1
|
Chumsantivut S, Lertmaharit S, Rattananupong T, Lertsuwunseri V, Athisakul S, Wanlapakorn C, Srimahachota S. Mortality rate of percutaneous coronary interventions in ST-segment elevation myocardial infarction patients under the public health insurance schemes of Thailand. Front Cardiovasc Med 2024; 11:1397015. [PMID: 39429758 PMCID: PMC11486745 DOI: 10.3389/fcvm.2024.1397015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/07/2024] [Indexed: 10/22/2024] Open
Abstract
Background In Thailand, access to specific pharmaceuticals and medical devices for ST-elevation myocardial infarction (STEMI) patients is restricted within certain healthcare systems, leading to inequalities in the quality of medical care among different healthcare systems. This study aims to compare mortality rates within one year of STEMI patients among the public health insurance schemes of Thailand. Methodology This study is a single-center retrospective analysis of patients with STEMI treated with primary percutaneous coronary intervention (pPCI). It involves patients utilizing various state health insurance schemes in Thailand from January 1, 2010, to December 31, 2020. Data collection occurred through the hospital's computerized management system and the registration administration office of the Department of Provincial Administration. Results The study involved 1,077 patients, categorized into three groups based on their state health insurance: Universal Health Coverage (UC) (546 patients, 50.7%), Social Security System (SS) (199 patients, 18.5%), and Civil Service Reimbursement (CS) (332 patients, 30.8%). The one-year mortality rates in these groups were 10.57%, 4.21%, and 6.47%, respectively (p = 0.010). In the unadjusted model, the SS group showed a lower risk of one-year mortality [Hazard Ratio (HR) 0.38, 95% CI 0.18-0.80, p = 0.011], and the CS group also demonstrated a lower risk (HR 0.59, 95% CI 0.35-0.99, p = 0.047) compared to the UC group. In the adjusted model, only the CS group significantly reduced the risk of one-year mortality. Other factors that affected one-year mortality were age ≥65 years, prior coronary artery diseases, Killip class 3-4, pre-discharge prescription of angiotensin-converting enzyme inhibitors, occlusion in the left anterior descending artery, multivessel disease, in-hospital atrial fibrillation/flutter and in-hospital pericardial effusion. Conclusion Healthcare schemes play a significant role in influencing one-year mortality rates among STEMI patients treated with pPCI. This information would be crucial for developing strategies and programs to aid healthcare policymakers at both regional and international levels in reducing morbidity and mortality.
Collapse
Affiliation(s)
- Suppavit Chumsantivut
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somrat Lertmaharit
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Thanapoom Rattananupong
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Vorarit Lertsuwunseri
- Cardiac Center and Division of Cardiovascular Disease, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Siriporn Athisakul
- Cardiac Center and Division of Cardiovascular Disease, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Chaisiri Wanlapakorn
- Cardiac Center and Division of Cardiovascular Disease, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| | - Suphot Srimahachota
- Cardiac Center and Division of Cardiovascular Disease, Department of Medicine, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
| |
Collapse
|
2
|
|
3
|
Shara N, Yassin SA, Valaitis E, Wang H, Howard BV, Wang W, Lee ET, Umans JG. Randomly and Non-Randomly Missing Renal Function Data in the Strong Heart Study: A Comparison of Imputation Methods. PLoS One 2015; 10:e0138923. [PMID: 26414328 PMCID: PMC4587557 DOI: 10.1371/journal.pone.0138923] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2015] [Accepted: 09/04/2015] [Indexed: 01/19/2023] Open
Abstract
Kidney and cardiovascular disease are widespread among populations with high prevalence of diabetes, such as American Indians participating in the Strong Heart Study (SHS). Studying these conditions simultaneously in longitudinal studies is challenging, because the morbidity and mortality associated with these diseases result in missing data, and these data are likely not missing at random. When such data are merely excluded, study findings may be compromised. In this article, a subset of 2264 participants with complete renal function data from Strong Heart Exams 1 (1989-1991), 2 (1993-1995), and 3 (1998-1999) was used to examine the performance of five methods used to impute missing data: listwise deletion, mean of serial measures, adjacent value, multiple imputation, and pattern-mixture. Three missing at random models and one non-missing at random model were used to compare the performance of the imputation techniques on randomly and non-randomly missing data. The pattern-mixture method was found to perform best for imputing renal function data that were not missing at random. Determining whether data are missing at random or not can help in choosing the imputation method that will provide the most accurate results.
Collapse
Affiliation(s)
- Nawar Shara
- MedStar Health Research Institute, Hyattsville, Maryland, United States of America
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia, United States of America
- * E-mail:
| | - Sayf A. Yassin
- MedStar Health Research Institute, Hyattsville, Maryland, United States of America
| | - Eduardas Valaitis
- Department of Mathematics and Statistics, American University, Washington, District of Columbia, United States of America
| | - Hong Wang
- MedStar Health Research Institute, Hyattsville, Maryland, United States of America
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia, United States of America
| | - Barbara V. Howard
- MedStar Health Research Institute, Hyattsville, Maryland, United States of America
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia, United States of America
| | - Wenyu Wang
- College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma, United States of America
| | - Elisa T. Lee
- College of Public Health, University of Oklahoma, Oklahoma City, Oklahoma, United States of America
| | - Jason G. Umans
- MedStar Health Research Institute, Hyattsville, Maryland, United States of America
- Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, District of Columbia, United States of America
| |
Collapse
|
4
|
McAllister DA, Halbesma N, Carruthers K, Denvir M, Fox KA. GRACE score predicts heart failure admission following acute coronary syndrome. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2014; 4:165-71. [PMID: 24986419 DOI: 10.1177/2048872614542724] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Congestive heart failure (CHF) is a common and preventable complication of acute coronary syndrome (ACS). Nevertheless, ACS risk scores have not been shown to predict CHF risk. We investigated whether the at-discharge Global Registry of Acute Coronary Events (GRACE) score predicts heart failure admission following ACS. METHODS AND RESULTS Five-year mortality and hospitalization data were obtained for patients admitted with ACS from June 1999 to September 2009 to a single centre of the GRACE registry. CHF was defined as any admission assigned WHO International Classification of Diseases 10 diagnostic code I50. The hazard ratio (HR) for CHF according to GRACE score was estimated in Cox models adjusting for age, gender and the presence of CHF on index admission. Among 1,956 patients, CHF was recorded on index admission in 141 patients (7%), and 243 (12%) were admitted with CHF over 3.8 median years of follow-up. Compared to the lowest quintile, patients in the highest GRACE score quintile had more CHF admissions (116 vs 17) and a shorter time to first admission (1.2 vs 2.0 years, HR 9.87, 95% CI 5.93-16.43). Per standard deviation increment in GRACE score, the instantaneous risk was more than two-fold higher (HR 2.28; 95% CI 2.02-2.57), including after adjustment for CHF on index admission, age and gender (HR 2.49; 95% CI 2.06-3.02). The C-statistic for CHF admission at 1-year was 0.74 (95% CI 0.70-0.79). CONCLUSIONS The GRACE score predicts CHF admission, and may therefore be used to target ACS patients at high risk of CHF with clinical monitoring and therapies.
