Cardiac Outcome after Peripheral Vascular Surgery: Comparison of General and Regional Anesthesia Effect of beta-blockers on the mortality of Japanese patients with myocardial infarction. A Prospective Randomised Trial Comparing Spinal Anaesthesia using Hyperbaric Cinchocaine with General Anaesthesia for Lower Limb Vascular Surgery Neuraxial block, death and serious cardiovascular morbidity in the POISE trial. Reduction in mortality after myocardial infarction with long-term beta-adrenoceptor blockade. Multicentre international study: supplementary report. Impact of beta blockade therapy on long-term mortality after ST-segment elevation acute myocardial infarction in the percutaneous coronary intervention era. Is general anesthesia a risk for myocardium? Effect of anesthesia on myocardial function as assessed by cardiac troponin-i in two different groups (isofluran+N2O inhalation and propofol+fentanyl iv anesthesia) Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the survival and ventricular enlargement trial. The SAVE Investigators. Perioperative Morbidity in Patients Randomized to Epidural or General Anesthesia for Lower Extremity Vascular Surgery Effect of antiarrhythmic therapy on mortality in survivors of myocardial infarction with asymptomatic complex ventricular arrhythmias: Basel Antiarrhythmic Study of Infarct Survival (BASIS) Early discharge following acute myocardial infarction. Long-term follow-up of randomized patients. Cardiac rehabilitation after myocardial infarction. Combined experience of randomized clinical trials. Effect of implementing routine early invasive strategy on one-year mortality in patients with acute myocardial infarction. Effect of mivazerol on perioperative cardiac complications during non-cardiac surgery in patients with coronary heart disease: the European Mivazerol Trial (EMIT). Randomized trial of primary anesthetic agents on outcome of coronary artery bypass operations. The effect of the angiotensin-converting-enzyme inhibitor zofenopril on mortality and morbidity after anterior myocardial infarction. The Survival of Myocardial Infarction Long-Term Evaluation (SMILE) Study Investigators. Improved clinical outcome after invasive management of patients with recent myocardial infarction and proven myocardial viability: primary results of a randomized controlled trial (VIAMI-trial)
Background Despite evidence that regional anesthesia may be associated with fewer perioperative complications than general anesthesia , most studies that have compared cardiac outcome after general or regional anesthesia alone have not shown major differences . This study examines the impact of anesthetic choice on cardiac outcome in patients undergoing peripheral vascular surgery who have a high likelihood of associated coronary artery disease . Methods Four hundred twenty‐three patients , between 1988 and 1991 , were r and omly assigned to receive general ( n = 138 ) , epidural ( n = 149 ) , or spinal anesthesia ( n = 136 ) for femoral to distal artery bypass surgery . All patients were monitored with radial artery and pulmonary artery catheters . Postoperatively , patients were in a monitored setting for 48–72 h and had daily electrocardiograms for 4–5 days and creatine phosphokinase/isoenzymes every 8 h x 3 , then daily for 4 days . Cardiac outcomes recorded were myocardial infa rct ion , angina , and congestive heart failure . Results Baseline clinical characteristics were not different between anesthetic groups . Overall , the patient population included 86 % who were diabetic , 69 % with hypertension , 36 % with a history of a prior myocardial infa rct ion , and 41 % with a history of smoking . Cardiovascular morbidity and overall mortality were not significantly different between groups when analyzed by either intention to treat or type of anesthesia received . In the intention to treat analysis , incidences of cardiac event or death for general , spinal , and epidural groups were 16.7 % , 21.3 % , and 15.4 % , respectively . The absolute risk difference observed between general and all regional anesthesia groups for cardiac event or death was ‐1.6 % ( 95 % confidence interval ‐9.2 % , 6.1 % ) This reflected a nonsignificant trend for lower risk of postoperative events with general anesthesia . Conclusions The choice of anesthesia , when delivered as described , does not significantly influence cardiac morbidity and overall mortality in patients undergoing peripheral vascular surgery BACKGROUND After a myocardial infa rct ion , a higher prevalence of coronary vasospastic response has been reported in the Japanese population than in the Caucasian population . Beta-blockers may exacerbate