A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective

Increase in the proportion of patients hospitalized with acute myocardial infarction with do-not-resuscitate orders already in place between 2001 and 2007: a nonconcurrent prospective study

BACKGROUND AND OBJECTIVE

Shared decision making and advance planning in end-of-life decisions have become increasingly important aspects of the management of seriously ill patients. Here, we describe the use and timing of do-not-resuscitate (DNR) orders in patients hospitalized with acute myocardial infarction (AMI).

STUDY DESIGN AND SETTING

The nonconcurrent prospective study population consisted of 4182 patients hospitalized with AMI in central Massachusetts in four annual periods between 2001 and 2007.

RESULTS

One-quarter (25%) of patients had a DNR order written either prior to or during hospitalization. The frequency of DNR orders remained constant (24% in 2001; 26% in 2007). Among patients with DNR orders, there was a significant increase in orders written prior to hospitalization (2001: 9%; 2007: 55%). Older patients and those with a medical history of heart failure or myocardial infarction were more likely to have prior DNR orders than respective comparison groups. Patients with prior DNR orders were less likely to die 1 month after hospitalization than patients whose DNRs were written during hospitalization.

CONCLUSION

Although the use of DNR orders in patients hospitalized with AMI was stable during the period under study, in more recent years, patients are increasingly being hospitalized with DNR orders already in place.

Post-myocardial-infarction quality of care among disabled Medicaid beneficiaries with and without serious mental illness

OBJECTIVE

The objective was to examine the association between serious mental illness and quality of care for myocardial infarction among disabled Maryland Medicaid beneficiaries.

METHODS

We conducted a retrospective cohort study of disabled Maryland Medicaid beneficiaries with myocardial infarction from 1994 to 2004. Cardiac procedures and guideline-based medication use were compared for persons with and without serious mental illness.

RESULTS

Of the 633 cohort members with myocardial infarction, 137 had serious mental illness. Serious mental illness was not associated with differences in receipt of cardiac procedures or guideline-based medications. Overall use of guideline-based medications was low; 30 days after the index hospitalization for myocardial infarction, 19%, 35% and 11% of cohort members with serious mental illness and 22%, 37% and 13% of cohort members without serious mental illness had any use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta-blockers and statins, respectively. Study participants with and without serious mental illness had similar rates of mortality. Overall, use of beta-blockers [hazard ratio 0.93, 95% confidence interval (CI) 0.90-0.97] and statins (hazard ratio 0.93, 95% CI 0.89-0.98) was associated with reduced risk of mortality.

CONCLUSIONS

Quality improvement programs should consider how to increase adherence to medications of known benefit among disabled Medicaid beneficiaries with and without serious mental illness.

Twenty-two-year trends in incidence of myocardial infarction, coronary heart disease mortality, and case fatality in 4 US communities, 1987-2008

BACKGROUND

Knowledge of trends in the incidence of and survival after myocardial infarction (MI) in a community setting is important to understanding trends in coronary heart disease (CHD) mortality rates.

METHODS AND RESULTS

We estimated race- and gender-specific trends in the incidence of hospitalized MI, case fatality, and CHD mortality from community-wide surveillance and validation of hospital discharges and of in- and out-of-hospital deaths among 35- to 74-year-old residents of 4 communities in the Atherosclerosis Risk in Communities (ARIC) Study. Biomarker adjustment accounted for change from reliance on cardiac enzymes to widespread use of troponin measurements over time. During 1987-2008, a total of 30 985 fatal or nonfatal hospitalized acute MI events occurred. Rates of CHD death among persons without a history of MI fell an average 4.7%/y among men and 4.3%/y among women. Rates of both in- and out-of-hospital CHD death declined significantly throughout the period. Age- and biomarker-adjusted average annual rate of incident MI decreased 4.3% among white men, 3.8% among white women, 3.4% among black women, and 1.5% among black men. Declines in CHD mortality and MI incidence were greater in the second decade (1997-2008). Failure to account for biomarker shift would have masked declines in incidence, particularly among blacks. Age-adjusted 28-day case fatality after hospitalized MI declined 3.5%/y among white men, 3.6%/y among black men, 3.0%/y among white women, and 2.6%/y among black women.

CONCLUSIONS

Although these findings from 4 communities may not be directly generalizable to blacks and whites in the entire United States, we observed significant declines in MI incidence, primarily as a result of downward trends in rates between 1997 and 2008.

Age related issues in reperfusion of myocardial infarction

Advances in pharmacological treatment and effective early myocardial revascularization have led to improved clinical outcomes in patients with acute myocardial infarction (AMI). However, it has been suggested that compared to younger subjects, elderly AMI patients are less likely to receive evidence-based treatment. Several reasons have been postulated to explain this trend, including uncertainty regarding the benefits of the commonly used interventions in the older age group as well as increased risk associated with comorbidities. The diagnosis, management, and post-hospitalization care of elderly patients presenting with an acute coronary syndrome (ACS) pose many difficulties at present due, at least in part, to the fact that trial data are scanty as elderly patients have been poorly represented in most clinical trials. Thus it appears that these high-risk individuals are often managed with more conservative strategies, compared to younger patients. This article reviews current evidence regarding management of AMI in the elderly.

The impact of COPD on management and outcomes of patients hospitalized with acute myocardial infarction: a 10-year retrospective observational study

BACKGROUND

There are limited data describing contemporary trends in the management and outcomes of patients with COPD who develop acute myocardial infarction (AMI).

METHODS

The study population consisted of patients hospitalized with AMI at all greater Worcester, Massachusetts, medical centers between 1997 and 2007.

RESULTS

Of the 6,290 patients hospitalized with AMI, 17% had a history of COPD. Patients with COPD were less likely to be treated with β-blockers or lipid-lowering therapy or to have undergone interventional procedures during their index hospitalization than patients without COPD. Patients with COPD were at higher risk for dying during hospitalization (13.5% vs 10.1%) and at 30 days after discharge (18.7% vs 13.2%), and their outcomes did not improve during the decade-long period under study. After multivariable adjustment, the adverse effects of COPD remained on both in-hospital (OR, 1.25; 95% CI, 0.99-1.50) and 30-day all-cause mortality (OR, 1.31; 95% CI, 1.10-1.58). The use of evidence-based therapies for all patients with AMI increased between 1997 and 2007, with a particularly marked increase for patients with COPD.

CONCLUSIONS

Our results suggest that the gap in medical care between patients with and without COPD hospitalized with AMI narrowed substantially between 1997 and 2007. Patients with COPD, however, remain less aggressively treated and are at increased risk for hospital adverse outcomes than patients without COPD in the setting of AMI. Careful consideration is necessary to ensure that these high-risk complex patients are not denied the benefits of effective cardiac therapies.