Collapse
Affiliation(s)
| | - Nynke Halbesma
- Centre for Population Health Sciences, University of Edinburgh, UK
| | | | - Martin Denvir
- Centre for Cardiovascular Science, University of Edinburgh, UK
| | - Keith A Fox
- Centre for Cardiovascular Science, University of Edinburgh, UK
| |
Collapse
|
5
|
Allahwala UK, Murphy JC, Nelson GIC, Bhindi R. Absence of a 'smoker's paradox' in field triaged ST-elevation myocardial infarction patients undergoing percutaneous coronary intervention. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 14:213-7. [PMID: 23856073 DOI: 10.1016/j.carrev.2013.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 05/25/2013] [Accepted: 06/03/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE The 'smoker's paradox' refers to the observation of favorable prognosis in current smokers following an acute myocardial infarction (AMI). Initial positive findings were in the era of fibrinolysis, with more contemporary studies finding conflicting results. We sought to determine the presence of a 'smoker's paradox' in a cohort of ST Elevation Myocardial Infarction (STEMI) patients identified via field triage, treated with primary percutaneous coronary intervention (pPCI). METHODS This was a single center retrospective cohort study identifying consecutive STEMI patients presenting for pPCI via field triage. The primary end points were all cause mortality, major adverse cardiac events (MACE), major bleeding, in-hospital cardiac arrest and length of stay (LOS). RESULTS A total of 382 patients were included in the study. Current smokers were more likely to be younger (p<0.00001), male (p<0.001) and have fewer comorbidities, including renal impairment (p<0.01) and a history of AMI (p<0.05). Current smokers also had a shorter ischemic time (p<0.05), were less likely to have collateral circulation (p<0.05), and more likely to have signs of pulmonary edema at presentation (p<0.05). There was no difference between smoking groups and all cause mortality (p=0.67), MACE (p=0.49), major bleeding (p=0.49) or in-hospital cardiac arrest (p=0.43). Current smokers had a shorter LOS (p<0.05). In multivariate analysis smoking status did not correlate with primary outcomes. CONCLUSION The 'smoker's paradox' does not appear to be relevant among STEMI patients undergoing pPCI, identified via field triage. The previously documented 'smoker's paradox' may have been an indication of patient characteristics and the historical treatment of STEMI with thrombolysis. Further studies with larger numbers may be warranted.
Collapse
Affiliation(s)
- Usaid K Allahwala
- Department of Cardiology, Royal North Shore Hospital, Sydney, Australia.
| | | | | | | |
Collapse
|
6
|
Lin Y, Pan W, Ning S, Song X, Jin Z, Lv S. Prevalence and management of hypertension in patients with acute coronary syndrome vary with gender: Observations from the Chinese registry of acute coronary events (CRACE). Mol Med Rep 2013; 8:173-7. [PMID: 23657820 DOI: 10.3892/mmr.2013.1461] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2012] [Accepted: 03/13/2013] [Indexed: 11/05/2022] Open
Abstract
Hypertension affects one billion people worldwide and is an independent risk factor for death after acute coronary syndrome (ACS). The aim of this study was to examine the prevalence and medical treatment of hypertension among 1,301 ACS patients enrolled into the Chinese registry of acute coronary events (CRACE) trial. Analyses were performed by gender, with both genders combined and according to international practice. Multivariable models identified factors associated with use of different classes of antihypertensive medication, and examined the correlation between hypertension and gender with mortality. The use of angiotensin‑converting enzyme inhibitors (ACEI), β-blockers, calcium channel blockers (CCBs) and diuretics increased in both genders during management of presenting ACS. Hypertensive men were more likely to have been receiving β-blockers when they were discharged (77.2%) than women (69.2%). Hypertensive women were more likely to have received diuretics when they were discharged (28.4%) than men (22%). ACEI use increased by ~60% (absolute increase) in both women and men as a result of ACS treatment, but remained similar between the genders, and the same phenomenon was observed in the use of CCBs. Moreover, hypertensive women were less likely to receive evidence‑based medication to treat their acute coronary event than men (for women and men, respectively: β-blocker, 69.2 vs. 77.2%; ACEI, 85.8 vs. 87.5%). Hypertension is more prevalent in women than in men with ACS, and its medical management varies with gender, but it has a similar association with mortality in both genders. Opportunities exist to improve medical therapy and outcomes for women with hypertension.
Collapse
Affiliation(s)
- Yun Lin
- Department of Cardiology, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing 100029, PR China
| | | | | | | | | | | |
Collapse
|
7
|
Influence of 23 coronary artery disease variants on recurrent myocardial infarction or cardiac death: the GRACE Genetics Study. Eur Heart J 2012; 34:993-1001. [DOI: 10.1093/eurheartj/ehs389] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
|
8
|
Chia CC, Rubinfeld I, Scirica BM, McMillan S, Gurm HS, Syed Z. Looking Beyond Historical Patient Outcomes to Improve Clinical Models. Sci Transl Med 2012; 4:131ra49. [DOI: 10.1126/scitranslmed.3003561] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
|
9
|
Management of acute coronary syndromes in developing countries: acute coronary events-a multinational survey of current management strategies. Am Heart J 2011; 162:852-859.e22. [PMID: 22093201 DOI: 10.1016/j.ahj.2011.07.029] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 07/21/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND The burden of cardiovascular diseases is predicted to escalate in developing countries. We investigated the descriptive epidemiology, practice patterns, and outcomes of patients hospitalized with acute coronary syndromes (ACS) in African, Latin American, and Middle Eastern countries. METHODS In this prospective observational registry, 12,068 adults hospitalized with a diagnosis of ACS were enrolled between January 2007 and January 2008 at 134 sites in 19 countries in Africa, Latin America, and the Middle East. Data on patient characteristics, treatment, and outcomes were collected. RESULTS A total of 11,731 patients with confirmed ACS were enrolled (46% with ST-elevation myocardial infarction [STEMI], 54% with non-ST elevation-ACS). During hospitalization, most patients received aspirin (93%) and a lipid-lowering medication (94%), 78% received a β-blocker, and 68% received an angiotensin-converting enzyme inhibitor. Among patients with STEMI, 39% did not receive fibrinolysis or undergo percutaneous coronary intervention. All-cause death at 12 months was 7.3% and was higher in patients with STEMI versus non-ST elevation-ACS (8.4% vs 6.3%, P < .0001). Clinical factors associated with higher risk of death at 12 months included cardiac arrest, antithrombin treatment, cardiogenic shock, and age >70 years. CONCLUSIONS In this observational study of patients with ACS, the use of evidence-based pharmacologic therapies for ACS was quite high, yet 39% of eligible patients with STEMI received no reperfusion therapy. These findings suggest opportunities to further reduce the risk of long-term ischemic events in patients with ACS in developing countries.
