Variation in patient management and outcomes for acute coronary syndromes in Latin America and North America: results from the Platelet IIb/IIIa in Unstable Angina: Receptor Suppression Using Integrilin Therapy (PURSUIT) trial

Considerations and Guidance for the Structure, Organisation, and Operation of Cardiometabolic Prevention Units: A Consensus Statement of the Inter-American Society of Cardiology

Cardiovascular diseases (CVDs) remain the leading cause of death worldwide, particularly in low- and middle-income regions such as Latin America. This is because of the combination and interaction in different proportions of a high prevalence of cardiometabolic risk factors and socio-economic and cultural characteristics. This reality brings about the need to change paradigms to consistently and systematically boost cardiovascular prevention as the most cost-effective medium- to long-term strategy to reduce their prevalence in medium- and low-resource countries, not only in Latin America but also in other global regions.

To achieve the therapeutic goals in various diseases, including CVD, the current literature demonstrates that the most effective way is to carry out the patient’s diagnosis and treatment in multidisciplinary units. For this reason, the Inter American Society of Cardiology (IASC) proposes the creation of cardiometabolic prevention units (CMPUs) as a regional initiative exportable throughout the world to standardise cardiovascular prevention based on the best available evidence. This ensures homogeneity in the global management of cardiometabolic risk factors and access to quality medicine independently of the population’s social situation. These guidelines, written by a panel of experts in cardiovascular prevention, defines what a CMPU is, its objectives and the minimum requirements for it, as well as proposing three categories and suggesting an operational scheme. It must be used as a guide for all individuals or centres that, aware of the need for multidisciplinary and standardised work, want to create a unit for the comprehensive management of cardiometabolic risk established as an international research network.

Lastly, the document makes meaningful points on the determination of cardiovascular risk and its importance. These guidelines do not cover specific targets and therapeutic schemes, as these topics will be extensively discussed in another SIAC publication, namely a statement on residual cardiometabolic risk.

The Seattle Post Myocardial Infarction Model (SPIM): prediction of mortality after acute myocardial infarction with left ventricular dysfunction

AIMS

Ischemic heart disease is a leading worldwide cause of death. The Seattle Post Myocardial Infarction Model (SPIM) was developed to predict survival 6 months to 2 years after an acute myocardial infarction with evidence of left ventricular dysfunction.

METHODS AND RESULTS

A total of 6632 subjects from the EPHESUS trial were used to derive the predictive model, while 5477 subjects from the OPTIMAAL trial were used to validate the model. Cox proportional hazards modeling was used to develop a multivariate risk score predictive of all-cause mortality. The SPIM risk score integrated lab and vital parameters, Killip class, reperfusion or revascularization, the number of cardiac evidence-based medicines (aspirin, statin, β blocker, ACEI/ARB, aldosterone blocker), and the number of cardiac risk factors. The model was predictive of all-cause mortality after myocardial infarction, with an AUC of 0.75 at 6 months and 0.75 at 2 years in the derivation cohort and 0.77 and 0.78 for the same time points in the validation cohort. Model predicted versus Kaplan-Meier observed survival was excellent in the derivation cohort. It remained so in the validation cohort--84.9% versus 85.0% at 2 years. The 10% of subjects with the highest predicted risk had approximately 25 times higher mortality at 2 years than the 10% of subjects with the lowest predicted risk.

CONCLUSION

The SPIM score was a powerful predictor of outcomes after myocardial infarction with left ventricular dysfunction. Its highly accurate predictions should improve patient and physician understanding of survival and may prove a useful tool in post-infarct risk stratification.

International comparison of treatment and long-term outcomes for acute myocardial infarction in the elderly: Minneapolis/St. Paul, MN, USA and Goteborg, Sweden

AIMS

International studies provide an opportunity to compare treatment approaches and outcomes. The present study compares elderly hospitalized acute myocardial infarction (AMI) patients in Minneapolis/St. Paul, USA (MSP) and Göteborg, Sweden (GB).