Epidemiology and risk factors of cerebral ischemia and ischemic heart diseases: similarities and differences

Cerebral ischemia and ischemic heart diseases, common entities nowadays, are the main manifestation of circulatory diseases. Cardiovascular diseases, followed by stroke, represent the leading cause of mortality worldwide. Both entities share risk factors, pathophisiology and etiologic aspects by means of a main common mechanism, atherosclerosis. However, each entity has its own particularities. Ischemic stroke shows a variety of pathogenic mechanisms not present in ischemic heart disease. An ischemic stroke increases the risk of suffering a coronary heart disease, and viceversa. The aim of this chapter is to review data on epidemiology, pathophisiology and risk factors for both entities, considering the differences and similarities that could be found in between them. We discuss traditional risk factors, obtained from epidemiological data, and also some novel ones, such as hyperhomocisteinemia or sleep apnea. We separate risk factors, as clasically, in two groups: nonmodifiables, which includes age, sex, or ethnicity, and modifiables, including hypertension, dyslipidemia or diabetis, in order to discuss the role of each factor in both ischemic events, ischemic stroke and coronary heart disease.

Trends in Q-wave acute myocardial infarction case fatality from 1978 to 2007 and analysis of the effectiveness of different treatments

BACKGROUND

We sought to analyze the trends in first Q-wave acute myocardial infarction (AMI) case fatality from 1978 to 2007 in a population-based hospital register, to determine the variables related to these changes, and to assess the effectiveness of current AMI management.

METHODS

Population-based hospital registry included patients with first Q-wave AMI aged 25 to 74 years admitted between 1978 and 2007. Sociodemographic and clinical characteristics, treatments, and procedures used during hospital stay, and 28-day case fatality were recorded. Logistic regression was used for multivariate analysis of six 5-year periods.

RESULTS

The 30-year study included 3,982 patients. Mean 28-day case fatality was 8.96%, with a decreasing trend from 16.6% in the first 5-year period to 4.7% in the sixth (P for trend < .001). Study period was independently associated with case fatality. Case-fatality reduction attributable to pharmacologic treatments was 51% overall; in 24-hour survivors, pharmacologic treatments and broad use of invasive procedures explained 39% and 38%, respectively, of the difference between the observed case fatality in 2003-2007 and 1978-1982.

CONCLUSION

A dramatic decrease in 28-day case fatality occurred during this 30-year period and was mainly related to the use of antiplatelet drugs, β-blockers, thrombolysis, and invasive procedures. These data support the current guidelines for the management of acute coronary syndrome.

Anti-ischemic and antiarrhythmic effectiveness of long-term bisoprolol therapy in patients with myocardial infarction

Aim. To study the effects of long-term bisoprolol (B) therapy on exercise capacity (EC) dynamics, ventricular arrhythmia (VA), and clinical course in patients with myocardial infarction (MI). Material and methods. The study included 114 men with MI (age 30-63 years), receiving long-term B treatment (2,5-10 mg once a day). The parameters assessed included EC dynamics, VA, and clinical course of the disease. Results. Patients with sub-acute MI were characterised by low EC and VA presence, including life-threatening VA forms. Long-term B treatment was associated with a significant reduction in angina attack rate (by 3,9 times) and in the number of nitroglycerin tablets per week (by 4,3 times). In most patients (79,7%), B therapy increased the work performed during stress test (+99%), EC (+43,4%), and exercise time (+52%). In 44 patients (55,7%), an antiarrhythmic effect was observed, including the individuals with high-grade VA (13 out of 15). Long-term B treatment also improved the clinical course of the disease, significantly reducing the end-point rates (in 86,1%). Conclusion. Early started, adequate-dose long-term B therapy improved clinical course of the disease and demonstrated good anti-ischemic, antianginal, and antiarrhythmic effects in MI patients, including those with life-threatening VA forms.

30-year trends in heart failure in patients hospitalized with acute myocardial infarction

Despite significant advances in its treatment, acute myocardial infarction (AMI) remains an important cause of heart failure (HF). Contemporary data remain lacking, however, describing long-term trends in incidence rates, demographic and clinical profiles, and outcomes of patients who develop HF as a complication of AMI. Our study sample consisted of 11,061 residents of the Worcester (Massachusetts) metropolitan area hospitalized with AMI at all greater Worcester hospitals in 15 annual study periods from 1975 to 2005. Overall, 32.4% of patients (n = 3,582) with AMI developed new-onset HF during their acute hospitalization. Patients who developed HF were generally older, more likely to have pre-existing cardiovascular disease, and were less likely to receive cardiac medications or undergo revascularization procedures during their hospitalization than patients who did not develop HF (p <0.001). Incidence rates of HF remained relatively stable from 1975 to 1991 at 26% but decreased thereafter. Decreases were also noted in hospital and 30-day death rates in patients with acute HF (p <0.001). However, patients who developed new-onset HF remained at significantly higher risk for dying during their hospitalization (21.6%) than patients who did not develop this complication (8.3%, p <0.001). Our large community-based study of patients hospitalized with AMI demonstrates that incidence rates of and mortality attributable to HF have decreased over the previous 3 decades. In conclusion, HF remains a common and frequently fatal complication of AMI to which increased surveillance and treatment efforts should be directed.

Mortality and morbidity trends: is there compression of morbidity?

OBJECTIVE

This paper reviews trends in mortality and morbidity to evaluate whether there has been a compression of morbidity.

METHODS

Review of recent research and analysis of recent data for the United States relating mortality change to the length of life without 1 of 4 major diseases or loss of mobility functioning.

RESULTS

Mortality declines have slowed down in the United States in recent years, especially for women. The prevalence of disease has increased. Age-specific prevalence of a number of risk factors representing physiological status has stayed relatively constant; where risks decline, increased usage of effective drugs is responsible. Mobility functioning has deteriorated. Length of life with disease and mobility functioning loss has increased between 1998 and 2008.

DISCUSSION

Empirical findings do not support recent compression of morbidity when morbidity is defined as major disease and mobility functioning loss.

Age- and sex-specific in-hospital mortality after myocardial infarction in routine clinical practice

Background. Literature regarding the influence of age/sex on mortality trends for acute myocardial infarction (AMI) hospitalizations is limited to hospitals participating in voluntary AMI registries. Objective. Evaluate the impact of age and sex on in-hospital AMI mortality using a nationally representative hospital sample. Methods. Secondary data analysis using AMI hospitalizations identified from the Nationwide-Inpatient-Sample (NIS). Descriptive and Cox proportional hazards analysis explored mortality trends by age and sex from 1997–2006 while adjusting for the influence of, demographics, co-morbidity, length of hospital stay and hospital characteristics. Results. From 1997–2006, in-hospital AMI mortality rates decreased across time in all subgroups (P < .001), except for males aged <55 years. The greatest decline was observed in females aged <55 years, compared to similarly aged males, mortality outcomes were poorer in 1997-1998 (RR 1.47, 95% CI  =  1.30–1.66), when compared with 2005-2006 (RR 1.03, 95% CI  =  0.90–1.18), adjusted P value for trend demonstrated a statistically significant decline in the relative AMI mortality risk for females when compared with males (<0.001). Conclusion. Over the last decade, in-hospital AMI mortality rates declined for every age/sex group except males <55 years. While AMI female-male mortality disparity has narrowed, some room for improvement remains.

Long-term prognosis after hospital admission for acute myocardial infarction from 1987 to 2006

BACKGROUND

Recent population-based estimates for long-term cardiovascular disease (CVD) mortality after hospitalization for a first acute myocardial infarction (AMI) are not well established.