coronary vasospasm . However , beta-blockers are given to Japanese patients after an acute myocardial infa rct ion , though the mortality benefit is unknown . Thus , we investigated the mortality benefit of beta-blockers given to Japanese patients after an acute myocardial infa rct ion . METHODS We prospect ively studied consecutive patients with a first myocardial infa rct ion admitted to the coronary care unit of Kansai Medical University Hospital , Osaka , Japan from May 1994 through the end of 2001 . Patients who died during hospitalization or who were referred for coronary artery bypass graft surgery were excluded . The association of beta-blocker use with mortality after discharge was assessed by a proportional hazards regression analysis . RESULTS There were 546 patients and 400 ( 73.3 % ) patients were treated with beta-blockers  at the time of discharge from hospital . During a mean follow-up of 2 years , 46 ( 8.4 % ) patients died . Beta-blocker therapy was associated with a reduced mortality after adjustment for age , gender , Q wave myocardial infa rct ion , reperfusion therapy during acute phase , Killip functional class , serum creatinine level , cardiovascular risk factors , and medications ( hazard ratio=0.51 , 95 % confidence interval=0.27 to 0.95 ) . CONCLUSIONS Contrary to the concern that beta-blocker therapy might induce coronary vasospasm and reduce survival , beta-blocker therapy improved survival after discharge in Japanese patients with a first myocardial infa rct ion One hundred and one patients were r and omly allocated to have their peripheral vascular surgery performed under general anaesthesia ( 51 patients ) or spinal anaesthesia ( 50 patients ) .  Intraoperative haemodynamic changes were markedly different between the two groups with a higher incidence of hypotension in the spinal group ( 72 % vs 31 % ) and a higher incidence of hypertension in the general anaesthesia group ( 22 % vs 0 % ) . Blood loss was significantly less in the spinal group ( 560 , SD 340 , ml vs 792 , SD 440 , ml ) . Postoperatively three patients from the general anaesthesia group died from causes unrelated to the anaesthesia , and one had a myocardial infa rct . Two patients in the spinal group had myocardial infa rcts , both had been treated for bradycardia and hypotension intraoperatively , and one died . There was a significantly higher incidence of postoperative chest infection in the general anaesthesia group ( 33 % vs 16 % ) . There was no significant difference between the groups in the incidence of postoperative confusion , or lower limb amputation rate or need for further surgery prior to hospital discharge BACKGROUND This post hoc analysis aim ed to determine whether neuraxial block was associated with a composite of cardiovascular death , non-fatal myocardial infa rct ion ( MI ) and non-fatal cardiac arrest within 30 days of r and omization in POISE trial patients . METHODS A total of 8351 non-cardiac surgical patients at high risk of cardiovascular complications were r and omized  to β-blocker or placebo . Neuraxial block was defined as spinal , lumbar or thoracic epidural anaesthesia . Logistic regression , with weighting using estimated propensity scores , was used to determine the association between neuraxial block and primary and secondary outcomes . RESULTS Neuraxial block was associated with an increased risk of the primary outcome [ 287 ( 7.3 % ) vs 229 ( 5.7 % ) ; odds ratio ( OR ) , 1.24 ; 95 % confidence interval ( CI ) , 1.02 - 1.49 ; P=0.03 ] and MI [ 230 ( 5.9 % ) vs 177 ( 4.4 % ) ; OR , 1.32 ; 95 % CI , 1.07 - 1.64 ; P=0.009 ] but not stroke [ 23 ( 0.6 % ) vs 32 ( 0.8 % ) ; OR , 0.76 ; 95 % CI , 0.44 - 1.33 ; P=0.34 ] , death [ 96 ( 2.5 % ) vs 111 ( 2.8 % ) ; OR , 0.87 ; 95 % CI , 0.65 - 1.17 ; P=0.37 ] or clinical ly significant hypotension [ 522 ( 13.4 % ) vs 484 ( 12.1 % ) ; OR , 1.13 ; 95 % CI , 0.99 - 1.30 ; P=0.08 ] . Thoracic epidural with general anaesthesia was associated with a worse primary outcome than general anaesthesia alone [ 86 ( 12.1 % ) vs 119 ( 5.4 % ) ; OR , 2.95 ; 95 % CI , 2.00 - 4.35 ; P<0.001 ] . CONCLUSIONS In patients at high risk of cardiovascular morbidity , neuraxial block was associated with an increased risk of adverse cardiovascular outcomes , which could be causal or because of residual confounding In a controlled multicentre trial carried out to assess the value of long-term practolol treatment  after myocardial infa rct ion the provisional results showed a significant reduction in mortality , though some of the data were lacking . These have now been included and the results up date d. The final figures for all  deaths  were 78 in the placebo