In most cases, the best treatment for a severe heart attack is emergency angioplasty wherea catheter is inserted into the clogged artery.  A small balloon is used to widen the artery and a stent is placed in the artery to keep it open.  Unfortunately, the sophisticated treatment is available at only a minority of hospitals in the U.S.  Another, less successful but still useful approach is to use clot-busting drugs in an attempt at opening the artery.  A recent study suggests that adding clot-busters to angioplasty is of no added benefit.  The key is getting to the right hospital as soon as possible.  However, since I am a psychiatrist and will never treat heart attacks, I don't have any studies on the acute treatment. 

64% of Those Who Die, Die Suddenly Before Being Hospitalized: Of 729,000 heart disease deaths in 1999, 47% died before getting to ER and 17% in ER. Of those over 85, 61% died before getting to the hospital. CDC. 2/14/02. Atlanta AP

Statins Help Survive Heart Attack: The study tracked treatment of more than 170,000 patients taken to hospitals after heart attacks. Of those who received a statin within 24 hours of the attack, there was a 54% better chance of living through the experience than those who did not. Gregg Fonarow, et al. UCLA. AFP-Los Angeles 8/29/05.

By-Pass Heart Surgery Increases Risk of Alzheimer's: In a 5-year follow-up study, 5,216 people who underwent coronary artery bypass graft surgery (CABG) were compared to 3,954 people who had a percutaneous transluminal coronary angioplasty (PTCA). Over 5 years, 78 who had bypass surgery and 41 who had angioplasty developed Alzheimer's disease. The coronary bypass patients had a 70 percent increased risk of developing Alzheimer's disease. Show some heart surgery patients experience memory problems immediately following the procedure. However, at a one-year follow-up most patients regain cognitive function. Heart bypass surgery represents a traumatic insult to the brain, particularly by reducing oxygen supply to the brain and increasing the stress response. Assessment of the Emergence of Alzheimer's Disease Following Coronary Artery Bypass Graft Surgery or Percutaneous Transluminal Coronary Angioplasty. Todd A. Lee, et al. Boston University. Journal of Alzheimer's Disease 9/2005:7(4).

Smaller Heart Attacks Respond to Meds: Contrary to standard practice, a new study from the Netherlands finds that medications work just as well as the much more expensive bypasses and angioplasties for blocked coronary arteries in people suffering the more common smaller heart attacks which 1.5 million Americans get admitted to the hospital for each year. In a randomized study of 1,200 heart attack victims, the follow-up rate of death or repeat heart attack or chest pain was 21% for medication treatment vs. 23% for surgery. New Eng J Med 9/15/05.

Defibrillation in Community Worthwhile: An Olmstead County, MN, study of putting defibrillatories with police, firefighters, etc. When a person puts the paddles on a patient, the machine determines if the patient is in V fib and verbally instructs person how to defibrillate or to give CPR. 200 persons treated in year with 72% surviving to hospital and 42% to discharge with 40% neurologically intact. The intact people had the same amount of longevity and life enjoyment as matched controls with same health risks. Bunch TJ, White RD, Gersh BJ, Meverden RA, Hodge DO, Ballman KV, et al. Long-term outcomes of out-of-hospital cardiac arrest after successful early defibrillation. N Engl J Med 2003;348:2626-33

ACE Inhibitor Cuts CHF Development in High Risk: 9271 in Hope Study 4.5 years average age 66 with HBP, DM, and/or s/p MI on ramipril 10 mg/d in DB PC. Reduced number developing CHF by 23%. Circulation 3/03.