Collapse
|
10
|
Yan Y, Liao Y, Yang L, Wu J, Du J, Xuan W, Ji L, Huang Q, Liu Y, Bin J. Late-phase detection of recent myocardial ischaemia using ultrasound molecular imaging targeted to intercellular adhesion molecule-1. Cardiovasc Res 2010; 89:175-83. [PMID: 20733010 DOI: 10.1093/cvr/cvq269] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
AIMS in this study, we attempted to detect a recent myocardial ischaemic event using ultrasound molecular imaging (UMI) with microbubbles (MB) targeted to intercellular adhesion molecule-1 (ICAM-1) in the late phase of reperfusion. METHODS AND RESULTS we created a myocardial ischaemia-reperfusion model in 60 C57/BL male mice to simulate an angina attack (ischaemia for 15 min, reperfusion for 1-24 h). The degree of myocardial inflammation and levels of ICAM-1 protein were determined by histological and immunohistochemical analyses. UMI with MB targeted to endothelial ICAM-1, as well as routine non-invasive methods including electrocardiography, echocardiography, and plasma troponin I levels, were utilized to evaluate ischaemia over the time course of reperfusion. Levels of ICAM-1 in the vascular endothelium were significantly increased over the time course of reperfusion (8-24 h) of the ischaemic myocardium. The video intensity of ICAM-1 molecular images of the ischaemic anterior wall was almost three times greater than that in the non-ischaemic posterior wall during the late phase (8-24 h) of reperfusion. In contrast, routine methods yielded only weak evidence of ischaemia. CONCLUSION UMI with MB targeted to endothelial ICAM-1 provides reliable evidence of a recent myocardial ischaemic event in the late phase of reperfusion.
Collapse
Affiliation(s)
- Yi Yan
- Department of Cardiology, Nanfang Hospital, Southern Medical University, 1838 North Guangzhou Avenue, Guangzhou 510515, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Cabrerizo García JL, Zalba Etayo B, Pérez Calvo JI. Valor pronóstico del filtrado glomerular en el síndrome coronario agudo: ¿índice de Cockcroft o ecuación MDRD? Med Clin (Barc) 2010; 134:624-9. [DOI: 10.1016/j.medcli.2009.09.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2009] [Revised: 09/16/2009] [Accepted: 09/17/2009] [Indexed: 11/25/2022]
|
12
|
Buysschaert I, Carruthers KF, Dunbar DR, Peuteman G, Rietzschel E, Belmans A, Hedley A, De Meyer T, Budaj A, Van de Werf F, Lambrechts D, Fox KAA. A variant at chromosome 9p21 is associated with recurrent myocardial infarction and cardiac death after acute coronary syndrome: the GRACE Genetics Study. Eur Heart J 2010; 31:1132-41. [PMID: 20231156 DOI: 10.1093/eurheartj/ehq053] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
AIMS Recent genetic studies identified the rs1333049 variant on chromosome 9p21 as a major susceptibility locus for coronary artery disease and myocardial infarction (MI). Here, we evaluated whether this variant also contributes to recurrent MI or cardiac death following an acute coronary syndrome (ACS). METHODS AND RESULTS A total of 3247 patients with ACS enrolled in the Global Registry of Acute Coronary Events (GRACE) in three distinct populations (UK, Belgium and Poland) were prospectively followed for 6 months and genotyped for rs1333049, in addition to 3004 and 2467 healthy controls from the UK and Belgium. After having confirmed that the at-risk C allele of rs1333049 was associated with index ACS in the UK and Belgian populations, we found that the rs1333049 at-risk C allele was significantly and independently associated with recurrent MI [age- and gender-adjusted hazard ratio (HR) 1.48, CI = 1.00-2.19, P = 0.048; and multivariable-adjusted HR 1.47, CI = 0.99-2.18; P = 0.053] and with recurrent MI or cardiac death (age- and gender-adjusted HR 1.58, CI = 1.00-2.48; P = 0.045; and multivariable adjusted HR 1.49, CI = 1.03-1.98; P = 0.028) within 6 months after an index ACS. Inclusion of rs1333049 into the GRACE risk score significantly improved classification for recurrent MI or cardiac death (P = 0.040), as calculated by the integrated discrimination improvement method. CONCLUSION In this large observational study, the 9p21 variant was independently associated with adverse cardiac outcome after ACS.
Collapse
Affiliation(s)
- Ian Buysschaert
- Vesalius Research Center, VIB and KULeuven, Campus Gasthuisberg, Herestraat 49, Box 912, B-3000 Leuven, Belgium
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Valeur N, Clemmensen P, Grande P, Saunamäki K. Prognostic evaluation by clinical exercise test scores in patients treated with primary percutaneous coronary intervention or fibrinolysis for acute myocardial infarction (a Danish Trial in Acute Myocardial Infarction-2 Sub-Study). Am J Cardiol 2007; 100:1074-80. [PMID: 17884364 DOI: 10.1016/j.amjcard.2007.05.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 05/01/2007] [Accepted: 05/01/2007] [Indexed: 10/23/2022]
Abstract
The prognostic accuracy of exercise testing after myocardial infarction is low, and different models have been proposed to enhance the predictive value for subsequent mortality. This study tested a simple score against 3 established scores. Patients with ST-elevation myocardial infarctions were randomized in the Danish Trial in Acute Myocardial Infarction-2 (DANAMI-2) to either primary percutaneous coronary intervention or fibrinolysis with predischarge exercise testing. Clinical and exercise test data were collected prospectively and were available for 1,115 patients. A simple score was derived, awarding 1 point for history or new signs of heart failure, 1 point for a left ventricular ejection fraction <40%, 1 point for age >65 years in men and age >70 years in women, and 1 point for exercise capacity <5 METs in men and exercise capacity <4 METs in women. This DANAMI score was compared with the Veterans Affairs Medical Center score, the Duke treadmill score, and the Gruppo Italiano per lo Studio Della Sopravvivenza nell'Infarto Miocardico-2 (GISSI-2) score in multivariate Cox models and receiver-operating characteristic plots. All scoring systems were predictive of adverse outcomes. The DANAMI score performed better, with greater chi-square values (142 vs 53 to 88 for the prediction of death). Areas under the receiver-operating characteristic curves were compared and were larger for the DANAMI score (C-statistic 0.79 vs 0.71 to 0.74 for the other tests regarding mortality). The DANAMI score stratified patients into a small high-risk group (8% of the population with 43% mortality in 6 years), an intermediate-risk group (13% with 16% mortality in 6 years), and a low-risk group (79% with 4% mortality in 6 years). In conclusion, a simple exercise test score composed of age, METs, heart failure, and a left ventricular ejection fraction <40% seems to outperform the Duke treadmill score, Veterans Affairs Medical Center score, and GISSI-2 score in risk stratifying patients after myocardial infarction and deserves further evaluation.
