Introduction Prevalence and Impact

The Big Heart Disease Lie

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At the beginning of the 21st century, cardiovascular (CV) disease remains the leading cause of death (1). Over 12,400,000 Americans are living with clinical coronary heart disease (CHD), and this year, an estimated 1,100,000 Americans will have a fatal or nonfatal acute myocardial infarction (AMI). CV disease was responsible for 950,000 deaths in the United States in 1998, accounting for over 40% of all deaths, and CHD was the leading cause of cardiovascular death, claiming 460,000 lives. Half of CHD deaths (a quarter million/yr) are directly related to AMI. Death occurs suddenly, out-of-hospital, in 220,000 annually, and most of these deaths are triggered by coronary ischemia (2-4). Indeed, at least one-half of AMI-related deaths occur within 1 h of onset of symptoms and before reaching a hospital emergency department (5). Although CV mortality rates declined between 1980 and 1992 in men, they increased over the same

From: Contemporary Cardiology: Management of Acute Coronary Syndromes, Second Edition Edited by: C. P. Cannon © Humana Press Inc., Totowa, NJ

period in women, and for the past 10 yr, they have failed to decline or have increased in men as well (1). Thus, the impact of CV disease, and AMI specifically, continues to be great.

Over 5 million people visit U.S. emergency departments each year for evaluation of chest pain and related symptoms, and almost 1.5 million are hospitalized for an acute coronary syndrome (ACS) (6,7). ACS patients on presentation are triaged into ST-ele-vation AMI and non-ST elevation AMI/unstable angina categories (8,9). In 1990, ST-elevation AMI accounted for 55% of AMIs, whereas in 1999, it had declined to 37% (10). The cause of this redistribution is uncertain, but it likely involves changes in patient demographics and preventive care.

Acute reperfusion (achieved by thrombolysis or coronary angioplasty) has marked a significant conceptual and practical advance for therapy of ST-segment elevation (STE)-AMI (11). With broad application of reperfusion therapy, 30-d mortality rates from STE-AMI have progressively declined (from 20-30% to 5-10%) (10,12,13).

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