group of 1533 patients and 48 in the practolol group of 1520 patients . The reduction in mortality ( 38 % ) was significant at the 1 % level . The figures for non-fatal reinfa rct ion ( 97 in the placebo group , and 75 in the practolol group ) were not significantly different . Patients with pre-entry anterior infa rct ion , and especially those with a diastolic blood pressure equal to or below the mean ( 78 mm Hg ) at entry to the trial , were at high risk but benefited particularly well from beta-adrenoceptor blockade . After pre-entry inferior infa rct ion the percentage reduction in deaths occurring within two hours after symptoms of a new event was similar to that after anterior infa rct ion , but the incidence of death more than two hours after the event was greater in the practolol-treated group . Thus the difference between groups in total deaths after pretrial inferior infa rct ion was marginal . Until the results of further trials are reported long-term beta-adrenoceptor blockade ( possibly up to two years ) is recommended after uncomplicated anterior myocardial infa rct ion Although clinical guidelines recommend long-term β-blocker ( BB ) therapy to decrease mortality after acute myocardial infa rct ion , these recommendations are based predominantly on evidence from before the reperfusion and thrombolytic eras . To investigate the effects of BB therapy for patients with acute myocardial infa rct ions on mortality in the percutaneous coronary intervention era , a total of 5,628 consecutive patients who were admitted < 24 hours after the onset of ST-segment elevation myocardial infa rct ion , treated with emergent percutaneous coronary intervention , and discharged alive were studied . During a median follow-up period of 1,430 days , mortality rates did not differ between patients with and without BB therapy ( 5.2 % vs 6.2 % , p = 0.786 ) . Multivariate analysis revealed that BB treatment was not associated with a reduced risk for mortality ( hazard ratio 0.935 , 95 % confidence interval 0.711 to 1.230 , p = 0.534 ) . The results of propensity score matching also indicated that the mortality rates did not differ between the 2 groups . However , subgroup analyses among matched population s revealed that BB treatment was associated with a significantly lower mortality risk for high-risk patients , who were defined as those with Global Registry of Acute Coronary Events ( GRACE ) risk scores ≥121 ( hazard ratio 0.596 , 95 % confidence interval 0.416 to 0.854 , p = 0.005 ) or those administered diuretics ( hazard ratio 0.602 , 95 % confidence interval 0.398 to 0.910 , p = 0.016 ) , but not for lower risk patients . In conclusion , BB treatment was associated with reduced long-term mortality in patients after ST-segment elevation myocardial infa rct ion at higher risk , but not in those at lower risk . Although r and omized controlled studies are warranted to confirm these results , the implementation of BB therapy for discharged patients with ST-segment elevation myocardial infa rct ion may need to be assessed on the basis of individual mortality risk in the percutaneous coronary intervention era Background and objectives Peroperative myocardial infa rct ion ( MI ) is the most common cause of morbidity and mortality . What is the role of general anesthesia in this process ? Is general anesthesia a risk for myocardial infa rct ion ? The present study was design ed to determine whether the measurement of serum levels of cardiac troponin I ( cTnI ) , a highly sensitive and specific marker for cardiac injury , would help establish the diagnosis of myocardial infa rct ion in two different types of anesthesia . Method Elective abdominal hysterectomy  was planned with the permission of the ethic committee in 40 patients who were 20–45 years range , in ASA-I group , and have a Goldman Cardiac Risk Index-0 . The patients were divided into two groups . Isoflurane + N2O was administrated to first group , and Propofol + Fentanyl to second group .  