METHODS

Data from the Swedish hospital discharge and death registries were used to record all first-ever hospital admissions in patients (n=348,772) 35-84 years with AMI from 1987 to 2006 and subsequent all-cause and CVD case fatality during up to 5 years.

RESULTS

During the 20-year period, 28-day case fatality was reduced by almost two thirds in patients aged <75 years. For cases with a first AMI 1999-2002 long-term case fatality for men surviving the first 28 days and <55 years was 10.3/1000 person years, with rates of 23.6, 58.0 and 137.0 for men aged 55-64, 65-74 and 75-84 years. Corresponding figures for women were 10.5, 24.3, 51.8, 124.1 deaths/1000 years. In 1999-2002 estimated long-term risk of fatal CVD (based on survival until 2007) for men below 55 years was 6.1/1000 years, and 13.8, 34.6, 92.9 for men aged 55-64, 65-74, and 75-84 years, respectively. Corresponding figures for women were 4.8, 11.9, 30.1, 86.2/1000 years. The total reduction in CVD case fatality was two thirds among patients aged <55 and approximately one third among those aged 75-84.

CONCLUSIONS

Long-term case fatality after hospitalization for AMI decreased markedly from 1987 to 2006, particularly with respect to CVD mortality and in younger patients. However, because of a steep increase in case fatality with age and a large proportion of older patients, long-term prognosis overall still remains poor.

Declining length of stay for patients hospitalized with AMI: impact on mortality and readmissions

BACKGROUND

Length of hospital stay after acute myocardial infarction decreased significantly in the 1980s and 1990s. Whether length of stay has continued to decrease during the 2000s, and the impact of decreasing length of stay on rehospitalization and mortality, is unclear. We describe decade-long (1995-2005) trends in length of stay after acute myocardial infarction, and examine whether declining length of stay has impacted early rehospitalization and postdischarge mortality in a population-based sample of hospitalized patients.

METHODS

The study sample consisted of 4184 patients hospitalized with acute myocardial infarction in a central New England metropolitan area during 6 annual periods (1995, 1997, 1999, 2001, 2003, 2005).

RESULTS

The average age of the study sample was 71 years, and 54% were men. The average length of stay decreased by nearly one third over the 10-year study period, from 7.2 days in 1995 to 5.0 days in 2005 (P <.001). Younger patients (<65 years), men, and patients with an uncomplicated hospital stay had significantly shorter lengths of stay than respective comparison groups. Lengths of stay shorter than the median were not associated with significantly higher odds of hospital readmission at 7 or 30 days postdischarge, or with mortality in the year after discharge. In contrast, longer lengths of stay were associated with significantly higher odds of short-term mortality. These findings did not vary by year under study.

CONCLUSIONS

Length of stay in patients hospitalized for acute myocardial infarction decreased significantly between 1995 and 2005. Declining length of stay is not associated with an increased risk for early readmission or all-cause mortality.

Role of Endothelial Cells in Myocardial Ischemia-Reperfusion Injury

Minimizing myocardial ischemia-reperfusion injury has broad clinical implications and is a critical mediator of cardiac surgical outcomes. “Ischemic injury” results from a restriction in blood supply leading to a mismatch between oxygen supply and demand of a sufficient intensity and/or duration that leads to cell necrosis, whereas ischemia-reperfusion injury occurs when blood supply is restored after a period of ischemia and is usually associated with apoptosis (i.e. programmed cell death). Compared to vascular endothelial cells, cardiac myocytes are more sensitive to ischemic injury and have received the most attention in preventing myocardial ischemia-reperfusion injury. Many comprehensive reviews exist on various aspects of myocardial ischemia-reperfusion injury. The purpose of this review is to examine the role of vascular endothelial cells in myocardial ischemia-reperfusion injury, and to stimulate further research in this exciting and clinically relevant area. Two specific areas that are addressed include: 1) data suggesting that coronary endothelial cells are critical mediators of myocardial dysfunction after ischemia-reperfusion injury; and 2) the involvement of the mitochondrial permeability transition pore in endothelial cell death as a result of an ischemia-reperfusion insult. Elucidating the cellular signaling pathway(s) that leads to endothelial cell injury and/or death in response to ischemia-reperfusion is a key component to developing clinically applicable strategies that might minimize myocardial ischemia-reperfusion injury.

Recent declines in hospitalizations for acute myocardial infarction for Medicare fee-for-service beneficiaries: progress and continuing challenges

BACKGROUND

Amid recent efforts to reduce cardiovascular risk, whether rates of acute myocardial infarction (AMI) in the United States have declined for elderly patients is unknown.

METHODS AND RESULTS

Medicare fee-for-service patients hospitalized in the United States with a principal discharge diagnosis of AMI were identified through the use of data from the Centers for Medicare and Medicaid Services from 2002 to 2007, a time period selected to reduce changes arising from the new definition of AMI. The Medicare beneficiary denominator file was used to determine the population at risk. AMI hospitalization rates were calculated annually per 100,000 beneficiary-years with Poisson regression analysis and stratified according to age, sex, and race. The annual AMI hospitalization rate in the fee-for-service Medicare population fell from 1131 per 100,000 beneficiary-years in 2002 to 866 in 2007, a relative 23.4% decline. After adjustment for age, sex, and race, the AMI hospitalization rate declined by 5.8%/y. From 2002 to 2007, white men experienced a 24.4% decrease in AMI hospitalizations, whereas black men experienced a smaller decline (18.0%; P<0.001 for interaction). Black women had a smaller decline in AMI hospitalization rate compared with white women (18.4% versus 23.3%, respectively; P<0.001 for interaction).

CONCLUSIONS

AMI hospitalization rates fell markedly in the Medicare fee-for-service population between 2002 and 2007. However, black men and women appeared to have had a slower rate of decline compared with their white counterparts.

Contemporary trends in evidence-based treatment for acute myocardial infarction

BACKGROUND

Guidelines for the management of patients with acute myocardial infarction recommend the routine use of 4 effective cardiac medications: angiotensin-converting enzyme inhibitors, aspirin, beta-blockers, and lipid-lowering agents. Limited data are available, however, about the contemporary and changing use of these therapies, particularly from a population-based perspective. The study describes differences in the use of these medications during hospitalization for acute myocardial infarction according to age, gender, and period of hospitalization.

METHODS

The study population consisted of 6334 women and men treated at 11 hospitals in the Worcester, Mass, metropolitan area for acute myocardial infarction in 6 annual periods between 1995 and 2005.

RESULTS

Increases in the use of all 4 cardiac medications during hospitalization for acute myocardial infarction were noted between 1995 and 2005 for all men and in those of different age strata: less than 65 years (4%-47%); 65 to 74 years (4%-46%); 75 to 84 years (2%-48%); and more than 85 years (0%-23%). Increases in the use of all 4 cardiac medications also were observed in all women and in those of all ages over time (2%-42%); 65 to 74 years (8%-47%); 75 to 84 years (1%-44%); and more than 85 years (1%-44%).