Collapse
Affiliation(s)
- Nana Valeur
- Department of Cardiology, The Heart Center, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | | |
Collapse
|
14
|
Wong CK, Newby LK, Bhapker MV, Aylward PE, Pfisterer M, Alexander KP, Armstrong PW, Hochman JS, Van de Werf F, Califf RM, White HD. Use of evidence-based medicine for acute coronary syndromes in the elderly and very elderly: insights from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes trials. Am Heart J 2007; 154:313-21. [PMID: 17643582 DOI: 10.1016/j.ahj.2007.04.031] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2007] [Accepted: 04/16/2007] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence-based medications (EBM) are underused in older patients despite potentially larger absolute benefits. Little is known about factors influencing prescribing in the elderly with acute coronary syndromes. METHODS Among the 15,904 patients from the Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) and second SYMPHONY trials, we examined the rates of use of EBM according to age (< 75 or > or = 75 years, and 3 subgroups of 5 year increments among patients > or = 75 years). RESULTS Ninety-day mortality increased with age (< 75 years, 1.3%; > or = 75 to < 80 years, 4.4%; > or = 80 to < 85 years, 6.0%; > or = 85 years, 9.6%). Compared with subjects < 75 years (n = 14,043), acute EBM use was lower among patients > or = 75 years (n = 1794): aspirin (83% vs 85%), heparin (73% vs 78%), and beta-blockers (70% vs 76%). Similarly, discharge use of beta-blockers (69% vs 76%) and statins (28% vs 40%) was lower, although this was not the case for angiotensin-converting enzyme inhibitors (44% vs 41%). These patterns persisted among eligible patients. Beyond the age of 75 years, EBM use was not further influenced by age except for statins and angiotensin-converting enzyme inhibitors, which were used less frequently in those > or = 85 years. Among patients aged > or = 75 years, prediction for use of each EBM in multivariable modeling was modest (C indices, approximately 0.7); except for statins, increasing age did not predict lower EBM use. CONCLUSIONS Despite higher mortality risk, EBM use was lower among older patients even considering eligibility. Among those aged > or = 75 years, age was no longer the major factor predicting EBM use. The modest C indices suggest other factors are associated with prescribing, underscoring the need for treatment algorithms and quality assurance measures in older patients.
Collapse
Affiliation(s)
- Cheuk-Kit Wong
- Cardiology, Dunedin School of Medicine, Otago University, Dunedin, New Zealand
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
15
|
Carda Barrio R, de Agustín JA, Manzano MC, García-Rubira JC, Fernández-Ortiz A, Vilacosta I, Macaya C. Valor pronóstico intrahospitalario del filtrado glomerular en pacientes con síndrome coronario agudo y creatinina normal. Rev Esp Cardiol 2007. [DOI: 10.1157/13108276] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
16
|
Shara NM, Umans JG, Wang W, Howard BV, Resnick HE. Assessing the impact of different imputation methods on serial measures of renal function: the Strong Heart Study. Kidney Int 2007; 71:701-5. [PMID: 17264875 DOI: 10.1038/sj.ki.5002105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Missing data are a common problem in epidemiologic studies. This study had two aims: (a) to determine which method for imputing missing renal function data provides estimates closest to those made with complete data and (b) to determine which measure of renal function better estimates cardiovascular disease (CVD) risk. For these analyses, a subset of Strong Heart Study participants with complete data for renal function was identified. Data were randomly dropped from this complete set at three rates: 30, 45, and 60%. Five common techniques for handling missing data were compared: imputation using the mean, adjacent value (AV), single imputation, multiple imputation, and listwise deletion. Differences between the imputed sets and the complete set were determined for each method. Imputation methods were used to fill in missing values for serum creatinine (Scr) in one model and estimated glomerular filtration rate (eGFR) in another. For both Scr and eGFR, the AV method provided the most favorable results in predicting CVD risk, regardless of the rate of missing data.
Collapse
Affiliation(s)
- N M Shara
- Department of Epidemiology and Statistics, MedStar Research Institute, Hyattsville, Maryland, USA.
| | | | | | | | | |
Collapse
|
17
|
Archbold RA, Balami D, Al-Hajiri A, Suliman A, Liew R, Cooper J, Ranjadayalan K, Knight CJ, Deaner A, Timmis AD. Hemoglobin concentration is an independent determinant of heart failure in acute coronary syndromes: cohort analysis of 2310 patients. Am Heart J 2006; 152:1091-5. [PMID: 17161058 DOI: 10.1016/j.ahj.2006.07.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2006] [Accepted: 07/27/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND Anemia is an important determinant of heart failure and death after ST elevation myocardial infarction (STEMI). The frequency of anemia and its impact on these outcomes across the range of acute coronary syndromes (ACS), however, have not been defined. METHODS This is a cohort study of 2310 patients with ACS stratified by quartiles of admission hemoglobin concentration [Hb]): Q1, <12.5 g/dL; Q2, 12.5-13.6 g/dL; Q3, 13.7-14.7 g/dL; Q4, >14.7 g/dL. RESULTS There were 29.7% of women and 23.2% of men who were anemic. Rates of STEMI increased across [Hb] quartile groups from 25.0% (Q1) to 35.5% (Q4) as rates of unstable angina decreased from 52.0% (Q1) to 40.7% (Q4) (P < .0005). Despite this, rates of left ventricular failure (LVF) were inversely related to [Hb] in all diagnostic groups, patients with unstable angina (Q1, 14.2%; Q4, 4.4%; P < .0005) showing a similar trend to patients with non-STEMI (Q1, 26.8%; Q4, 10.4%; P < .0005) and STEMI (Q1, 33.8%; Q4, 20.6%; P < .0005). The age-adjusted odds of LVF in Q4 compared with Q1 were 0.64 (95% confidence interval, 0.45-0.90). Inhospital cardiac mortality was 3.0% and was not influenced by [Hb]. CONCLUSIONS Anemia is a common comorbidity in patients presenting with ACS, and it is a powerful independent determinant of LVF. The association with LVF occurs not only in STEMI but also in less severe diagnostic groups.