ACE Inhibitor, Not Vitamin E Helped: In a DB 4.5-year study of an ACE inhibitor vs. Vitamin E 400, researchers found no benefit from Vitamin E but the ACE inhibitor decreased heart failure, diabetic nephropathy and new diabetes. Cleve Clin J Med 2000 Apr;67(4):287-93

ACE Inhibitor Perindopril Helped After Heart Attack in Elderly: In a 1-year DB PC study of 1252 elderly, average age 73, after a heart attack, the ACE inhibitor reduced remodelling by 46% when compared to a placebo, according to a study presented at the European Society of Cardiology congress. Remodelling occurs when the heart adapts to injury caused during a heart attack. It results in enlargement of the organ and a change in its shape, causing it to pump blood less effectively. In the elderly, the heart typically deteriorates significantly over the following months after a heart attack leading to heart failure. There is a growing body of evidence suggesting that most patients should be put on ACE inhibitors following a heart attack. Roberto Ferrari, et al. University of Ferrara, Italy. European Society of Cardiology Congress 9/3/05.

Angioplasty Drugs Very Expensive: Platelet glycoprotein Iib/IIIa receptor antagonists used for angioplasty in acute coronary syndromes=unstable angina or non-Q-wave MI. Three are available: eptifibatide $1625, tirofiban $1260, and abciximab (ReoPro) $2160. The increase in the number alive at one month in only 1-2%. The cost to add roughly 2 years of life is $216,000 in most instances! Still, this unreasonably expensive treatment is used routinely.

Angina Helps by Nicorandil: In a DB PC study of 5126 angina patients assigned to 20 mg nicorandil twice daily or placebo in addition to standard antianginal therapy, follow-up was 1.6 years. The rate of acute coronary syndromes was 7.6% in the placebo group and 6.1% in the nicorandil group (0.79; p=0.028), and the corresponding rates for all cardiovascular events were 17.0% and 14.7% (p=0.027). Effect of nicorandil on coronary events in patients with stable angina: the Impact Of Nicorandil in Angina (IONA) randomised trial. IONA Study group. Lancet. 2002 Apr 13;359(9314):1269-75

Angina: Ranolazine Helps Angina Exercise Tolerance a Little:

Angina Helped in Large Study: In a 6-month study of 200 angina patients, L-carnitine 2 g/day significantly reduced the number of premature ventricular contractions (PVC) at rest, as well as an increased exercise tolerance and reduced ST-segment depression during maximal effort. Cardiac function improved with a reduction in the consumption of cardioactive drugs. Laboratory analysis showed an improvement in plasma lipid levels. The therapeutic effect of L-carnitine in patients with exercise-induced stable angina: a controlled study. Cacciatore L, Cerio R, et al., University of Naples, Italy. Drugs Exp Clin Res. 1991;17(4):225-35. 

Angina Helped by Carnitine: In a DB PC study of 44 men with chronic angina using L-carnitine (1 g twice daily), the mean exercise work load increased after L-carnitine (103 vs. 97 watts, p = 0.001), as did the watts to onset of angina (96 vs. 87, p = 0.000). ST segment depression was reduced by L-carnitine at the maximum work load (1.40 vs. 1.69 mm, p = 0.05). 22.7% of the patients became free of angina with L-carnitine and 9.1% with placebo. Resting and exercise blood pressure, heart-rate and double product were unaffected by L-carnitine. 1 patient decided to discontinue the trial because of gastric pyrosis while taking the active drug. Effects of L-carnitine on exercise tolerance in chronic stable angina: a multicenter, double-blind, randomized, placebo controlled crossover study. Cherchi A, Lai C, et al. Int J Clin Pharmacol Ther Toxicol. 1985 Oct;23(10):569-72.

Angina Helped by Carnitine: In a DB PC study of 12 stable angina patients of L-carnitine (900 mg. daily), the exercise time was 11.4 minutes in the placebo period. This increased to 12.2 min (p < 0.05) after 4 weeks and 12.8 min (p < 0.01) after 12 weeks of treatment with carnitine. The time required for 1 mm ST depression to occur was 6.4 min in the placebo period, 7.6 after 4 weeks and 8.8 min after 12 weeks of treatment (p < 0.05). Effects of L-carnitine on exercise tolerance in patients with stable angina pectoris. Kamikawa T, Suzuki Y, et al. Jpn Heart J. 1984 Jul;25(4):587-97.