cTnI levels were determined before anesthesia , after induction before surgery and 9 hours after the second period respectively . Results There was no significant difference between the groups by the means of demographic properties , hemodynamic parameters and cTnI levels , and the cTnI levels were determined under the basal levels in all sample s. Conclusion General anesthesia is not a risk for myocardial infa rct ion to state eliminating risk factors and protection hemodynamia cardiac BACKGROUND Left ventricular dilatation and dysfunction after myocardial infa rct ion are major predictors of death . In experimental and clinical studies , longterm therapy with the angiotensin-converting -- enzyme inhibitor captopril attenuated ventricular dilatation and remodeling . We investigated whether captopril could reduce morbidity and mortality in patients with left ventricular dysfunction after a myocardial infa rct ion . METHODS Within 3 to 16 days after myocardial infa rct ion , 2231 patients with ejection fractions of 40 percent or less but without overt heart failure or symptoms of myocardial ischemia were r and omly assigned to receive doubleblind treatment with either placebo ( 1116 patients ) or captopril ( 1115 patients ) and were followed for an average of 42 months . RESULTS Mortality from all causes was significantly reduced in the captopril group ( 228 deaths , or 20 percent ) as compared with the placebo group ( 275 deaths , or 25 percent ) ; the reduction in risk was 19 percent ( 95 percent confidence interval , 3 to 32 percent ; P = 0.019 ) . In addition , the incidence of both fatal and nonfatal major cardiovascular events was consistently reduced in the captopril group . The reduction in risk was 21 percent ( 95 percent confidence interval , 5 to 35 percent ; P = 0.014 ) for death from cardiovascular causes , 37 percent ( 95 percent confidence interval , 20 to 50 percent ; P less than 0.001 ) for the development of severe heart failure , 22 percent ( 95 percent confidence interval , 4 to 37 percent ; P = 0.019 ) for congestive heart failure requiring hospitalization , and 25 percent ( 95 percent confidence interval , 5 to 40 percent ; P = 0.015 ) for recurrent myocardial infa rct ion . CONCLUSIONS In patients with asymptomatic left ventricular dysfunction after myocardial infa rct ion , long-term administration of captopril was associated with an improvement in survival and reduced morbidity and mortality due to major cardiovascular events . These benefits were observed in patients who received thrombolytic therapy , aspirin , or beta-blockers , as well as those who did not , suggesting that treatment with captopril leads to additional improvement in outcome among selected survivors of myocardial infa rct ion Background : Perioperative morbidity may be modifiable in high risk patients by the anesthesiologist 's choice of either regional or general anesthesia . This clinical trial compared outcomes between epidural ( EA ) and general ( GA ) anesthesia/analgesia regimens In a group of patients at high risk for cardiac and other morbidity who were undergoing similarly stressful surgical procedures . Methods : One hundred patients scheduled for elective vascular reconstruction of the lower extremities were r and omized to receive either EA for surgery followed by epidural analgesia , or GA for surgery followed by intravenous patient-controlled analgesia .  Hemodynamic monitoring , blood pressure , and heart rate limits were determined prior to r and omization . Management of anesthesia in the immediate postoperative period was st and ardized . The data collected included continuous electrocardiographic monitoring from the day before surgery through the third postoperative day , serial electrocardiograms , and cardiac enzymes . Cardiac ischemia , myocardial infa rct ion , unstable angina , and cardiac death were identified by a cardiologist blinded to the type of anesthesia received . Other major morbidity was determined at the time of hospital discharge and at 1 and 6 months after surgery . Results : Eleven patients who received GA required regrafting or an embolectomy during their hospital stay , compared with two patients who received EA . This association of GA with reoperation remained significant after adjustment for baseline differences . Cardiac outcomes were similar in the two groups with respect to perioperative death ( 1 EA and 1 GA ) , death within 6 months ( 4 EA and 3 GA ) , nonfatal myocardial infa rct ion within 7 days ( 2 EA and 2 GA ) , unstable angina ( 0 EA and 2 GA ) , and myocardial ischemia following r and omization ( 17 EA and 23 GA ) . Rates of major infections in the two groups ( 1 EA and 2 GA ) , renal failure ( 3 EA and 3 GA ) , and pulmonary complications ( 3 EA and 7 GA ) also were similar . Conclusions : Carefully conducted epidural and general anesthesia appear to be associated with comparable rates of cardiac and most other morbidity in patients undergoing lower extremity vascular surgery . However , compared with general anesthesia , epidural anesthesia is associated with a lower incidence of reoperatlon for inadequate tissue perfusion and , therefore , may be advantageous for this surgical population In view of the high risk of sudden cardiac death and the prognostic importance of complex ventricular ectopic activity , the effects of