Collapse
Affiliation(s)
- R Andrew Archbold
- Department of Cardiology, Newham University Hospital, London, United Kingdom.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Fox KAA, Dabbous OH, Goldberg RJ, Pieper KS, Eagle KA, Van de Werf F, Avezum A, Goodman SG, Flather MD, Anderson FA, Granger CB. Prediction of risk of death and myocardial infarction in the six months after presentation with acute coronary syndrome: prospective multinational observational study (GRACE). BMJ 2006; 333:1091. [PMID: 17032691 PMCID: PMC1661748 DOI: 10.1136/bmj.38985.646481.55] [Citation(s) in RCA: 1027] [Impact Index Per Article: 57.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To develop a clinical risk prediction tool for estimating the cumulative six month risk of death and death or myocardial infarction to facilitate triage and management of patients with acute coronary syndrome. DESIGN Prospective multinational observational study in which we used multivariable regression to develop a final predictive model, with prospective and external validation. SETTING Ninety four hospitals in 14 countries in Europe, North and South America, Australia, and New Zealand. POPULATION 43,810 patients (21,688 in derivation set; 22,122 in validation set) presenting with acute coronary syndrome with or without ST segment elevation enrolled in the global registry of acute coronary events (GRACE) study between April 1999 and September 2005. MAIN OUTCOME MEASURES Death and myocardial infarction. RESULTS 1989 patients died in hospital, 1466 died between discharge and six month follow-up, and 2793 sustained a new non-fatal myocardial infarction. Nine factors independently predicted death and the combined end point of death or myocardial infarction in the period from admission to six months after discharge: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST segment deviation. The simplified model was robust, with prospectively validated C-statistics of 0.81 for predicting death and 0.73 for death or myocardial infarction from admission to six months after discharge. The external applicability of the model was validated in the dataset from GUSTO IIb (global use of strategies to open occluded coronary arteries). CONCLUSIONS This risk prediction tool uses readily identifiable variables to provide robust prediction of the cumulative six month risk of death or myocardial infarction. It is a rapid and widely applicable method for assessing cardiovascular risk to complement clinical assessment and can guide patient triage and management across the spectrum of patients with acute coronary syndrome.
Collapse
Affiliation(s)
- Keith A A Fox
- Royal Infirmary of Edinburgh, University of Edinburgh, Edinburgh EH16 4SB.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Shibata MC, Collinson J, Taneja AK, Bakhai A, Flather MD. Long term prognosis of heart failure after acute coronary syndromes without ST elevation. Postgrad Med J 2006; 82:55-9. [PMID: 16397082 PMCID: PMC2563714 DOI: 10.1136/pgmj.2005.035766] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Information about long term outcomes of patients with acute coronary syndromes (ACS) who have clinically diagnosed heart failure is scarce. METHODS In a UK registry, this study evaluated patients with non-ST elevation ACS, recording treatment, and clinical outcomes for six months. In a subgroup, a four year mortality follow up was performed to estimate the impact of the clinical diagnosis of heart failure on survival. RESULTS Of 1046 patients, 139 (13%) had a history of clinically diagnosed heart failure. At discharge, ACE inhibitors were prescribed for 58% and 28%, of those with and without a history of heart failure respectively (p<0.001). Rates of angiography, percutaneous intervention, and coronary artery bypass graft were 17.3% and 29.2% (p = 0.003), 5.0% and 8.4% (p = 0.17), and 5.0% and 7.5% (p = 0.3) for these groups respectively. Death or new myocardial infarction at six months occurred in 22% and 10% (p<0.001) and at four years death occurred in 60% and 20% of these groups respectively (p<0.001). In a multivariate analysis prior heart failure carried an odds ratio of 2.0 (p = 0.001) for death or myocardial infarction at six months and 2.4 (p<0.001) for death over four years. New heart failure was associated with an increased risk of death at six months (20% compared with 5%, p<0.001). CONCLUSION A clinical history of heart failure carries a substantial risk of death in patients admitted with ACS without ST elevation. Nearly 60% of those with prior heart failure are dead after four years. After adjustment for confounding factors, prior heart failure more than doubles the risk compared with those with no history.
Collapse
Affiliation(s)
- M C Shibata
- Clinical Trials and Evaluation Unit, Royal Brompton Hospital, London, UK
| | | | | | | | | |
Collapse
|
20
|
Rosengren A, Wallentin L, Simoons M, Gitt AK, Behar S, Battler A, Hasdai D. Age, clinical presentation, and outcome of acute coronary syndromes in the Euroheart acute coronary syndrome survey. Eur Heart J 2006; 27:789-95. [PMID: 16464911 DOI: 10.1093/eurheartj/ehi774] [Citation(s) in RCA: 208] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIMS Age is one of the most powerful determinants of prognosis in myocardial infarction, but there is comparatively little recent data across the whole spectrum of acute coronary syndromes (ACS). We examined the impact of increasing age on clinical presentation and hospital outcome in a large sample of patients with ACS. METHODS AND RESULTS Patients (n = 10 253) from the Euroheart ACS survey in 103 hospitals in 25 countries were investigated. There was a significant inverse association between the age and the likelihood of presenting with ST-elevation. For each decade of life, the odds of presenting with ST-elevation decreased by 0.82 [95% confidence interval (CI) 0.79-0.84]; P < 0.0001. Elderly patients were considerably less often treated by cardiologists, less extensively investigated, and, when presenting with ST-elevation ACS, less likely to be treated with reperfusion. Compared with patients <55 years, the odds ratios of hospital mortality were 1.87 (1.21-2.88) at age 55-64, 3.70 (2.51-5.44) at age 65-74, 6.23 (4.25-9.14) at age 75-84, and 14.5 (9.47-22.1) among patients > or =85 years, with no major differences across different types of admission or discharge diagnoses. CONCLUSION Elderly ACS patients were less likely to present with ST-elevation but had substantial in-hospital mortality, yet they were markedly less intensively treated and investigated.
Collapse
Affiliation(s)
- Annika Rosengren
- Department of Medicine, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden.
| | | | | | | | | | | | | |
Collapse
|
21
|
Soiza RL, Leslie SJ, Harrild K, Peden NR, Hargreaves AD. Age-dependent differences in presentation, risk factor profile, and outcome of suspected acute coronary syndrome. J Am Geriatr Soc 2006; 53:1961-5. [PMID: 16274379 DOI: 10.1111/j.1532-5415.2005.53573.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVES To compare the presenting complaint, risk factors, and outcome of suspected acute coronary syndrome (ACS) in those aged 65 and older with those of a younger cohort. DESIGN Prospective observational cohort study. SETTING A typical Scottish district general hospital covering a population of 150,000. PARTICIPANTS Patients presenting with suspected ACS (N=869) over a 6-month period. MEASUREMENTS Main presenting complaint and major risk factors including electrocardiogram (ECG) changes. Primary outcome measures were percutaneous coronary intervention, recurrent myocardial infarction, and death at 3-month follow-up. RESULTS Four hundred seventy-seven (55%) were aged 65 and older. Older patients were less likely to present with chest pain and more likely to present with breathlessness or collapse. They had fewer major risk factors for heart disease. There was a higher proportion with ischemic ECG changes, elevated troponin, and major acute coronary events at follow-up. Older patients were less likely to be accepted for angiography even though they were more likely than the younger cohort to have significant coronary artery disease when angiography was performed (chi-square test, P<.01 for all above). CONCLUSION Older patients with suspected ACS were more likely to present atypically and have worse outcomes than their younger counterparts, despite having fewer major risk factors. The results highlight the importance of age as a predictor of adverse outcome and suggest that clinicians need to ensure equitable access to angiography for older patients.