Antibiotics Help After Heart Attack: 325 patients with acute coronary syndromes. About half the patients tested positive for H pylori and about 40% for C pneumoniae. One group was given placebo, a second group received amoxicillin, metronidazole, and omeprazole, and a third group had azithromycin, metronidazole, and omeprazole. The amoxicillin regimen is effective against H pylori, and the azithromycin regimen works against C pneumoniae. All patients treated with antibiotics did better on clinical end points of cardiac death or readmission with acute coronary syndrome up to one year later, whether or not they had H pylori or C pneumoniae. BMJ 8/31/02

Anti-Depressants: SSRI, Not CBT, Reduces Recurrence: After a first attack, depression raises the risk of recurrence two- and fourfold. Study 1,800 patients who had suffered a heart attack in the past month and now met criteria for depression. Half the depressed patients received cognitive psychotherapy, a treatment aimed at reversing self-disparaging thoughts. The other half received "usual care," without psychotherapy. Psychotherapy had no effect on the recurrence of heart attacks or on mortality. Therapy lowered the degree of depression early on; over time, the differences between the treatment and control groups vanished. For ethical reasons, if subjects had severe depression or if they failed to respond to psychotherapy, they were offered medication, principally sertraline. By the end of the study, almost a quarter of the subjects had taken antidepressants for substantial periods of time. Antidepressants were associated with a 30-40% reduction in death or heart attack recurrence. NYT & JAMA 6/22/03

Arginine Might Help Heart Attacks a Little: L-arginine is a substrate for nitric oxide synthesis in vascular endothelial cells, NO bioavailability is decreased during myocardial infarction (MI). In a 30-day DB PC study of 792 patients with heart attacks within 24 hours, oral L-arginine (3.0 g t.i.d for 30 days) had a composite of 30 day cardiovascular death, reinfarction, successful resuscitation, shock/pulmonary edema or recurrent myocardial ischemia in 24% patients treated with L-arginine and 27% with placebo (OR 0.63, p=0.06). The end point was observed less frequently in 226 patients with hyperlipidemia (19 vs 31, p<0.05). No serious adverse effects were observed during L-arginine supplementation. Efficacy and safety of oral l-arginine in acute myocardial infarction. Results of multicenter, randomized, double-blind, placebo-controlled ARAMI pilot trial. Bednarz B, Jaxa-Chamiec T, et al. Grochowski Hospital, Warsaw. Kardiol Pol. 2005 May;62(5):421-427.

Aspirin Good, But for Secondary Prevention Only: Meta-analysis of 16 studies with 55000 found decr MI and ischemic stroke much greater than incr in hemorrhagic stroke. JAMA 12/9/98. Review says that for primary prevention, the risk may exceed the benefit.

Aspirin: Chew One if Having Heart Attack: American J Cardiology. U Texas Southwestern, 12 volunteers. Swallowing a whole aspirin takes 12 minutes to have any effect on blood's clotting time; drinking remedy containing aspirin takes seven minutes, chewing a regular aspirin tablet begins showing benefits in five minutes. 5/22/03

Aspirin Doesn’t Help Those with Uncontrolled High Blood Pressure: In a 7-year British trial of 5,500 men aged 45 to 69 at increased risk for heart disease of warfarin (75 mg daily) plus aspirin, warfarin alone, aspirin alone, or placebo, aspirin reduced the risk of heart attack or death from heart disease by 20%. The drug was most effective in men with systolic BPs below 130 mm Hg, reducing the likelihood of an event by 45%; in those with a systolic BP above 145, aspirin did not reduce risk. The same held true for stroke; warfarin, which also reduced the overall risk of events by 20%, did not correlate with blood pressure or other variables. BMJ. 2000;321:13-7.