prophylactic antiarrhythmic treatment were investigated prospect ively in patients with persisting asymptomatic complex arrhythmias after myocardial infa rct ion . End points were total mortality and arrhythmic events ( sudden death , sustained ventricular tachycardia and ventricular fibrillation ) . Of 1,220 consecutively screened survivors of myocardial infa rct ion , 312 had Lown class 3 or 4b arrhythmia on 24 h electrocardiographic recordings before hospital discharge and consented to the study . They were r and omized to individualized antiarrhythmic treatment ( Group 1 , n = 100 ) , treatment with low dose amiodarone , 200 mg/day ( Group 2 , n = 98 ) or no antiarrhythmic therapy ( Group 3 [ control group ] , n = 114 ) . During the 1 year follow-up period , 10 patients in Group 1 died , as did 5 in Group 2 and 15 in Group 3 . On the basis of an intention to treat analysis , the probability of survival of patients given amiodarone was significantly greater than that of control patients ( p less than 0.05 ) . In addition , arrhythmic events were significantly reduced by amiodarone ( p less than 0.01 ) . These effects were less marked and not significant for individually treated patients ( Group 1 ) . These findings suggest that low dose amiodarone decreases mortality in the 1st year after myocardial infa rct ion in patients at high risk of sudden death Long-term follow-up was obtained on 138 patients who participated in a prospect i ve , r and omized study comparing two weeks with three weeks of hospitalization following uncomplicated acute myocardial infa rct ion . Follow-up information was available on 123 ( 89 % ) of all r and omized patients . The mean follow-up period was 35 months for those patients who died and 99 months for those who survived . No differences were found between the two groups with respect to survival , cardiac-related deaths , frequency or severity of angina pectoris , subsequent myocardial infa rct ion , incidence of congestive heart failure , number of ventricular aneurysms , or subsequent medical therapy . A significantly greater number of survivors in both groups stopped smoking and had a normal initial heart size than those who died . This long-term follow-up study further supports the conclusions of earlier short-term studies that two weeks of hospitalization is safe in patients with uncomplicated acute myocardial infa rct ion R and omized clinical trials of cardiac rehabilitation following myocardial infa rct ion have typically demonstrated a lower mortality in treated patients , but with a statistically significant reduction in only one trial . To overcome the problem of not being able to detect small but clinical ly important benefits in mortality in r and omized clinical trials of exercise and risk factor rehabilitation after myocardial infa rct ion with small numbers of patients , we carried out a meta- analysis on the combined results of ten r and omized clinical trials that included 4347 patients ( control , 2145 patients ; rehabilitation , 2202 patients ) . The pooled odds ratios of 0.76 ( 95 % confidence intervals , 0.63 to 0.92 ) for all-cause death and of 0.75 ( 95 % confidence intervals , 0.62 to 0.93 ) for cardiovascular death were significantly lower in the rehabilitation group than in the control group , with no significant difference for nonfatal recurrent myocardial infa rct ion . These results suggest that , for appropriately selected patients , comprehensive cardiac rehabilitation has a beneficial effect on mortality but not on nonfatal recurrent myocardial infa rct ion The aim of the present study was to investigate whether the implementation of an early invasive strategy for unselected patients with acute myocardial infa rct ion ( AMI ) would be associated with reduced long-term mortality compared to a conservative approach . In this prospect i ve observational cohort study of consecutive patients admitted for AMI in 2003 ( conservative cohort , n = 311 ) and 2006 ( invasive cohort [ IC ] , n = 307 ) , an 11 % absolute and 41 % relative reduction in 1-year mortality was found for patients with AMI in the IC compared to the conservative cohort ( p = 0.001 ) . These findings were consistent after adjustment for age , gender , previous AMI , previous stroke , diabetes , smoking status , previous left ventricular systolic dysfunction , and serum creatinine at admission ( hazard ratio 0.54 , 95 % confidence interval 0.38 to 0.78 ) and Global Registry of Acute Coronary Events risk score ( hazard ratio 0.67 , 95 % confidence interval 0.46 to 0.97 ) . More patients with ST-segment elevation myocardial infa rct ion received  primary percutaneous coronary intervention  