Collapse
Affiliation(s)
- Roy L Soiza
- Department of Medicine for the Elderly, Woodend Hospital, Aberdeen, United Kingdom.
| | | | | | | | | |
Collapse
|
22
|
Frazier CG, Shah SH, Armstrong PW, Bhapkar MV, McGuire DK, Sadowski Z, Kristinsson A, Aylward PE, Klein WW, Weaver WD, Newby LK. Prevalence and management of hypertension in acute coronary syndrome patients varies by sex: observations from the Sibrafiban versus aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes (SYMPHONY) randomized clinical trials. Am Heart J 2005; 150:1260-7. [PMID: 16338269 DOI: 10.1016/j.ahj.2005.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2005] [Accepted: 08/08/2005] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hypertension affects 1 billion individuals worldwide and is an independent risk factor for death after acute coronary syndromes (ACS). METHODS We examined the prevalence and medical treatment of hypertension among 15,904 ACS patients randomized in the SYMPHONY and 2nd SYMPHONY trials. Analyses were performed overall and according to sex for the United States and across international practice. Multivariable models identified factors associated with use of antihypertensive medication classes and examined the association of hypertension and sex with mortality. RESULTS In the United States, hypertension was more prevalent in women than in men, overall (63% vs 50%) and within every decile of age. Hypertensive women more often received calcium-channel blockers (35% vs 30%) and diuretics (33% vs 19%) and less often received beta-blockers (51% vs 57%). Angiotensin-converting enzyme inhibitor use was similar (35% vs 34%). Women received multiple agents more frequently than did men: 2 agents, 35% vs 30%; > or = 3 agents, 16% vs 13%. Female sex independently predicted drug-class use only for diuretics. Mortality was higher in hypertensive women than in hypertensive men; after multivariable adjustment, mortality was similar without evidence of a differential association between hypertension and mortality according to sex. Although there was international variation in the use of individual classes of agents, the overall findings by sex were similar across regions. CONCLUSION Hypertension is more prevalent in women than in men with ACS, and its medical management varies by sex, but its association with mortality is similar. Opportunities exist to improve medical therapy and outcomes in women with hypertension.
Collapse
Affiliation(s)
- Camille G Frazier
- Duke University Medical Center, Clinical Research Institute, Durham, NC, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Skali H, Zornoff LAM, Pfeffer MA, Arnold MO, Lamas GA, Moyé LA, Plappert T, Rouleau JL, Sussex BA, St John Sutton M, Braunwald E, Solomon SD. Prognostic use of echocardiography 1 year after a myocardial infarction. Am Heart J 2005; 150:743-9. [PMID: 16209977 DOI: 10.1016/j.ahj.2004.10.033] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2004] [Accepted: 10/18/2004] [Indexed: 11/29/2022]
Abstract
BACKGROUND Left ventricular (LV) and right ventricular (RV) function are known predictors of morbidity and mortality after an acute myocardial infarction (MI). However, the prognostic use of a late evaluation of cardiac function after an MI remains unclear. METHODS We analyzed echocardiograms obtained 1 year after MI in patients with LV dysfunction at baseline (ejection fraction [EF] < or = 40%) from 291 patients enrolled in the SAVE echocardiographic substudy who did not develop heart failure (HF) or a recurrent MI during this first year. Left ventricular EF and RV fractional area change were assessed. RESULTS After a median follow-up of 22 months after the 1-year echocardiogram, a low LVEF (< 30%) at 1 year was associated with an increased risk of death and/or HF (hazards ratio [HR] 2.7, 95% CI 1.3-5.3). Presence of RV dysfunction was also associated with an increased risk of death (HR 8.9, 95% CI 3.5-22.1), development of HF (HR 7.1, 95% CI 3.4-15.0), and the composite end point of death or HF (HR 7.6, 95% CI 4.1-14.2). In multivariate analyses, both low LVEF and RV dysfunction remained independently predictive of the composite end point of death or HF. Patients with biventricular dysfunction were at the greatest risk of death and/or HF (HR 19.4, 95% CI 8.2-46.0) in follow-up. CONCLUSIONS In a stable population of survivors of MI, impaired LV and RV function at 1 year after MI are independently and additively predictive of increased risk of HF or death.
Collapse
Affiliation(s)
- Hicham Skali
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
24
|
Eisenstein EL, McGuire DK, Bhapkar MV, Kristinsson A, Hochman JS, Kong DF, Califf RM, Van de Werf F, Yancy WS, Newby LK. Elevated body mass index and intermediate-term clinical outcomes after acute coronary syndromes. Am J Med 2005; 118:981-90. [PMID: 16164884 DOI: 10.1016/j.amjmed.2005.02.017] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2004] [Indexed: 11/19/2022]
Abstract
PURPOSE Obesity is a coronary disease risk factor, but its independent effect on clinical outcomes following acute coronary syndromes has not been quantified. We evaluated the relationship between elevated body mass index (BMI) and 30-day, 90-day, and 1-year clinical outcomes postacute coronary syndromes. SUBJECTS AND METHODS Using 15 071 patients (normal weight [BMI = 18.5-24.9 kg/m(2)], overweight [BMI = 25-29.9 kg/m(2)], obese [BMI = 30-34.9 kg/m(2)] or very obese [BMI > or =35 kg/m(2)]) randomized from 1997-1999 in the SYMPHONY (Sibrafiban vs aspirin to Yield Maximum Protection from ischemic Heart events postacute cOroNary sYndromes) and 2nd SYMPHONY trials, we evaluated the relationships between BMI and 30-day, 90-day, and 1-year mortality and 30-day and 90-day death or myocardial infarction. RESULTS Increasing BMI was associated with younger age, multiple comorbidities, and greater cardiac medication and procedure use; however, systolic function and coronary disease extent were similar for all BMI categories. Unadjusted Kaplan-Meier mortality estimates were higher for normal-weight patients than for all other BMI groups. After multivariable adjustment, the 30-day mortality hazard ratios (95% confidence interval [CI]) were: overweight, 0.66 (95% CI: 0.47 to 0.94); obese, 0.61 (95% CI: 0.39 to 0.97); very obese, 0.89 (95% CI: 0.48 to 1.64). Adjusted hazard ratios were similar for 90-day and 1-year mortality. There were no statistically significant differences among BMI groups in 30-day and 90-day death or myocardial infarction (unadjusted or adjusted). CONCLUSION Overweight and obese BMI classifications were associated with better intermediate-term survival after acute coronary syndromes than normal weight and very obese, but death or myocardial infarction rates were similar. Further study is required to understand the apparent association of overweight and moderate obesity with better intermediate-term outcomes.
