Sex and racial differences in the management of acute myocardial infarction, 1994 through 2002

Regionalization of ST-segment elevation acute coronary syndromes care: putting a national policy in proper perspective

A uniform policy for regionalization of ST-segment elevation myocardial infarction (STEMI) care raises several concerns. Transferring all STEMI patients to obtain primary percutaneous coronary intervention (PCI) may be less effective than transferring only high-risk STEMI patients. Delays in time to treatment >60 min associated with transferring patients for primary PCI may result in increased mortality for the average patient as compared with providing immediate fibrinolytic therapy at their initial hospital; yet more than 95% of patients transferred for primary PCI in the U.S. exceed this 60-min benchmark. Superior outcomes associated with treatment at higher-volume regional STEMI centers are inconsistent among centers, and there is no direct evidence that patients will benefit by a transfer to a high-volume hospital from a low-volume hospital. Published data suggest as many as 800 PCI patients would need to be transferred to a high-volume PCI hospital to avoid a single death at a low-volume PCI hospital. Although European randomized trial data suggest transferring patients with STEMI for primary PCI may be superior to immediate fibrinolytic therapy, these findings are unlikely to generalize to the U.S. health care system given size, geography, and organization. ST segment elevation myocardial infarction care regionalization would require a massive redistribution of health care resources, depriving several hospitals of advanced cardiac care facilities, expertise, and associated revenue. Clearer evidence of the benefits and discussion of potential harms are needed before adopting a national STEMI regionalization policy.

Temporal trends in the utilization of diagnostic testing and treatments for cardiovascular disease in the United States, 1993-2001

BACKGROUND

Rates of invasive testing and treatment for coronary artery disease have increased over time. Less is known about trends in the utilization of noninvasive cardiac testing for coronary artery disease. The objective of this study was 2-fold: to explore temporal trends in the utilization of noninvasive and invasive cardiac services in relation to changes in the prevalence of cardiac disease, and to examine whether temporal increases have been targeted to potentially underserved populations.

METHODS AND RESULTS

We performed an annual cross-sectional population-based study of Medicare patients from 1993 to 2001. We identified stress testing, cardiac catheterization, and revascularization procedures, as well as hospitalizations for acute myocardial infarction, during each year and calculated population-based rates for each using the total fee-for-service Medicare population as the denominator and adjusting for age, gender, and race. We observed marked growth in the utilization rates of cardiac services over time, with relative rates nearly doubling for most services. Acute myocardial infarction hospitalization rates have remained stable over the study period. Although rates of all procedures except coronary artery bypass increased in all subgroups, differences in rates of cardiac testing and treatment between nonblack men and other subgroups persisted over time.

CONCLUSIONS

Temporal increases in the use of noninvasive and invasive cardiac services are not explained by changes in disease prevalence and have not succeeded in narrowing preexisting treatment differences by gender and race. Such increases, although conferring benefit for some, may expose others to risk and cost without benefit.

Legal regulation of the use of race in medical research

In this article, we discuss current legal restrictions governing the use of race in medical research. In particular, we focus on whether the use of race in various types of research is presently permitted under federal law and the federal constitution. We also discuss whether federal restrictions on the use of race in research ought to be expanded, and whether federal policies that encourage the use of race ought to be abandoned.

Are we 'WISE'r? Findings from the NHLBI-sponsored Women's Ischemia Syndrome Evaluation study

Recognition of cardiovascular disease as the leading healthcare threat to women continues to shape the prioritization of efforts to more effectively diagnose and treat heart disease in women. At its inception almost 8 years ago, the National Heart, Lung and Blood Institute in the USA sponsored the Women's Ischemia Syndrome Evaluation (WISE) study, aiming to optimize symptom evaluation and diagnostic testing for ischemic heart disease in women and to explore pathophysiologic mechanisms for symptoms and myocardial ischemia in the absence of epicardial coronary artery stenosis. The WISE study has investigated the spectrum of anginal symptoms, diagnostic strategies for micro- and macrovascular coronary disease, and the role of psychosocial variables and reproductive hormones in ischemic heart-disease presentation. One of the pivotal WISE findings sheds light on chest pain in the absence of significant obstructive epicardial luminal coronary stenosis, otherwise known as Cardiac Syndrome X. In the WISE study, using coronary vasomotor testing during angiography, investigators observed prevalent abnormalities in coronary flow reserve, suggestive of microvascular coronary dysfunction in relation to adverse morbidity and mortality among these women. Findings such as these from the WISE study have significantly added to the current management approach to heart disease in women.

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