L-Carnitine Helped Heart Attacks:  In a DB PC 101-patient study after myocardial infarction, those given l-carnitine 2 g/day had decreased angina (17% vs. 36%), arrhythmias (14% vs. 28%), and L-ventricular enlargement (23% vs. 36%). Deaths due to heart disease or heart attacks were 15% with l-carnitine vs. 26% placebo. Singh, India, Postgrad Med J ’96;72:45

L-Carnitine Helps After Acute MI: Early and long-term administration of L-carnitine attenuates progressive left ventricular dilatation after acute anterior MI. Results show significant, consistent reductions in end-diastolic volume and end-systolic volume in patients who received L-carnitine compared with placebo. DB multi-center Italian study. Am Heart J 2000 Feb;139(2 Pt 3):S124-30

L-Carnitine Helped Heart Failure: In a 3-year Greek DB study of 80 adults with 3 years of L-carnitine administration for heart failure caused by dilated cardiomyopathy with moderate to severe heart failure (New York Heart Association classification III to IV), there was a lower death rate with one carnitine death vs. six with placebo. Am Heart J 2000 Feb;139(2 Pt 3):S120-3 

Carnitines: Angina: Propionyl-L-Carnitine and Diltiazem Each Helped: In a DB study of 46 patients, researchers found a decrease in angina episodes from both meds in range of 57%-70%. Bartels, Eur Heart J ’96;17:414

Clopidogrel (Plavix) Better Than ASA But Too $$: Like aspirin, Plavix (clopidogrel) keeps blood platelets from forming clots. It works by selectively inhibiting the binding of adenosine diphosphate (ADP) to its platelet receptor and the subsequent ADP-mediated activation of the plycoprotein complex that leads to aggregation.  It is somewhat better than aspirin, which cuts the risk of heart attack, stroke or death by 30 percent in people with heart disease. Topol said Plavix is generally used for 30 days after an angioplasty, and guidelines issued in March recommend it for 90 days after chest pain or a mild heart attack. For the analysis, Dr. Lee Goldman used a computer model of the U.S. population over 35 with heart disease. They predicted how many people would have heart attacks, strokes or die over the next 25 years and what it would cost to treat them. They factored in operations, hospital stays and the added cost of living longer because of the drugs' benefits. Aspirin ($.04) used alone was considered cost-effective at $11,000 per year of life gained. Plavix ($3.22) used alone or combined with aspirin was deemed ``financially unattractive'' at $130,000 per year gained. NEJM 6/5/02

Clopidogrel Said Cost-Effective for Unstable Angina: In the 9-month DB PC Clopidogrel in Unstable angina to prevent Recurrent Events (CURE) study of 12,562 patients in 28 countries, clopidogrel (300-mg load followed by 75 mg/day) was compared to placebo, both in addition to aspirin, excluding clopidogrel costs, average costs of hospitalizations alone were 325 dollars less for the clopidogrel arm using diagnosis-related group-based Medicare reimbursement rates. When including clopidogrel costs (766 dollars greater for the clopidogrel arm), average total costs were 442 dollars higher for the clopidogrel arm. The incremental cost-effectiveness ratio (ICER) on the basis of the Framingham Heart Study was 6,318 dollars per life-year gained (LYG) with clopidogrel, with 94% of bootstrap-derived ICER estimates <50,000 dollars/LYG; based on Saskatchewan, the ICER was 6,475 dollars/LYG with 98% of estimates <50,000 dollars. Long-term cost-effectiveness of clopidogrel given for up to one year in patients with acute coronary syndromes without ST-segment elevation. Weintraub WS, Mahoney EM, et al. Emory University. J Am Coll Cardiol. 2005 Mar 15;45(6):838-45. Ed: I don't know where Emory buys their medicines, but on 3/21/05 9 months of clopidogrel costs $1143 at Walgreens, America's largest pharmaceutical chain.  This raises the cost to about $12,000 per year of life saved.  Of course these industry-sponsored trials are often tilted in favor of the medicine, no one ever knows how. 

