QJM : monthly journal of the Association of Physicians
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We studied changes in stroke prevention in 2000 ischaemic stroke patients using prospectively collected data from an incident stroke register over 3 years. Patients were divided into those with risk factors but no previous history of a vascular event (asymptomatic vascular disease) and those with risk factors and a previous history of stroke or TIAs, ischaemic heart disease, angina, myocardial infarction or peripheral vascular disease (symptomatic vascular disease). Time trends were analysed for the use of aspirin, management of hypertension and atrial fibrillation prior to the presenting episode. ⋯ The proportion of patients receiving antihypertensive treatment for symptomatic vascular disease was unchanged with time (66% to 64%) but there was a significant increase in the number of patients receiving antihypertensive treatment for asymptomatic vascular disease (28% to 44%) (p<0.05). The proportion of patients with atrial fibrillation receiving antithrombotic treatment did not increase for asymptomatic vascular disease (23% to 21%) (p=0.54) but did increase for symptomatic vascular disease (19.5% to 37%) (p<0.01) over 3 years. The use of warfarin in atrial fibrillation increased both in the case of asymptomatic (4.5% to 42%) (p<0.01) and symptomatic vascular disease (12.5% to 33.0%) (p<0.01).
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Patients with acute chest pain suggestive of myocardial ischaemia, and normal or non-diagnostic electrocardiograms, form a difficult subgroup for diagnosis and early risk stratification. We prospectively evaluated the role of troponin T (cTnT), troponin I (cTnI), CKMB mass and myoglobin, in the diagnosis and risk stratification of 214 patients with acute chest pain of < or = 24 h and non-diagnostic or normal ECGs admitted directly to the Cardiac Unit of the Royal Victoria Hospital Belfast from the Mobile Coronary Care Unit or the Accident/Emergency Department. This was a single-centre prospective study, and follow-up (3 months) was complete for all patients. ⋯ Significantly higher event rates occurred when any of the biochemical markers was elevated, but the statistical significance was highest for patients with elevated cTnI (p < 0.0001). Whilst gender, history of ischaemic heart disease (IHD), stress test response, cTnT, cTnI, CKMB mass and myoglobin were univariate predictors, cTnI at 12 h and stress test response were the only two independent significant predictors for a subsequent cardiac event at 3 months. Raised cTnI at 12 h after admission had the highest sensitivity for the diagnosis of acute coronary syndromes, and was independently associated with a 2-3 times increased risk of future cardiac events within 3 months among patients with acute chest pain suggestive of myocardial ischaemia but with normal or non-diagnostic ECGs.