CONCLUSION

The present results suggest marked increases over time in the use of evidence-based therapies in patients hospitalized with acute myocardial infarction. Educational efforts to augment the use of these effective cardiac therapies, as well as attempts to identify suboptimally treated groups, remain warranted.

Elemental carbon exposure at residence and survival after acute myocardial infarction

BACKGROUND

Particulate air pollution has been consistently related to cardiovascular mortality. Some evidence suggests that particulate matter may accelerate the atherosclerotic process. Effects of within-city variations of particulate air pollution on survival after an acute cardiovascular event have been little explored.

METHODS

We conducted a cohort study of hospital survivors of acute myocardial infarction (MI) from the Worcester, MA, metropolitan area to investigate the long-term effects of within-city variation in traffic-related air pollution on mortality. The study builds on an ongoing community-wide investigation examining changes over time in MI incidence and case-fatality rates. We included confirmed cases of MI in 1995, 1997, 1999, 2001, and 2003. Long-term survival status was ascertained through 2005. A validated spatiotemporal land use regression model for traffic-related air pollution was developed and annual averages of elemental carbon at residence estimated. The effect of estimated elemental carbon on the long-term mortality of patients discharged after MI was analyzed using a Cox proportional hazards model, controlling for a variety of demographic, medical history, and clinical variables.

RESULTS

Of the 3895 patients with validated MI, 44% died during follow-up. Exposure to estimated elemental carbon in the year of entry into the study was 0.44 microg/m on average. All-cause mortality increased by 15% (95% confidence interval = 0.03%-29%) per interquartile range increase in estimated yearly elemental carbon (0.24 microg/m) after the second year of survival. No association between traffic-related pollution and all-cause mortality was observed during the first 2 years of follow-up.

CONCLUSIONS

Chronic traffic-related particulate air pollution is associated with increased mortality in hospital survivors of acute MI after the second year of survival.

Reduction in acute myocardial infarction mortality in the United States: risk-standardized mortality rates from 1995-2006

CONTEXT

During the last 2 decades, health care professional, consumer, and payer organizations have sought to improve outcomes for patients hospitalized with acute myocardial infarction (AMI). However, little has been reported about improvements in hospital short-term mortality rates or reductions in between-hospital variation in short-term mortality rates.

OBJECTIVE

To estimate hospital-level 30-day risk-standardized mortality rates (RSMRs) for patients discharged with AMI.

DESIGN, SETTING, AND PATIENTS

Observational study using administrative data and a validated risk model to evaluate 3,195,672 discharges in 2,755,370 patients discharged from nonfederal acute care hospitals in the United States between January 1, 1995, and December 31, 2006. Patients were 65 years or older (mean, 78 years) and had at least a 12-month history of fee-for-service enrollment prior to the index hospitalization. Patients discharged alive within 1 day of an admission not against medical advice were excluded, because it is unlikely that these patients had sustained an AMI.

MAIN OUTCOME MEASURE

Hospital-specific 30-day all-cause RSMR.

RESULTS

At the patient level, the odds of dying within 30 days of admission if treated at a hospital 1 SD above the national average relative to that if treated at a hospital 1 SD below the national average were 1.63 (95% CI, 1.60-1.65) in 1995 and 1.56 (95% CI, 1.53-1.60) in 2006. In terms of hospital-specific RSMRs, a decrease from 18.8% in 1995 to 15.8% in 2006 was observed (odds ratio, 0.76; 95% CI, 0.75-0.77). A reduction in between-hospital heterogeneity in the RSMRs was also observed: the coefficient of variation decreased from 11.2% in 1995 to 10.8%, the interquartile range from 2.8% to 2.1%, and the between-hospital variance from 4.4% to 2.9%.

CONCLUSION

Between 1995 and 2006, the risk-standardized hospital mortality rate for Medicare patients discharged with AMI showed a significant decrease, as did between-hospital variation.

Trends in the use of echocardiography and left ventriculography to assess left ventricular ejection fraction in patients hospitalized with acute myocardial infarction

BACKGROUND

Although current guidelines strongly recommend the measurement of ejection fraction (EF) in all patients hospitalized with acute myocardial infarction (AMI), there are limited data available describing trends in the use of diagnostic modalities to assess EF in these patients. The purpose of this study was to evaluate trends in the use of ventriculography and echocardiography to measure EF in a community sample of patients hospitalized with AMI.

METHODS

The medical records of 5,380 residents of the Worcester (MA) metropolitan area hospitalized with AMI at 11 greater Worcester medical centers between 1997 and 2005 were reviewed.

RESULTS

Between 1997 and 2005, the proportion of patients hospitalized with AMI undergoing measurement of EF by both ventriculography and echocardiography increased from 11% to 18%, whereas the percentage of patients who did not receive an evaluation of EF by either modality decreased from 37% to 27%. The percentage of patients undergoing measurement of EF by ventriculography alone increased from 14% to 20%, whereas the percentage of patients undergoing measurement of EF by echocardiography alone remained stable at 37%. In 1997, echocardiography was performed before ventriculography in approximately two thirds of hospitalized patients, whereas in 2005, ventriculography was performed before echocardiography in approximately two thirds of patients with AMI.

CONCLUSIONS

The use of left ventriculography and the concurrent use of both ventriculography and echocardiography to assess EF in patients with AMI are increasing. Although the proportion of patients who do not have their EF assessed has declined during recent years, many still do not receive a determination of their EF.

Trends in atrial fibrillation complicating acute myocardial infarction

Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI) and this arrhythmia is associated with increased morbidity and mortality in patients with AMI. Limited information is available, however, about changing, and contemporary, trends in the incidence and death rates associated with AF complicating AMI. We examined the magnitude and impact of AF and the risk of stroke and hospital and long-term death rates in a population-based study of patients hospitalized with AMI. The study population consisted of 7,513 residents of the Worcester, Massachusetts, metropolitan area hospitalized with AMI at all greater Worcester medical centers during 9 biennial years from 1990 to 2005. Overall incidence of AF complicating AMI was 13.3% and rates of AF increased during the most recent years under study. Patients who developed AF were at greater risk for acute stroke (adjusted odds ratio 2.25, 95% confidence interval 1.36 to 3.71) and dying during hospitalization (adjusted odds ratio 1.79, 95% confidence interval 1.46 to 2.19) compared with patients who did not develop AF during hospitalization for AMI. Postdischarge survival was significantly poorer in patients who developed AF. Odds of dying after AF did not change appreciably over the years under study. In conclusion, results of this study in residents of a large New England metropolitan area suggest that AF remains a frequent complication of AMI and is associated with a poor prognosis. Increased surveillance and targeted therapeutic approaches appear warranted for these high-risk patients.

Traffic particles and occurrence of acute myocardial infarction: a case-control analysis

Objectives:

We modelled exposure to traffic particles using a latent variable approach and investigated whether long-term exposure to traffic particles is associated with an increase in the occurrence of acute myocardial infarction (AMI) using data from a population-based coronary disease registry.

Methods:

Cases of individually validated AMI were identified between 1995 and 2003 as part of the Worcester Heart Attack Study. Population controls were selected from Massachusetts, USA, resident lists. NO₂ and PM_2.5 filter absorbance were measured at 36 locations throughout the study area. The air pollution data were used to estimate exposure to traffic particles using a semiparametric latent variable regression model. Conditional logistic models were used to estimate the association between exposure to traffic particles and occurrence of AMI.