Clopidogrel Called Cost-Effective: CURE trial involved 12,562 patients presenting with unstable angina or a non-ST elevation myocardial infarction (MI) who were randomized to clopidogrel or placebo. After 9 months, there were 20% fewer cardiovascular deaths, nonfatal MIs or strokes in the treated group compared with the placebo group (P < .001).  Using the Framingham database, the cost of each extra year gained by clopidogrel treatment would be $6,318, Dr. Weintraub reported. Using the Saskatchewan database, it would be $6,475.  In comparison, aspirin for acute MI costs $2,400 per life-year gained and eptifibatide for ACS costs $16,491 per life-year saved, he noted.  The CREDO trial of 2116 patients with coronary artery disease undergoing planned or probable percutaneous coronary intervention (PCI) were randomized to clopidogrel loading before PCI plus 1 year of therapy or placebo. At 1 year, long-term clopidogrel therapy was associated with a 26.9% relative reduction in the combined risk of death, MI, or stroke compared with placebo. Sean Beinart, MD, MsCR, Emory University.  At 12 months, the cost-effectiveness of daily clopidogrel in addition to a clopidogrel-loading strategy prior to PCI compared with placebo was $3,685 per life-year saved, with 84.1% of life-years gained costing less than $50,000, the study showed. AHA Scientific Sessions 2003: Abstract 1925, presented Nov. 10, 2003; abstract 3495, presented Nov. 12, 2003.

Cooling Helps: European study of 275 patients, half were chilled with circulating cold air and ice packs from a normal 98.6 degrees to between 89.6 and 93.2 degrees for 24 hours. Fifty-five percent of the cooled group had a favorable outcome compared with 39 percent of the group that did not get the treatment. The death rate at six months was 41 percent in the cooled group and 55 percent in the group that was not cooled. The researchers in Melbourne, Australia, used ice packs, and cooling was started by paramedics. Forty-three of 77 patients were chilled to 91.4 degrees for 12 hours. Forty-nine percent of the treated group recovered well enough to go home or to a rehabilitation center, compared with 26 Enbrel Helps CHF: Congestive Heart Failure associated with heart producing tumor necrosis factor which causes inflam. Enbrel blocks TNF. Costs $1500 per month. 50% helped on low dose and 60% on high dose in phase I and II trials on going at Emory & U Pitt. Enbrel may also be good for Crohn’s, Ulc Colitis, Psoriasis. CNN 12/2/00

CoQ10 Considerably Improves Survival in Heart Attacks Treated with Hypothermia: In a DB PC study of 49 heart attack victims, hypothermia plus CoQ10 150 mg t.i.d. had much better 3-month survival (68%) than hypothermia alone (29%) (P=0.0413). Coenzyme Q10 Combined With Mild Hypothermia After Cardiac Arrest. A Preliminary Study. Damian MS, Ellenberg D, et al., University Hospitals of Leicester, United Kingdom. Circulation. 2004 Nov 1

CoQ10 Helped Patients Awaiting Heart Transplant: In a DB PC study of 32 patients awaiting heart transplants, 60 mg U/day of CoQ10 (a special preparation to increase intestinal absorption) for 3 months led to significant improvement in the 6-min walk test and a decrease in dyspnea, New York Heart Association (NYHA) classification, nocturia, and fatigue. No significant changes were noted after 3 months of treatment in echocardiography parameters (dimensions and contractility of cardiac chambers) or ANF and TNF blood levels. Coenzyme Q10 in patients with end-stage heart failure awaiting cardiac transplantation: a randomized, placebo-controlled study. Berman M, Erman A, Ben-Gal T, Dvir D, Georghiou GP, Stamler A, Vered Y, Vidne BA, Aravot D. Rabin Medical Center, Israel. Clin Cardiol. 2004 May;27(5):295-9.