Collapse
Affiliation(s)
- Eric L Eisenstein
- Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC 27715, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
25
|
Reddan DN, Szczech L, Bhapkar MV, Moliterno DJ, Califf RM, Ohman EM, Berger PB, Hochman JS, Van de Werf F, Harrington RA, Newby LK. Renal function, concomitant medication use and outcomes following acute coronary syndromes. Nephrol Dial Transplant 2005; 20:2105-12. [PMID: 16030030 DOI: 10.1093/ndt/gfh981] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Chronic kidney disease (CKD) is highly prevalent in patients with cardiovascular disease. We explored the associations of CKD with outcomes using combined data from two large acute coronary syndrome (ACS) trials. We also explored the associations of CKD with prescription patterns for common cardiovascular medications and the association of these prescription patterns with clinical outcomes. METHODS Patients were stratified by CKD stage using creatinine clearance (CrCl, ml/min) estimated by the modified MDRD equation using baseline core laboratory creatinine measures. Serum creatinine > or =1.5 mg/dl was an exclusion criterion for the SYMPHONY trials. Baseline characteristics and outcomes across CKD categories were compared and Cox proportional hazards regression was used to assess the relationship of renal insufficiency with clinical outcomes after adjusting for previously identified outcome predictors. Interactions between the use of specific medications and calculated CrCl were tested in the final Cox proportional hazards model predicting time to mortality. RESULTS Of 13 707 patients analysed, 6840 had CKD stage I (CrCl > or =90 ml/min), 5909 stage II (CrCl 60-89 ml/min), 955 stage III (CrCl 30-59 ml/min) and three stage IV (CrCl <30 ml/min). Patients with more advanced CKD (III) were older, more often female, non-smokers and more likely to have co-morbid diseases including diabetes mellitus, hypertension and congestive heart failure. Cardiovascular medications were used less frequently in patients with CKD. Unadjusted survival was poorer in patients with CKD stages > or =II. In adjusted analyses, for those with CrCl < or =91, each 10 ml/min increase in CrCl was associated with a significantly decreased risk of mortality (hazards ratio 0.897, 95% confidence interval 0.815-0.986) (P = 0.024). The interaction between use of angiotensin-converting enzyme (ACE) inhibitors and CrCl was significantly associated with outcomes; the benefit of drug therapy was greater among patients with CKD. CONCLUSIONS CKD is an independent predictor of risk among ACS patients, and is associated with less frequent use of proven medical therapies. More aggressive use of conventional cardiovascular therapies in patients with CKD and ACS may be warranted.
Collapse
|
26
|
Parsons E, Newby LK, Bhapkar MV, Alexander KP, White HD, Shah SH, Bushnell CD, Califf RM. Postmenopausal hormone use in women with acute coronary syndromes. J Womens Health (Larchmt) 2005; 13:863-71. [PMID: 15671702 DOI: 10.1089/jwh.2004.13.863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Recent trials reveal no benefit and possible harm from chronic hormone replacement therapy (HRT). Less is known about intermediate-term outcomes associated with HRT use in the setting of acute coronary syndromes (ACS). METHODS To examine the prevalence of HRT use and relationships with intermediate-term outcomes among women with ACS, we classified as HRT users or nonusers 4029 postmenopausal women (age > 50 years or postmenopausal by case report form) randomized in the Sibrafiban versus Aspirin to Yield Maximum Protection from Ischemic Heart Events Post-Acute Coronary Syndromes (SYMPHONY) and 2nd SYMPHONY trials. Outcomes included 90-day and 1-year death and 90-day stroke, death, or myocardial infarction (MI); death, MI, or stroke; and death, MI, or severe recurrent ischemia (SRI). RESULTS HRT use was 13% overall and varied by region (Asia, 0%; Eastern Europe, 0.2%; Latin America, 0.8%; Western Europe, 4%; Australia/New Zealand, 12%; Canada, 14%; United States, 24%); estrogen-only regimens were most common (90%). HRT users were younger, had higher estimated creatinine clearance, more frequently were smokers and had prior revascularization, but less frequently had diabetes, prior angina, or heart failure. Unadjusted 90-day and 1-year mortality rates were lower among HRT users (hazard ratios [95% CI] 0.48 [0.23-0.98] and 0.35 [0.18-0.68], respectively) but after multivariable adjustment, were not significantly different. Ninety-day stroke and composite end points did not differ between HRT users and nonusers. CONCLUSIONS HRT use (predominantly estrogen-only) was low among patients with ACS but varied by region and was not associated with improved intermediate-term outcomes. These results are consistent with the absence of benefit from HRT use (combination or estrogen only) in previous studies in more stable populations.
Collapse
|
27
|
Abstract
National Kidney Foundation guidelines define chronic kidney disease (CKD) as persistent kidney damage (confirmed by renal biopsy or markers of kidney damage) and/or glomerular filtration rate (GFR) <60 mL/min/1.73m2 for greater than three months. Patients with CKD experience higher mortality and adverse cardiovascular (CV) event rates, which remains significant after adjustment for conventional coronary risk factors. This progressive CV risk associated with worsening renal function may be explained by other factors that become increasingly important with renal decline. In this regard, more investigation of nonconventional factors that have received a lot of attention includes associations with inflammation, albuminuria, reduced vascular compliance, and homocysteine. In addition, individuals with CKD encounter the problem of "therapeutic nihilism," in which there is a lack of appropriate risk factor modification and intervention, despite established awareness of their high cardiovascular risk. Several studies suggest that these individuals derive as much, if not more, benefit from evidence-based cardiovascular therapies and strategies. Greater educational efforts are needed to reduce this therapeutic gap.
Collapse
Affiliation(s)
- Nagesh S Anavekar
- Baker Cardiovascular Research Institute, Alfred Hospital, Monash University, Melbourne, Victoria, Australia
| | | |
Collapse
|
28
|
Bodí V, Sanchis J, Llàcer A, Fácila L, Núñez J, Pellicer M, Bertomeu V, Ruiz V, Chorro FJ. Multimarker risk strategy for predicting 1-month and 1-year major events in non-ST-elevation acute coronary syndromes. Am Heart J 2005; 149:268-74. [PMID: 15846264 DOI: 10.1016/j.ahj.2004.05.053] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The aim of this study was to define the utility of the combined measurement of troponin I, myoglobin, C-reactive protein, fibrinogen, and homocysteine to predict risk in non-ST elevation acute coronary syndromes. METHODS Troponin I, myoglobin, high-sensitivity C-reactive protein, fibrinogen, and homocysteine were measured in 557 consecutive patients admitted to our institution for non-ST elevation acute coronary syndrome. The risk for major events (death or nonfatal myocardial infarction) at first month and at first year follow-up was analyzed. RESULTS In a multivariate model adjusting for baseline characteristics and electrocardiographic changes, the only biomarkers related to major events at first month were C-reactive protein (P = .007) and myoglobin (P = .02), and at first year troponin I (P = .02), C-reactive protein (P = .03), and homocysteine (P = .04). The rate of major events depending on the number (0-5) of elevated biomarkers were at first month: 4.1%, 3.7%, 5.7%, 6.1%, 6.5%, and 30.8% (P < .0001), and at first year: 8.2%, 11.1%, 12.3%, 16.2%, 23.7%, and 50% (P < .0001). A simple score including the number of elevated biomarkers showed an adjusted risk of major events of 1.6 [1.3-1.9] at first month and of 1.4 [1.2-1.7] at first year. CONCLUSIONS Markers of myocardial damage, inflammation, and homocysteine analyzed separately provide prognostic information. The number of elevated biomarkers is an independent risk predictor of major events.