Results:

Modelled exposure to traffic particles was highest near the city of Worcester. Cases of AMI were more exposed to traffic and traffic particles compared to controls. An interquartile range increase in modelled traffic particles was associated with a 10% (95% CI 4% to 16%) increase in the odds of AMI. Accounting for spatial dependence at the census tract, but not block group, scale substantially attenuated this association.

Conclusions:

These results provide some support for an association between long-term exposure to traffic particles and risk of AMI. The results were sensitive to the scale selected for the analysis of spatial dependence, an issue that requires further investigation. The latent variable model captured variation in exposure, although on a relatively large spatial scale.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decisionanalytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

A 30-year perspective (1975-2005) into the changing landscape of patients hospitalized with initial acute myocardial infarction: Worcester Heart Attack Study

BACKGROUND

The effects of lifestyle changes and evolving treatment practices on coronary disease incidence rates, demographic and clinical profile, and the short-term outcomes of patients hospitalized with acute myocardial infarction have not been well characterized. The purpose of this study was to examine multidecade-long trends (1975-2005) in the incidence rates, demographic and clinical characteristics, treatment practices, and hospital outcomes of patients hospitalized with an initial acute myocardial infarction from a population-based perspective.

METHODS AND RESULTS

Residents of the Worcester, Mass, metropolitan area (median age, 37 years; 89% white) hospitalized with an initial acute myocardial infarction (n=8898) at all greater-Worcester medical centers during 15 annual periods between 1975 and 2005 comprised the sample of interest. The incidence rates of initial acute myocardial infarction were lower in 2005 (209 of 100,000 population) than in 1975 (277 of 100,000), although these trends varied inconsistently over time. Patients hospitalized during the most recent study years were significantly older (mean age, 64 years in 1975; 71 years in 2005), more likely to be women (38% in 1975; 48% in 2005), and have a greater prevalence of comorbidities. Hospitalized patients were increasingly more likely to receive effective cardiac medications and coronary interventional procedures for the period under investigation. Hospital survival rates improved significantly over time (81% survived in 1975; 91% survived in 2005), although varying trends were observed in the occurrence of clinically important complications.

CONCLUSIONS

The results of this community-wide investigation provide insight into the changing magnitude, characteristics, management practices, and outcomes of patients hospitalized with a first myocardial infarction.

Multidecade-long trends (1986-2005) in the utilization of coronary reperfusion and revascularization treatment strategies in patients hospitalized with acute myocardial infarction: a community-wide perspective

OBJECTIVES

The objectives of our community-wide investigation were to describe multidecade-long trends (1986-2005) in the utilization of thrombolytic therapy, percutaneous coronary interventions, and coronary artery bypass graft surgery in patients hospitalized with acute myocardial infarction (AMI).

METHODS

The study sample consisted of 9422 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 11 annual periods between 1986 and 2005.

RESULTS

Increases in the utilization of percutaneous coronary interventions were observed between 1986 (2.0%) and 2005 (50.7%) with the most rapid increases beginning in the late 1990s. Utilization of coronary artery bypass graft surgery during hospitalization for AMI increased moderately in the 1990s, remained stable thereafter, and declined to being performed in 3.8% of hospitalized patients in 2005. The use of thrombolytic therapy increased between 1986 and 1995 (9.3-25.2%) and decreased markedly thereafter through 2005 (<1%). Demographic and clinical characteristics of several patients were associated with the receipt of these treatment regimens.

CONCLUSION

The results of this study in residents of a large Central New England community suggest an increasingly invasive approach to the management of patients hospitalized with AMI.

Long-term trends in myocardial infarction incidence and case fatality in the National Heart, Lung, and Blood Institute's Framingham Heart study

BACKGROUND

Whereas the prevalence of coronary heart disease risk factors has declined over the past decades in the United States, acute myocardial infarction (AMI) rates have been steady. We hypothesized that this paradox is due partly to the advent of increasingly sensitive biomarkers for AMI diagnosis.

METHODS AND RESULTS

In Framingham Heart Study participants over 4 decades, we compared the incidence and survival rates of initial AMI diagnosis by ECG (AMI-ECG) regardless of biomarkers with those based exclusively on infarction biomarkers (AMI-marker). We used Poisson regression to calculate annual incidence rates of first AMI over 4 decades (1960 to 1969, 1970 to 1979, 1980 to 1989, and 1990 to 1999) and compared rates of AMI-ECG with rates of AMI-marker. Cox proportional-hazards analysis was used to compare AMI case fatality over 4 decades. In 9824 persons (54% women; follow-up, 212 539 person-years; age, 40 to 89 years), 941 AMIs occurred, including 639 AMI-ECG and 302 AMI-marker events. From 1960 to 1999, rates of AMI-ECG declined by approximately 50% and rates of AMI-marker increased approximately 2-fold. Crude 30-day, 1-year, and 5-year case fatality rates in 1960 to 1969 and 1990 to 1999 were 0.20 and 0.14, 0.24 and 0.21, and 0.45 and 0.41, respectively. Age- and sex-adjusted 30-day, 1-year, and 5-year AMI case fatality declined by 60% in 1960 to 1999 (P for trend <0.001), with parallel declines noted after AMI-ECG and AMI-marker.

CONCLUSIONS

Over the past 40 years, rates of AMI-ECG have declined by 50%, whereas rates of AMI-marker have doubled. Our findings offer an explanation for the apparently steady national AMI rates in the face of improvements in primary prevention.

Thirty-year trends (1975 to 2005) in the magnitude of, management of, and hospital death rates associated with cardiogenic shock in patients with acute myocardial infarction: a population-based perspective

BACKGROUND

Limited information is available about potentially changing and contemporary trends in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction. The objectives of our study were to examine 3-decade-long trends (1975 to 2005) in the incidence rates of cardiogenic shock complicating acute myocardial infarction, patient characteristics and treatment practices associated with this clinical complication, and hospital death rates in residents of a large central New England community hospitalized with acute myocardial infarction at all area medical centers.

METHODS AND RESULTS

The study population consisted of 13 663 residents of the Worcester (Mass) metropolitan area hospitalized with acute myocardial infarction at all greater Worcester medical centers during 15 annual periods between 1975 and 2005. Overall, 6.6% of patients developed cardiogenic shock during their index hospitalization. The incidence rates of cardiogenic shock remained stable between 1975 and the late 1990s but declined in an inconsistent manner thereafter. Patients in whom cardiogenic shock developed had a significantly greater risk of dying during hospitalization (65.4%) than those who did not develop cardiogenic shock (10.6%) (P<0.001). Encouraging increases in hospital survival in patients with cardiogenic shock, however, were observed from the mid-1990s to our most recent study years. Several patient demographic and clinical characteristics were associated with an increased risk for developing cardiogenic shock.

CONCLUSIONS

Our findings indicate improving trends in the hospital prognosis associated with cardiogenic shock. Given the high death rates associated with this clinical complication, monitoring future trends in the incidence and death rates and the factors associated with an increased risk for developing cardiogenic shock remains warranted.

