- Email: [email protected]
Third generation oral contraceptives and risk of myocardial infarction: An international case-control study
Abstracts 0 A POPULATION-BASED STUDY OF PROGNOSIS OF RUPTURED CEREBRAL ANEURYSM: MORTALITY AND RECURRENCE OF SUBARACHNOID HEMORRHAGE. Olafsson E. Hauser A, Gudmundsson G. Neurology. 1997;48:1191-5. This population-based study follows 86 individuals from Iceland with a first diagnosis of subarachnoid hemorrhage (SAH) caused by ruptured cerebral aneurysm (RCA) for a minimum of 24 years. It specifically addresses the long-term survivorship and risk of rebleeding in a population-based cohort of 6-month survivors of RCA. Previous studies report late (after 6 months) recurrence of SAH with RCA as 2 to 4% per year. This study found that rate to be much lower. In this cohort of patients. 38 of 86 (44%) died within 30 days of the index event, and 2 more died during the following 3 to 6 months. This early mortality was similar to other population-based cohorts of SAH. Only two of the &month survivors had no surgical intervention. Of the 6-month survivors, 18 had no neurologic impairment, IS had mild impairment, and 11 were severely impaired. Relative survivorship was directly related to the amount of residual impairment present at 6 months. There was no statistical difference found in mortality between those with no or only mild neurologic disability when compared to the general population. In contrast, those with severe neurologic disability had a greatly reduced (27%) relative survivorship. Only two of the 6-month survivors experienced recurrent SAH (both of which were fatal). This recurrence rate is significantly less than the expected values using all previously available studies ( 14 recurrences were expected). The authors speculate that this could be due to improvements in surgical techniques [Samuel J. Killian, MD] over the year\.
C EFFECTS OF MENTAL STRESS ON MYOCARDIAL ISCHEMIA DURING DAILY LIFE. Gullette ECD, Blumenthal JA, Babyak M, et al. J Am Med Assoc. 1997;227:1521-6. This prospective study using a case-crossover method of analysis investigates whether specific negative emotional states trigger myocardial ischemia. One hundred thirty-two patients with stable documented coronary artery disease underwent 48 h of ambulatory electrocardiographic monitoring. During the monitoring, patients recorded their physical activity level (heavy, moderate, light, none) and their emotional state (happiness, feeling in control, sadness, tension, frustration). Myocardial ischemia was defined as ST-segment depression of 1 mm or greater for 1 min or longer compared to baseline. AI1 subjects were withdrawn from their anti-ischemic medicines at least 48 before monitoring. For data analysis, the patients’ activities and emotional levels 1 h before an episode of ischemia (the “case” hour) was compared to their activity and emotional level during the remaining nonischemic hours or a comparable nonischemic hour on the alternate day (the “control“ hours). Of the 132 patients monitored, 60 patients displayed tran\ient rnyocardial &hernia and 2 of those were excluded from the study (one for not completing the daily diary, the other had ischemia time >6 SD’s above the mean), leaving a total of 58 patients for analysis. The patients averaged 63 total min of
905 ischemia, with an average of seven ischemic episodes lasting an average of 9 min. Only 2% of the ischemic episodes were associated with angina. Patients participated in light activity 3% of the time, moderate activity 10% of the time, and heavy activity 3% of the time. They generally experienced positive emotions. Only 4% of total hours were associated with high tension levels, 4% of hours with high frustration levels, and 1% of hours with the high sadness levels. The relative risks of myocardial ischemia associated with activity level was 15.7 (95% confidence interval (CI). 8.827.8, p < 0.001) for heavy activity, 2.6 (95% CI, I .7-4.1, p < 0.001) for moderate activity, 2.6 (95% CT, 1.4-4.4. P < 0.05) for tension. 2.2 (95% CI, 0.7-6.4, P = 0.16) for sadness. and 2.2 (95% Cl, 1.1-4.3, P <: 0.05) for frustration. The authors conclude that negative emotions during daily life can approximately double the risk of myocardial ischemia [Dan Stillman, MnJ in the subsequent hour. Editor’s Comment: This study has many limitations which put in question the significance of the results. For instance, the sample site is very small (4% with high levels of frustration or tension) and the authors rely on the patients’ diaries. The small study size leads to very wide CIs, and the diaries cannot explain other factors that may have been present during times of high stress or tension. Probably more important is the 15.7 relative risk for ischemia with heavy exercise and the fact thal only 2% of ischemic episodes were associated with angina.