in the IC ( 57 % vs 3 % , p < 0.001 ) , and a sixfold ( 25 % vs 4 % , p < 0.001 ) increase in early percutaneous coronary intervention  ( < 72 hours ) for patients with non-ST-segment elevation myocardial infa rct ion was observed . A greater proportion of patients in the IC received clopidogrel , aspirin , and statins  during follow-up ; otherwise , the secondary prevention measures were similar in the 2 cohorts . In conclusion , the introduction of a strategy for routine transfer to a high-volume percutaneous coronary intervention center for early invasive therapy was accompanied by a substantial reduction in mortality among unselected patients with AMI . Differences in unmeasured confounders might have accounted for a part of the difference in outcome BACKGROUND Mivazerol is a drug with alpha2-agonist properties that reduces post-ganglionic noradrenaline availability and spinal efferent sympathetic output . METHODS A double-blind r and omized placebo-controlled trial was conducted in 61 European centers during a 2.5-yr period on 2,854 patients : 1,897 with coronary heart disease and 957 patients without overt coronary heart disease but classified as at high risk for it . The present analysis was restricted to those patients with previous known coronary heart disease of whom 48 % had vascular surgery , 32 % non-vascular thoracic or abdominal surgery , and 20 % orthopedic surgery .  Mivazerol or placebo were given intravenously from the induction of anesthesia for up to 72 h. RESULTS In the 1,897 patients with established coronary heart disease , mivazerol did not reduce the primary endpoint -- the combination of myocardial infa rct ion or death -- or all-cause deaths significantly . A preplanned subgroup analysis of 904 patients with known coronary heart disease undergoing vascular surgery showed that there were fewer primary endpoints in those receiving mivazerol ( risk ratio [ RR ] , 0.67 ; 95 % CL , 0.45 - 0.98 ; P = 0.037 ) and fewer cardiac deaths ( 6 of 454 vs. 18 of 450 : RR , 0.33 ; 95 % confidence limits , 0.13 - 0.82 ; P = 0.017 ) . The all-cause death rate was also decreased ( RR , 0.41 ; 95 % CL , 0.18 - 0.91 ; P = 0.024 ) , although there was no significant reduction in myocardial infa rct ion . CONCLUSION The alpha2-adrenergic agonist , mivazerol , did not alter the rates of myocardial infa rct ion or cardiac death in patients with known coronary heart disease undergoing noncardiac surgery . However , it may have protected patients undergoing vascular surgery from further coronary events , and a specific study of such patients is now indicated To examine the role of primary anesthetic agent on outcome of coronary artery bypass grafting operations , 1,012 patients were prospect ively r and omized to receive enflurane ( 257 ) , halothane ( 253 ) , isoflurane ( 248 ) , or sufentanil ( 254 ) . Except for administration of the primary anesthetic , anesthesia management was st and ardized for all patients . The r and omized groups did not differ in demographic characteristics , extent of coronary artery disease , chronic antianginal therapy , hemodynamic characteristics including new myocardial ischemia at arrival to the operating room , and surgical characteristics that might influence the rate of postoperative myocardial infa rct ion or death . From anesthetic induction to start of cardiopulmonary bypass , new ST segment depression appeared in 310 ( 30.4 % ) patients and was not different among primary anesthetic groups ( 28.0 - 33.5 % ) . Similarly , the incidence of postoperative myocardial infa rct ion ( 3.6 - 4.7 % ) and death ( 1.2 - 2.4 % ) was not different . Although intraoperative hypotension was twice as common in patients receiving any volatile anesthetic and hypertension twice as common with sufentanil , tachycardia ( greater than or equal to 110 bpm ) was not related to any primary anesthetic ( 4.3 - 9.1 % ) and was the only hemodynamic abnormality significantly related to intraoperative ischemia . The strongest predictor of intraoperative ischemia was ischemia on arrival to the operating room . The authors postulate that approximately 90 % of new myocardial ischemia observed during anesthesia is the manifestation of silent ischemia observed in patients before operation and only 10 % is related to anesthetic management . They conclude that , despite differences in the hemodynamic consequences of the primary anesthetics studied , none of the primary anesthetics influenced outcome and the primary role of the anesthesiologist in management of these patients is control of heart rate BACKGROUND Left ventricular dilatation and neuroendocrine activation are common after acute anterior