Changing trends (1986-2003) in the use of lipid lowering medication in patients hospitalized with acute myocardial infarction: a community-based perspective

OBJECTIVES

The objectives of this community-wide observational study were to describe nearly two decade long (1986-2003) trends in the use of lipid lowering therapy in patients hospitalized with acute myocardial infarction (AMI) and clinical and demographic factors associated with underutilization of this treatment regimen.

METHODS

A total of 9429 greater Worcester (MA) residents hospitalized with confirmed AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003 comprised the study population. Hospital medical records were reviewed to ascertain the prescribing of lipid lowering agents during hospitalization for AMI.

RESULTS

The mean age of the study sample was 70 years, 58% were men, and the average total and LDL serum cholesterol levels were 203 and 114 mg/dL, respectively. There was a marked increase in the use of lipid lowering therapy in greater Worcester residents hospitalized with AMI between 1986 (<1%) and 2003 (76%). Increasing use of lipid lowering medication was observed both with regards to the maintenance of this therapy in patients who were already on this treatment regimen and in the new initiation of lipid lowering medication in patients who had not been previously treated with this therapy. Several patient demographic and clinical factors, including advanced age and an initial AMI, were associated with the failure to be prescribed lipid lowering therapy during hospitalization for AMI.

CONCLUSIONS

The results of this study suggest encouraging increases over time in the use of lipid lowering therapy in patients hospitalized with AMI. Despite these encouraging trends, several high-risk patient groups remain suboptimally treated.

Long term survival after evidence based treatment of acute myocardial infarction and revascularisation: follow-up of population based Perth MONICA cohort, 1984-2005

OBJECTIVE

To examine trends in long term survival in patients alive 28 days after myocardial infarction and the impact of evidence based medical treatments and coronary revascularisation during or near the event.

DESIGN

Population based cohort with 12 year follow-up.

SETTING

Perth, Australia.

PARTICIPANTS

4451 consecutive patients with a definite acute myocardial infarction according to the World Health Organization MONICA (monitoring trends and determinants in cardiovascular disease) criteria admitted to hospital during 1984-7, 1988-90, and 1991-3.

MAIN OUTCOME MEASURES

All cause mortality identified from official mortality records and the hospital morbidity data, with death from cardiovascular disease as a secondary end point.

RESULTS

In the 1991-3 cohort, 28 day survivors of acute myocardial infarction had a 7.6% absolute event reduction (95% confidence interval 4% to 11%) or a 28% lower relative risk reduction (16% to 38%), unadjusted for risk of death, over 12 years after the incident admission compared with the 1984-7 cohort, similar to the survival of the 1988-90 cohort. The improved survival for the 1991-3 cohort persisted after adjustment for demographic factors, coronary risk factors, severity of disease, and event complications with an adjusted relative risk reduction of 26% (14% to 37%), but this was not apparent after further adjustment for medical treatments in hospital and coronary revascularisation procedures within 12 months of the incident myocardial infarction.

CONCLUSION

The improving trends in 12 year survival after a definite acute myocardial infarction are associated with progressive use of evidence based treatments during the initial admission to hospital and in the 12 months after the event. These changes in the management of acute myocardial infarction are probably contributing to the continuing decline in mortality from coronary heart disease in Australia.

Thirty-year trends (1975-2005) in the magnitude, patient characteristics, and hospital outcomes of patients with acute myocardial infarction complicated by ventricular fibrillation

Limited contemporary data are available describing the incidence rates, hospital prognosis, and factors associated with the occurrence of ventricular fibrillation (VF) in patients hospitalized with acute myocardial infarction (AMI). The objectives of our study were to examine 3-decade-long trends (1975 to 2005) in the magnitude, predictors, and hospital case-fatality rates associated with VF in residents of a large New England metropolitan area hospitalized at all area medical centers with an uncomplicated AMI. The study population consisted of 7,472 residents of the Worcester (Massachusetts) metropolitan area hospitalized with an uncomplicated AMI in 15 annual periods from 1975 to 2005. The overall proportion of patients who developed VF was 4.2%. The incidence rates of VF remained stable from 1975 to 1995 but decreased thereafter, reaching their lowest frequency in 2005 (1.9%). Hospital case-fatality rates were significantly higher in patients with (40.9%) compared with those without (2.5%) VF. Decreases in hospital death rates over time were observed in patients with and without VF, with the decreases in death rates being greater for patients with VF. Patients who developed a Q-wave MI or a left or right bundle branch block were at particularly increased risk for developing VF. In conclusion, our results indicate that the incidence and hospital death rates associated with VF have decreased during recent years.

Twenty-year trends in the incidence of stroke complicating acute myocardial infarction: Worcester Heart Attack Study

BACKGROUND

Given the improved survival of patients after acute myocardial infarction (AMI), more patients are at risk for cerebrovascular complications of AMI. Trends in the magnitude of stroke in the setting of AMI are not well characterized, however, and neither have contemporary trends in the hospital death rates of patients developing acute stroke been examined.

RESULTS

Of 9220 patients without a history of stroke hospitalized with confirmed AMI between 1986 and 2005 in all greater Worcester medical centers, 132 (1.4%) experienced an acute stroke during hospitalization. The proportion of patients with AMI who developed a stroke increased through the 1980s and 1990s but declined slightly thereafter. Advanced age, female sex, a previous myocardial infarction (MI), and the occurrence of atrial fibrillation during hospitalization were associated with a greater risk of stroke. Receipt of a percutaneous coronary intervention during hospitalization was associated with a lower risk of stroke. Compared with patients who did not experience a stroke, patients developing a stroke in the 1990s were approximately 3 times more likely to die during hospitalization (odds ratio [OR], 2.91; 95% confidence interval [CI], 1.72-5.19), whereas those experiencing a stroke in the 2000s were 5 times more likely to die (OR, 5.36; 95% CI, 2.71-10.64).

CONCLUSIONS

Although the incidence rates of stroke complicating AMI have declined somewhat since 1999, there is not a corresponding decline in the odds of dying during hospitalization in those developing a stroke. Although contemporary therapies may be reducing the risk of stroke in patients with AMI, more attention should be directed to improving the short-term prognosis of these high-risk patients.

Disparities in myocardial infarction case fatality rates among the elderly: the 20-year Medicare experience

BACKGROUND

Case fatality rates after acute myocardial infarction (MI) have decreased markedly over the last 3 decades. Some subgroups may have benefited more than others, but this hypothesis has not been evaluated in a large nationally representative cohort. Accordingly, we sought to assess long-term temporal trends in mortality after hospitalization for MI and to assess whether these trends differ by sex, race, or age in a cohort of elderly patients.

METHODS

We studied a cohort of 4.9 million Medicare beneficiaries >or=65 years hospitalized for MI between 1984 and 2003 and calculated the proportion that died inhospital, within 30 days, and within 1 year of hospitalization. We used multivariable risk models to estimate relative and absolute changes in case fatality rate according to race, sex, and age groups.