0 THIRD GENERATION ORAL CONTRACEPTIVES AND RISK OF MYOCARDLAL I[NFARCTLON: AN INTERNATIONAL CASE-CONTROL STUDY. Lewis MA, Spitzer WO, Heinemann LA, et al. Br Med 3. 1996:312:88-90. A matched case-control study to determine whether an altered risk of myocardial infarction is seen with the use 01 third generation oral contraceptives (OCP) containing progestogens was done utilizing 16 centers in Austria, France, Ger.many, Switzerland. and the United Kingdom. Cases included 153 women ages 16 to 44 years with myocardial infarction. Controls including 498 women who did not have myocardial infarctions and were matched for age and community setting within 4 months of the index infarction. When third vs. second generation OCP users was compared, an odds ratio of 0.36 was generated. Odds ratio for use of second-generation products vs. no use was 3.1. whereas the odds ratio for use of thirdgeneration products vs. no use was 1. I. Smoking was the one confounding variable found to be important, with an increase in the odds ratio by approximately IO-fold. The authors cautiously concluded that third-generation OCP use is associated with a reduced risk of myocardial infarction when compared with second-generation OCP but the increased risk of venous throm boembolism associated with the use of third-generation OCP may balance the benefit seen. [Catherine M. Hurtj
q HEALTH
CARE UTILIZATION AND COST AMONG CHILDREN WITH ASTHMA WHO WERE ENROLLED IN A HEALTH MAINTENANCE ORGANIZATION.
C EFFECTS OF MENTAL STRESS ON MYOCARDIAL ISCHEMIA DURING DAILY LIFE. Gullette ECD, Blumenthal JA, Babyak M, et al. J Am Med Assoc. 1997;227:1521-6. This prospective study using a case-crossover method of analysis investigates whether specific negative emotional states trigger myocardial ischemia. One hundred thirty-two patients with stable documented coronary artery disease underwent 48 h of ambulatory electrocardiographic monitoring. During the monitoring, patients recorded their physical activity level (heavy, moderate, light, none) and their emotional state (happiness, feeling in control, sadness, tension, frustration). Myocardial ischemia was defined as ST-segment depression of 1 mm or greater for 1 min or longer compared to baseline. AI1 subjects were withdrawn from their anti-ischemic medicines at least 48 before monitoring. For data analysis, the patients’ activities and emotional levels 1 h before an episode of ischemia (the “case” hour) was compared to their activity and emotional level during the remaining nonischemic hours or a comparable nonischemic hour on the alternate day (the “control“ hours). Of the 132 patients monitored, 60 patients displayed tran\ient rnyocardial &hernia and 2 of those were excluded from the study (one for not completing the daily diary, the other had ischemia time >6 SD’s above the mean), leaving a total of 58 patients for analysis. The patients averaged 63 total min of
905 ischemia, with an average of seven ischemic episodes lasting an average of 9 min. Only 2% of the ischemic episodes were associated with angina. Patients participated in light activity 3% of the time, moderate activity 10% of the time, and heavy activity 3% of the time. They generally experienced positive emotions. Only 4% of total hours were associated with high tension levels, 4% of hours with high frustration levels, and 1% of hours with the high sadness levels. The relative risks of myocardial ischemia associated with activity level was 15.7 (95% confidence interval (CI). 8.827.8, p < 0.001) for heavy activity, 2.6 (95% CI, I .7-4.1, p < 0.001) for moderate activity, 2.6 (95% CT, 1.4-4.4. P < 0.05) for tension. 2.2 (95% CI, 0.7-6.4, P = 0.16) for sadness. and 2.2 (95% Cl, 1.1-4.3, P <: 0.05) for frustration. The authors conclude that negative emotions during daily life can approximately double the risk of myocardial ischemia [Dan Stillman, MnJ in the subsequent hour. Editor’s Comment: This study has many limitations which put in question the significance of the results. For instance, the sample site is very small (4% with high levels of frustration or tension) and the authors rely on the patients’ diaries. The small study size leads to very wide CIs, and the diaries cannot explain other factors that may have been present during times of high stress or tension. Probably more important is the 15.7 relative risk for ischemia with heavy exercise and the fact thal only 2% of ischemic episodes were associated with angina.
0 THIRD GENERATION ORAL CONTRACEPTIVES AND RISK OF MYOCARDLAL I[NFARCTLON: AN INTERNATIONAL CASE-CONTROL STUDY. Lewis MA, Spitzer WO, Heinemann LA, et al. Br Med 3. 1996:312:88-90. A matched case-control study to determine whether an altered risk of myocardial infarction is seen with the use 01 third generation oral contraceptives (OCP) containing progestogens was done utilizing 16 centers in Austria, France, Ger.many, Switzerland. and the United Kingdom. Cases included 153 women ages 16 to 44 years with myocardial infarction. Controls including 498 women who did not have myocardial infarctions and were matched for age and community setting within 4 months of the index infarction. When third vs. second generation OCP users was compared, an odds ratio of 0.36 was generated. Odds ratio for use of second-generation products vs. no use was 3.1. whereas the odds ratio for use of thirdgeneration products vs. no use was 1. I. Smoking was the one confounding variable found to be important, with an increase in the odds ratio by approximately IO-fold. The authors cautiously concluded that third-generation OCP use is associated with a reduced risk of myocardial infarction when compared with second-generation OCP but the increased risk of venous throm boembolism associated with the use of third-generation OCP may balance the benefit seen. [Catherine M. Hurtj
q HEALTH
CARE UTILIZATION AND COST AMONG CHILDREN WITH ASTHMA WHO WERE ENROLLED IN A HEALTH MAINTENANCE ORGANIZATION.