Eplerenone, an Aldosterone Blocker, Reduced Death After Heart Attack: In the 16-month DB PC Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS), eplerenone 25 mg/day started 3-14 days after a heart attack reduced all-cause mortality by 15% (p = 0.008) over a mean follow-up of 16 months when used with standard therapy in patients after AMI with an LVEF < or =40% and clinical signs of heart failure. At 30 days after randomization, eplerenone reduced the risk of all-cause mortality by 31% (3.2% vs. 4.6% in eplerenone and placebo-treated patients, respectively; p = 0.004) and reduced the risk of CV mortality/CV hospitalization by 13% (8.6% vs. 9.9% in eplerenone and placebo-treated patients, respectively; p = 0.074). Eplerenone also reduced the risk of CV mortality by 32% (p = 0.003) and the risk of sudden cardiac death by 37% (p = 0.051). Eplerenone reduces mortality 30 days after randomization following acute myocardial infarction in patients with left ventricular systolic dysfunction and heart failure. Pitt B. et al. University of Michigan. J Am Coll Cardiol. 2005 Aug 2;46(3):425-31.

Hawthorn for Congestive Heart Disease, No Evidence: Hawthorn (crataegus) is promoted for angina and conges HD. Letter Circ 11/10/98;98:2098. PubMed has three German articles without abstracts, two from 1960’s, and one Polish, also without abstract. Energy Tims 2/99 p.35. They also promote gingko, grape seeds, and bilberry extract to reduce platelet aggregatoin in place of aspirin. Garlic, CoQ10, cayenne, carnitine, and taurine are all promoted along with Mg and Se. Dan Gardner ND.

HDL (Synthetic) Reduces Plaques in Heart Arteries: Imitating unusually large high density lipoprotein (HDL) particles, sometimes called "good cholesterol," found to reduce heart disease in a small group of Italians due to a generic variation, scientists have found the weekly injections of a similar synthetic HDL reduced coronary arterial plaques by 4% over the 6 week study compared to placebo. Steven Nissan, Cleveland Clinic. JAMA 11/5/03.  

Ibuprofen Increases Recurrent Heart Attacks: Lancet 2/14/03 those taking both aspirin and ibuprofen were twice as likely to die during the study period as those who were taking aspirin alone or with other types of common pain relievers. Ibuprofen clogs a channel inside a clotting protein that aspirin acts on. Aspirin gets stuck behind the ibuprofen and cannot get to where it is supposed to go to thin the blood. 7,107 heart patients who had been discharged from hospitals between 1989 and 1997 with aspirin prescriptions and had survived at least one month after leaving the hospital. No extra deaths were seen in the groups taking the other types of NSAIDs, e.g. diclofenac.

Implanted Defibrillator Helps at Extremely High Price: 3/21/02 NEJM reports 31% increase longevity at 20 months in study of 1232 heart attack victims (14% dead vs. 20% in control group) at a cost of $40-60,000 per person or $500,000 per year of life saved through the end of the study.

Intercessory Prayer Didn’t Help: Outcomes death, heart attack, rehospitalization. Mayo Clin Proc 12/01;76:1192

L-Arginine Helps Exercise in Heart Failure: L-arginine, a precursor of nitric oxide (NO), may improve endothelium- dependent vasodilatation and exercise capacity. In a DB PC cross-over study of 21 patients with stable NYHA II-III congestive heart failure, L-arginine (9 g/day for 7 days) resulted in a higher prolongation of exercise duration time than placebo (99 vs. 70 seconds, p<0.05). L-arginine supplementation prolongs duration of exercise in congestive heart failure. Bednarz B, Jaxa-Chamiec T, Gebalska J, Herbaczynska-Cedro K, Ceremuzynski L. Warsaw, Poland. Kardiol Pol. 2004 Apr;60(4):348-53

Naproxen Cuts Heart Attacks: 4,425 heart attack patients and 17,700 others, linked naproxen use to a 16 percent to 20 percent reduction in heart attack risk. Two other studies with similar findings in same issue. Thought due to blood thinning effect. Arch Int Med 5/27/02.