RESULTS

After adjustment for age, sex, and race, between 1984 and 2003, there was a 54.3% (95% CI 53.7%-54.8%), 39.7% (95% CI 39.1%-40.3%), and 23.0% (95% CI 22.5%-23.5%) reduction in the risk of inhospital, 30-day, and 1-year mortality, respectively. Relative and absolute reductions were greater in whites than in blacks, with the biggest differences observed for 1-year mortality. Small and inconsistent differences were seen by sex after stratifying by race. Patients aged >or=90 years experienced the smallest relative reductions in case fatality rates, with the biggest differences observed for 1-year mortality.

CONCLUSIONS

Among US Medicare beneficiaries, short-term MI case fatality rates have decreased significantly in all groups, but more so among whites than blacks. Additional studies are needed to clarify the basis for these observations.

Thirty-year trends (1975-2005) in the magnitude and hospital death rates associated with complete heart block in patients with acute myocardial infarction: a population-based perspective

BACKGROUND

The contemporary magnitude and prognostic implications of complete heart block (CHB) in patients with acute myocardial infarction (AMI) are unknown. As part of a community-based study of patients hospitalized with AMI in the Worcester, MA, metropolitan area, changes over time in the incidence rates of CHB complicating AMI and the prognostic impact of CHB on short-term survival were examined.

METHODS

The study population consisted of 13,663 residents of the Worcester metropolitan area who were hospitalized with AMI at all greater Worcester medical centers during 15 annual periods between 1975 and 2005.

RESULTS

The average age of the hospitalized study sample was 69 years, and 58% were men. The overall proportion of patients with AMI who developed CHB was 4.1%. The incidence rates of CHB complicating AMI declined appreciably over time, with the greatest decline in these incidence rates occurring during the most recent years under study. In 2005, 2.0% of patients hospitalized with AMI developed CHB compared to 5.1% in the initial study year of 1975. Patients with AMI who developed CHB had higher inhospital death rates (43.2%) than did those who did not develop CHB (13.0%) (P < .001). The hospital death rates associated with CHB declined appreciably over time, particularly during the most recent years under study. Several patient characteristics were associated with an increased risk for developing CHB during hospitalization for myocardial infarcation.

CONCLUSIONS

Our findings indicate recent encouraging declines in the incidence rates of CHB complicating AMI and improving trends in the hospital prognosis of these patients.

Prehospital transport of patients with acute myocardial infarction: a community-wide perspective

OBJECTIVE

The objectives of this population-based study were to examine the use of emergency medical services (EMS) in greater Worcester, Massachusetts, residents (2000 census = 478,000) hospitalized with acute myocardial infarction (AMI) at all metropolitan Worcester medical centers in four biennial periods between 1997 and 2003. A secondary study aim was to describe the demographic and clinical characteristics of patients with AMI transported to metropolitan Worcester hospitals by EMS, compared with those transported by other means, and their hospital outcomes.

METHODS

We reviewed the medical records of 3805 patients hospitalized for confirmed AMI at 11 greater Worcester medical centers during 1997, 1999, 2001, and 2003. Information about the use of EMS, patient characteristics, and hospital outcomes was obtained through the review of hospital charts.

RESULTS

A total of 2693 greater Worcester residents with AMI (70.8%) were transported to area hospitals by ambulance. Patients transported by ambulance were older, were more likely to be women, had a greater prevalence of comorbidities, and had a different symptom profile than patients transported by other means. Patients arriving at greater Worcester hospitals by ambulance were more likely to develop serious clinical complications, including heart failure and cardiogenic shock, and die during hospitalization compared with patients not transported by EMS.

CONCLUSIONS

Our results suggest that the majority of greater Worcester residents seeking care for AMI are transported by EMS. Patients transported by ambulance differ from patients transported by other means and are more likely to experience adverse hospital outcomes. The reasons why patients use EMS in the setting of AMI need to be further explored and patients' care-seeking behavior enhanced.

Secular changes in cardiovascular risk factors and attack rate of myocardial infarction among men aged 50 in Gothenburg, Sweden. Accurate prediction using risk models

AIMS

Coronary risk factor changes were related to attack rate of acute myocardial infarction (AMI).

METHODS AND RESULTS

Cross-sectional population samples of 50-year-old men were examined every 10th year from 1963 to 2003. Attack rates of AMI were recorded from 1975 to 2004. Prevalence of smoking decreased from 56% in 1963 to 22% in 2003. Leisure time physical activity decreased (n.s.), while psychological stress remained the same. Diabetes prevalence increased from 3.6% to 6.6%. Body mass index (BMI) increased from 24.8 to 26.4 kg m(-2). Blood pressures decreased from 138.2/90.6 to 134.7/84.9 mmHg (P = 0.00001). Serum total cholesterol decreased from 6.42 to 5.50 mmol L(-1) (P = 0.0001), but serum triglycerides increased from 1.26 to 1.71 mmol L(-1) (P = 0.0001). The multivariable risk according to total cholesterol, blood pressure and smoking for AMI decreased from the set value 1.0 in 1963 to 0.418. From 1975-1979 to 2000-2004 attack rates for AMI for the age groups 35-44, 45-54 and 55-64 declined to 45%, 46% and 45%, respectively. The 28-day case fatality declined from 30%, 38% and 46% to 12%, 16% and 20%.

CONCLUSION

The more than 50% decline in attack rate of AMI during 30 years was comparable with the decline in risk factors.

Changing trends in the evaluation of ejection fraction in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study

BACKGROUND

Extent of left ventricular dysfunction in patients with acute myocardial infarction (AMI) is an important predictor of subsequent morbidity and mortality. It is unclear, however, how often ejection fraction (EF) findings are evaluated in the setting of AMI, and the characteristics of patients who do not have their EF evaluated, particularly from the more generalizable perspective of a population-based investigation.

PURPOSE

The purpose of this study was to examine nearly 3 decade long trends (1975-2003) in the evaluation of EF in patients admitted with confirmed AMI (n = 12,760) to all greater Worcester (Massachusetts) hospitals during 14 annual periods.

RESULTS

The percentage of patients undergoing evaluation of EF before hospital discharge increased substantially between 1975 (4%) and 2003 (73%). Despite these encouraging trends, approximately one quarter of patients in our most recent study year did not receive an EF evaluation. In the mid-1970s through mid-1980s, radionuclide ventriculography was typically used to assess EF, whereas echocardiography was most often used to evaluate EF during more recent periods. Predictors of not undergoing an evaluation of cardiac function included older age, shorter length of hospital stay, code status limitations, dying during hospitalization, Medicare insurance, several comorbidities, and a recent non-Q-wave myocardial infarction.

CONCLUSIONS

The results of this community-wide study suggest that a considerable proportion of patients with AMI fail to have their EF evaluated. Efforts remain needed to optimize the use of cardiac imaging studies and link the results of these studies to improved patient outcomes.

The Emergency Department presenting complaint as predictor of in-hospital fatality

BACKGROUND

The relationship between major discharge diagnoses and prediction of in-hospital death has been intensively studied. The relation between the presenting complaint at the Emergency Department (ED) and in-hospital fatality, however, is less well known.

OBJECTIVE

To investigate if presenting complaints add information regarding in-hospital fatality risk for nonsurgical ED patients.

