regression analysis; 95 % confidence limit for a single determination of ECHO-LVEF was 17.2). Interobserver variability by linear regression was r = 0.89, SEE = 7.1 with a mean difference between paired observations of-1.5 ± 6.9 (SD). In a random sample of 18 patients (45 observations), ECHO-LVEF allowed separation between RNV-LVEF values ≧ 40 and < 40, representing low and high risk groups following AMI. Thus, the results showed that simple, readily available wall motion-derived estimates of LVEF were as closely associated with LVEF measured by standard reference methods as were previously published, more cumbersome, plani-metric echocardiographic methods. Reporting on global LVEF function in LVEF units rather than in nonstandardized wall motion scores of index values may facilitate intra- and interhospital communication and the use of optimized echocardiographic risk stratification after AMI.

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.