Nisirizide (Natrecor), Nor Milrinone (Primicor) Help CHF Mortality: 949 pt DB study found non-signif higher death toll with milrinone for worsening CHF and suggests using it no more than 48 hours and only when nothing else helping. A second study of 489 found no mortality benefit with nisiride and only somewhat fewer side-effects than IV nitroglycerin. Duke, JAMA 3/26/02

Raloxifene Helps Some: High-risk women who took raloxifene (Evista) for four years were 40 percent less likely than women who took dummy pills to have heart attacks or other cardiovascular ``events,'' such as strokes or chest pain. Women were considered high-risk if they had previous heart trouble or had a combination of risk factors such as diabetes and high blood pressure. Raloxifene is a estrogen replacement, i.e. replacing estrogen meds for osterporosis, tho doesn’t help menopausal symptoms. Estrogens typically cause an increase in coronary events the first year in patients with heart disease. UCSD, JAMA 2/22/02.

Stents, Not Abciximab, Are Cost-Effective After Heart Attack: The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial randomized 1703 patients to percutaneous transluminal coronary angioplasty (PTCA) alone, PTCA plus abciximab, stenting alone, or stenting plus abciximab. Stenting increased hospital costs by $1384 per patient, but because repeat hospitalizations and revascularizations were significantly reduced, aggregate 1-year medical care costs were only $169. The calculated cost-effectiveness ratio was $11,237 per quality adjusted life year gained.  The use of abciximab increased the initial procedural costs by $1122. Significantly more rehospitalizations were required, and there was a trend toward increased number of revascularizations, so that aggregate 1-year costs were $1244 higher for abciximab than for standard anticoagulation.  David J. Cohen, Beth Israel Deaconess, Circulation 11/10/2003;108:000-000.

Xuezhikang Chinese Medicine Reduced Heart Attacks and Death in Huge Study: In a 4-year DB PC study of 4870 heart attack victims, the incidence of nonfatal myocardial infarction and deaths from CHD in patients taking Xuezhikang were 5.72% vs. 10.41% for placebo, with a reduction of relative risk by 45.1% (P = 0.0000). The incidence of deaths from CHD was 3.79% in the treatment group and 5.49% for placebo, with a reduction of relative risk by 31.0% (P < 0.0048); The incidence of nonfatal myocardial infarction reduced by 60.8% (1.93% vs 4.92%, P < 0.0000); Stroke, tumor, and PCI/CABG also decreased by 31.1% (6.92% vs 10.04% P < 0.0004). There were no significant differences in side effects and abnormal laboratory references between the two groups. China coronary secondary prevention study (CCSPS). Lu ZL et al. Peking Union Medical College, Beijing, China. Zhonghua Xin Xue Guan Bing Za Zhi. 2005 Feb;33(2):109-15.

Metoprolol Helps in Heart Failure: Study found adding metoprolol to standard treaatment for heart failure decreased mortality. Heart 4/98;79:337

Imipramine Helps Chest Pain with Coronary Angiograms: Ten to 30 percent of patients undergoing cardiac catheterization because of chest pain are found to have normal coronary angiograms. These patients may have a visceral pain syndrome unrelated to myocardial ischemia. Sixty patients with chest pain and normal coronary angiograms underwent cardiac, esophageal, psychiatric, and pain-sensitivity testing and then were treated in a DB PC 3-week study of clonidine at 0.1 mg twice daily, imipramine 50 mg nightly or placebo. 22% had ischemic-appearing electrocardiographic responses to exercise, 41% had abnormal esophageal motility, 63% had one or more psychiatric disorders, and 87% had their characteristic chest pain provoked by right ventricular electrical stimulation or intracoronary infusion of adenosine. Imipramine caused a reduction of 52% in episodes of chest pain, clonidine 39%, and placebo 1%. Repeat assessment of sensitivity to cardiac pain while the patients were receiving treatment showed significant improvement only in the imipramine group (P = 0.01). The response to imipramine did not depend on the results of cardiac, esophageal, or psychiatric testing at base line, or on the change in the psychiatric profile during the course of the study, which generally improved in all three study groups. Imipramine in patients with chest pain despite normal coronary angiograms. Cannon RO 3rd, Quyyumi AA, et al. NIH. N Engl J Med. 1994 May 19;330(20):1411-7