METHODS

Investigating the relationship of in-hospital fatality rate and presenting complaint by comparing the presenting complaints, discharge diagnoses and in-hospital fatality for all nonsurgical patients visiting the ED during 1 year.

RESULTS

Of 12,995 nonsurgical admissions, 40% were treated as in-hospital patients. Among these, 328 in-hospital deaths occurred. Age was the most powerful predictor of death in hospitalized patients (P<0.0001). After adjustment for age, the female sex was found to be protective [odds ratio (OR) 0.73, 95% confidence interval (CI) 0.58-0.92, P=0.007)]. Compared with the largest complaint group, chest pain with an in-hospital fatality rate of 2.5%, there was a significantly increased risk of dying among those with stroke-like symptoms (OR 2.04, 95% CI 1.35-3.08, P=0.0007), dyspnoea (OR 1.95, 95% CI 1.27-3.00, P=0.002) or general disability (OR 1.81, 95% CI 1.17-2.79, P=0.008).

CONCLUSIONS

The presenting complaint at the ED carries valuable information of the risk for in-hospital fatality in nonsurgical patients. This knowledge can be valuable in the prioritization between different patient groups in the process of initiating diagnostics and treatment procedures at the ED.

Identifying the best treatment among common nonsurgical neck pain treatments: a decision analysis

STUDY DESIGN

Decision analysis.

OBJECTIVE

To identify the best treatment for nonspecific neck pain.

SUMMARY OF BACKGROUND DATA

In Canada and the United States, the most commonly prescribed neck pain treatments are nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, and manual therapy. Deciding which treatment is best is difficult because of the trade-offs between beneficial and harmful effects, and because of the uncertainty of these effects.

METHODS

(Quality-adjusted) life expectancy associated with standard NSAIDs, Cox-2 NSAIDs, exercise, mobilization, and manipulation were compared in a decision-analytic model. Estimates of the course of neck pain, background risk of adverse events in the general population, treatment effectiveness and risk, and patient-preferences were input into the model. Assuming equal effectiveness, we conducted a baseline analysis using risk of harm only. We assessed the stability of the baseline results by conducting a second analysis that incorporated effectiveness data from a high-quality randomized trial.

RESULTS

There were no important differences across treatments. The difference between the highest and lowest ranked treatments predicted by the baseline model was 4.5 days of life expectancy and 3.4 quality-adjusted life-days. The difference between the highest and lowest ranked treatments predicted by the second model was 7.3 quality-adjusted life-days.

CONCLUSION

When the objective is to maximize life expectancy and quality-adjusted life expectancy, none of the treatments in our analysis were clearly superior.

Long-term trends (1986-2003) in the use of coronary reperfusion strategies in patients hospitalized with acute myocardial infarction in central Massachusetts

BACKGROUND

The objectives of our study were to examine long-term (1986-2003) trends in the use of percutaneous coronary interventions (PCI) and thrombolytic therapy in the management of patients hospitalized at all Central Massachusetts medical centers with acute myocardial infarction (AMI). Our secondary study goal was to examine factors associated with use of these coronary reperfusion strategies. Limited contemporary data are available about changing trends in the use of coronary reperfusion strategies, particularly from a population-based perspective.

METHODS

The sample consisted of 9422 greater Worcester (MA) residents hospitalized with AMI at all metropolitan Worcester medical centers in 10 annual periods between 1986 and 2003.

RESULTS

Divergent trends in the use of PCI and thrombolytic therapy during hospitalization for AMI were noted. Use of thrombolytic therapy increased after its introduction to clinical practice in the mid-1980s through the early 1990s with a progressive decline in use thereafter. In 2003, 3.5% of patients hospitalized with AMI were treated with clot lysing therapy. Marked increases in the use of PCI during hospitalization for AMI were noted over time. In 2003, 42.1% of patients with AMI received a PCI. Several demographic and clinical factors were associated with the use of these different treatment strategies.

CONCLUSIONS

The results of our study in a large New England (United States) community suggest evolving changes in the hospital management of patients with AMI. Current management practices emphasize the utilization of PCI to restore coronary reperfusion to the infarct related artery.

Electrocardiographic findings at presentation, in relation to in-hospital mortality and 30-day outcome of patients with Acute Coronary Syndromes; The GREECS study

BACKGROUND

We sought to evaluate the impact of initial electrocardiographic findings at presentation on in-hospital mortality and 30-day outcome of patients with acute coronary syndromes (ACS).

METHODS

From October 2003 to September 2004, a sample of 6 hospitals located in several urban and rural Greek regions was selected, and almost all survivors 24 h after an admission for ACS were enrolled into the study (2172 patients were included in the study; 76% were men and 24% women). ECG and biochemical indices of myocardial damage were considered in all patients. Electrocardiographic findings at presentation were categorized as ST-elevation (STE), non-STE and non-diagnostic ECG abnormalities.

RESULTS

Of the 2172 patients, 34% had STE, 24% had non-STE and the 32% of them had non-diagnostic ECG abnormalities. After adjusting for age, sex and various other risk factors we observed that patients with STE had 3.3 (95% CI 1.4 to 7.7) higher risk of dying during hospitalization compared to those who had non-diagnostic ECG abnormalities. Furthermore, patients with non-STE had 1.5 (95% CI 0.9 to 2.5) higher risk of having an event (death or re-hospitalization due to CVD) during the first 30-days following discharge as compared to those who had non-diagnostic ECG abnormalities. All patients presented with non-STE ACS had higher 30-day event rates.

CONCLUSION

Patients with STE had higher in-hospital mortality, but lower longer term event rate after ACS in our population, irrespective of age, gender and other characteristics.

Coronary heart disease mortality among young adults in the U.S. from 1980 through 2002: concealed leveling of mortality rates

OBJECTIVES

The objective of our study was to examine age-specific mortality rates from coronary heart disease (CHD), particularly those among younger adults.

BACKGROUND

Trends for obesity, diabetes, blood pressure, and metabolic syndrome among young adults raise concerns about the mortality rates from CHD in this group.

METHODS

We used mortality data from 1980 to 2002 to calculate age-specific mortality rates from CHD for U.S. adults age > or =35 years.

RESULTS

Overall, the age-adjusted mortality rate decreased by 52% in men and 49% in women. Among women age 35 to 54 years, the estimated annual percentage change (EAPC) in mortality was -5.4% (95% confidence interval [CI] -5.8 to -4.9) from 1980 until 1989, -1.2% (95% CI -1.6 to -0.8) from 1989 until 2000, and 1.5% (95% CI -3.4 to 6.6) from 2000 until 2002. Among men age 35 to 54 years, the EAPC in mortality was -6.2% (95% CI -6.4 to -5.9) from 1980 until 1989, -2.3% (95% CI -2.6 to -2.1) from 1989 until 2000, and -0.5% (95% CI -3.7 to 2.9) from 2000 until 2002. Among women and men age > or =55 years, the estimated annual percentage decrease in mortality from CHD accelerated in more recent years compared with earlier periods.

CONCLUSIONS

The mortality rates for CHD among younger adults may serve as a sentinel event. Unfavorable trends in several risk factors for CHD provide a likely explanation for the observed mortality rates.