Collapse
Affiliation(s)
- Vicent Bodí
- Servei de Cardiología, Hospital Clínic i Universitari, Universitat de València, València, Spain.
| | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Foley RN, Murray AM, Li S, Herzog CA, McBean AM, Eggers PW, Collins AJ. Chronic kidney disease and the risk for cardiovascular disease, renal replacement, and death in the United States Medicare population, 1998 to 1999. J Am Soc Nephrol 2004; 16:489-95. [PMID: 15590763 DOI: 10.1681/asn.2004030203] [Citation(s) in RCA: 670] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Knowledge of the excess risk posed by specific cardiovascular syndromes could help in the development of strategies to reduce premature mortality among patients with chronic kidney disease (CKD). The rates of atherosclerotic vascular disease, congestive heart failure, renal replacement therapy, and death were compared in a 5% sample of the United States Medicare population in 1998 and 1999 (n = 1,091,201). Patients were divided into the following groups: 1, no diabetes, no CKD (79.7%); 2, diabetes, no CKD (16.5%); 3, CKD, no diabetes (2.2%); and 4, both CKD and diabetes (1.6%). During the 2 yr of follow-up, the rates (per 100 patient-years) in the four groups were as follows: atherosclerotic vascular disease, 14.1, 25.3, 35.7, and 49.1; congestive heart failure, 8.6, 18.5, 30.7, and 52.3; renal replacement therapy, 0.04, 0.2, 1.6, and 3.4; and death, 5.5, 8.1, 17.7, and 19.9, respectively (P < 0.0001). With use of Cox regression, the corresponding adjusted hazards ratios were as follows: atherosclerotic vascular disease, 1, 1.30, 1.16, and 1.41 (P < 0.0001); congestive heart failure, 1, 1.44, 1.28, and 1.79 (P < 0.0001); renal replacement therapy, 1, 2.52, 23.1, and 38.9 (P < 0.0001); and death, 1, 1.21, 1.38, and 1.56 (P < 0.0001). On a relative basis, patients with CKD were at a much greater risk for the least frequent study outcome, renal replacement therapy. On an absolute basis, however, the high death rates of patients with CKD may reflect accelerated rates of atherosclerotic vascular disease and congestive heart failure.
Collapse
Affiliation(s)
- Robert N Foley
- United States Renal Data System Coordinating Center, 914 South 8th Street, Suite D-253, Minneapolis, MN 55404, USA.
| | | | | | | | | | | | | |
Collapse
|
30
|
Asher CR, Moliterno DJ, Bhapkar MV, McGuire DK, Rao SV, Holmes DR, Newby LK, Bates ER, Topol EJ. Association of race with complications and prognosis following acute coronary syndromes. Am J Cardiol 2004; 94:792-4. [PMID: 15374792 DOI: 10.1016/j.amjcard.2004.05.069] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2003] [Revised: 05/19/2004] [Accepted: 05/19/2004] [Indexed: 11/29/2022]
Abstract
The baseline characteristics, complications, and survival of 489 black and 6,890 non-black patients with acute coronary syndromes were studied. Important racial differences were observed in demographic features, atherosclerosis risk factors, and treatment strategies; however, despite these differences, no independent difference was observed in clinical outcomes according to race. The 1-year mortality rate was 2.9% for black patients and 2.5% for non-black patients (p = 0.93).
Collapse
Affiliation(s)
- Craig R Asher
- Department of Cardiology, The Cleveland Clinic Foundation, Weston, Florida, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
31
|
McGuire DK, Newby LK, Bhapkar MV, Moliterno DJ, Hochman JS, Klein WW, Weaver WD, Pfisterer M, Corbalán R, Dellborg M, Granger CB, Van De Werf F, Topol EJ, Califf RM. Association of diabetes mellitus and glycemic control strategies with clinical outcomes after acute coronary syndromes. Am Heart J 2004; 147:246-52. [PMID: 14760321 DOI: 10.1016/j.ahj.2003.07.024] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Diabetes is associated with an increased risk for coronary artery disease (CAD) and its complications. The relative effect of glucose-lowering strategies of "insulin provision" versus "insulin sensitization" among patients with CAD remains unclear. METHODS To evaluate the associations of diabetes and hypoglycemic strategies with clinical outcomes after acute coronary syndromes, we analyzed data from 15,800 patients enrolled in the SYMPHONY and 2nd SYMPHONY trials. RESULTS Compared with nondiabetic patients, patients with diabetes (n = 3101; 19.6%) were older, more often female, more often had prior CAD, hypertension, and hyperlipidemia, and less often were current smokers. The diabetic cohort had higher 90-day unadjusted risk of the composite of death/myocardial infarction (MI)/severe recurrent ischemia (SRI), death/MI, and death alone, as well as a near doubling of 1-year mortality rates. At 1 year, diabetes was associated with significantly higher adjusted risks of death/MI/SRI (OR, 1.3 [95% confidence interval, 1.1, 1.5]) and death/MI (OR, 1.2 [1.0, 1.4]). Hypoglycemic therapy including only insulin and/or sulfonylurea (insulin-providing; n = 1473) was associated with higher 90-day death/MI/SRI compared with therapy that included only biguanide and/or thiazolidinedione therapy (insulin-sensitizing; n = 100) (12.0% vs 5.0%); (adjusted OR, 2.1 [1.2, 3.7]). CONCLUSIONS Diabetic patients with acute coronary syndromes had worse clinical outcomes. Although the findings regarding the influence of glycemic-control strategies should be interpreted with caution because of the exploratory nature of the analyses and the relatively small sample size of the insulin-sensitizing group, the improved risk-adjusted outcomes associated with insulin-sensitizing therapy underscore the need to further evaluate treatment strategies for patients with diabetes and CAD.
Collapse
Affiliation(s)
- Darren K McGuire
- Donald W. Reynolds Cardiovascular Clinical Research Center at the University of Texas-Southwestern Medical Center, Dallas, Tex, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|