myocardial infa rct ion . Long-term treatment with an angiotensin-converting-enzyme ( ACE ) inhibitor may improve outcome by attenuating these processes . We investigated whether the ACE inhibitor zofenopril , administered for six weeks after anterior myocardial infa rct ion , could improve both short-term and long-term outcome . METHODS A total of 1556 patients were enrolled within 24 hours after the onset of symptoms of acute anterior myocardial infa rct ion , and they were r and omly assigned in a double-blind fashion to receive either placebo ( 784 patients ) or zofenopril ( 772 patients ) for six weeks . At this time we assessed the incidence of death or severe congestive heart failure . The patients were reexamined after one year to assess survival . RESULTS The incidence of death or severe congestive heart failure at six weeks was significantly reduced in the zofenopril group ( 55 patients , 7.1 percent ) , as compared with the placebo group ( 83 patients , 10.6 percent ) ; the cumulative reduction in the risk of death or severe congestive heart failure was 34 percent ( 95 percent confidence interval , 8 to 54 percent ; P = 0.018 ) . The reduction in risk was 46 percent ( 95 percent confidence interval , 11 to 71 percent ; P = 0.018 ) for severe congestive heart failure and 25 percent ( 95 percent confidence interval , -11 to 60 percent ; P = 0.19 ) for death . After one year of observation , the mortality rate was significantly lower in the zofenopril group ( 10.0 percent ) than in the placebo group ( 14.1 percent ) ; the reduction in risk was 29 percent ( 95 percent confidence interval , 6 to 51 percent ; P = 0.011 ) . CONCLUSIONS Treatment with zofenopril significantly improved both short-term and long-term outcome when this drug was started within 24 hours after the onset of acute anterior myocardial infa rct ion and continued for six weeks Background Patients with ST-elevation myocardial infa rct ion ( STEMI ) not treated with  primary or rescue percutaneous coronary intervention ( PCI )  are at risk for recurrent ischemia , especially when viability in the infa rct -area is present . Therefore , an invasive strategy with PCI of the infa rct -related coronary artery in patients with viability would reduce the occurrence of a composite end point of death , reinfa rct ion , or unstable angina ( UA ) . Methods Patients admitted with an (sub)acute myocardial infa rct ion , who were not treated by primary or rescue PCI , and who were stable during the first 48 hours after the acute event , were screened for the study . Eventually , we r and omly assigned 216 patients with viability ( demonstrated with low-dose dobutamine echocardiography ) to an invasive or a conservative strategy . In the invasive strategy stenting of the infa rct -related coronary artery was intended with abciximab as adjunct treatment . Seventy-five ( 75 ) patients without viability served as registry group . The primary endpoint was the composite of death from any cause , recurrent myocardial infa rct ion ( MI ) and unstable angina at one year . As secondary endpoint the need for ( repeat ) revascularization procedures and anginal status were recorded . Results The primary combined endpoint of death , recurrent MI and unstable angina was 7.5 % ( 8/106 ) in the invasive group and 17.3 % ( 19/110 ) in the conservative group ( Hazard ratio 0.42 ; 95 % confidence interval [ CI ] 0.18 - 0.96 ; p = 0.032 ) . During follow up revascularization- procedures were performed in 6.6 % ( 7/106 ) in the invasive group and 31.8 % ( 35/110 ) in the conservative group ( Hazard ratio 0.18 ; 95 % CI 0.13 - 0.43 ; p < 0.0001 ) . A low rate of recurrent ischemia was found in the non-viable group ( 5.4 % ) in comparison to the viable-conservative group ( 14.5 % ) . ( Hazard-ratio 0.35 ; 95 % CI 0.17 - 1.00 ; p = 0.051 ) . Conclusion We demonstrated that after acute MI ( treated with thrombolysis or without reperfusion therapy ) patients with viability in the infa rct -area benefit from a strategy of early in-hospital stenting of the infa rct -related coronary artery . This treatment results in a long-term uneventful clinical course . The study confirmed the low risk of recurrent ischemia in patients without viability . Trial registration Clinical Trials.gov : NCT00149591
: Compared with general anesthesia , neuraxial anesthesia may reduce the 0-to-30-day mortality for patients undergoing a surgery with an intermediate-to-high cardiac risk ( level of evidence moderate ) .
BACKGROUND : This analysis summarized Cochrane review s that assess the effects of neuraxial anesthesia on perioperative rates of death , chest infections , and myocardial infa rct ion .