METHODS AND RESULTS

A population-based sample of hospitalized AMI (ICD-9 410) patients aged ≥75 in MSP and GB in 2001-02 was abstracted by trained nurses. Mortality was ascertained from medical records and death certificates. Demographics, cardiovascular procedures, and prescription medications were compared using sex-specific generalized linear models. Adjusted hazard ratios (HR) were calculated with Cox regression. In MSP 839 (387 men, 452 women) and in GB 564 (275 men, 289 women) patients were identified. Age was similar (men: MSP 83 ± 7, GB 82 ± 5; women: MSP 84 ± 6, GB 84 ± 6) yet MSP patients had more previous cardiovascular comorbidities and procedures (PCI/CABG). Guideline-based medication use was high in both locations. MSP patients were significantly more likely to undergo PCI (men: MSP 33%, GB 7%; women: MSP 30%, GB 7%). Survival at 7.5 years was 27.8% among MSP patients (men: 26.6%, women: 28.8%) and 17.2% among GB patients (men: 17.5%, women: 17.0%). After adjustment for baseline characteristics and guideline-based therapies, survival was higher among MSP men [HR: 0.66, 95% confidence interval (CI): 0.50-0.88] and women (HR: 0.49, 95% CI: 0.36-0.67) compared with GB.

CONCLUSION

In MSP and GB, guideline-based therapy use was high. However, PCI use was markedly higher in MSP. Long-term survival was better among elderly men and women in MSP compared with GB possibly related to greater utilization of PCI.

Safety and efficacy of prasugrel compared with clopidogrel in different regions of the world

BACKGROUND

Among patients with acute coronary syndrome (ACS), demographics, procedural characteristics and adjunctive medications differ globally. We examined whether there were differential effects of prasugrel compared with clopidogrel in the multinational TRITON-TIMI 38 study.

METHODS

We divided the enrollment into 5 pre-specified geographic regions. Patients were randomized to prasugrel or clopidogrel without regard to country of enrollment. End points are expressed as Kaplan-Meier failure estimates through 15 months. Heterogeneity was evaluated using Cox proportional hazards model. Additional sensitivity analyses were performed by dividing countries into categories based on the Human Development Index (HDI), which is a composite measure of social and economic development.

RESULTS

13,608 patients were enrolled. Clinical characteristics including age, comorbidities, ACS presentation, stent types, and adjunctive medications differed broadly among regions. Despite these differences, no regional heterogeneity was observed with prasugrel compared to clopidogrel in the reduction of ischemic events (HR range: 0.76-0.87, p(interaction)>0.10 for each) and stent thrombosis (HR range: 0.34-0.72, p(interaction)>0.10 for each) or in the increased rate of non-CABG TIMI major bleeding (HR range: 1.16-1.76, p(interaction)>0.10 for each). There was a consistent trend in net clinical benefit (all cause death/MI/stroke/non-CABG TIMI major bleeding) favoring prasugrel (HR range: 0.81-0.97, p(interaction)>0.10 for each). Consistent results were also observed regarding the safety and efficacy of prasugrel compared with clopidogrel in both developed and developing countries.

CONCLUSIONS

Despite differences in patient demographics, procedural techniques and adjunctive medications, consistent reduction in ischemic events and increased bleeding were seen with prasugrel compared with clopidogrel throughout the world.

Current status of cardiac rehabilitation in Latin America and the Caribbean

BACKGROUND

The prevalence of coronary artery disease (CAD) in Latin America is increasing and contributes importantly to the global burden of cardiovascular diseases. Advanced resources for the diagnosis and treatment of CAD are available in most of the region. However, preventive approaches such as cardiovascular rehabilitation programs (CVRP) may not be widely implemented.

METHODS

We carried out a telephone-based survey to hospitals sampled in a random and population-weighted fashion from a list of 202 centers with cardiac catheterization laboratories in Mexico, Central and South America, and the Caribbean. We collected information of availability of cardiac procedures and imaging techniques and also extensive data about the presence, characteristics, and quality measures of CVRP.

RESULTS

A total of 98 centers were contacted, and a complete survey was provided by 59 centers (60%) from 13 countries. Cardiovascular rehabilitation programs were available in only 56% of centers. There were no differences between centers with and without CVRP regarding type of hospital, availability of cardiac surgery, and annual volume of patients with myocardial infarction. Among centers with CVRP, 70% offered all phases of CVRP. The lack of CVRP was attributed to lack of qualified personnel in 41% of centers, financial constraints in 33%, and lack of physical space in 13%. All centers without CVRP performed cardiac surgery and percutaneous interventions.

CONCLUSIONS

Despite the presence of state-of-the-art technology for the diagnosis and treatment of CAD, availability of CVRP, a less expensive yet effective tool for the treatment of CAD, appears to be limited in Latin America and the Caribbean.

Management of acute coronary syndromes in Mexico: gaps and opportunities to improve outcomes

Acute coronary syndromes (ACS) include unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). The management of ACS has improved greatly over the last 3 decades, with an associated steady decline in mortality from this condition seen in the US. The benefits of advances in the management of ACS observed in the US have not fully extended to Mexico, as thrombolytic therapy remains the most commonly used reperfusion strategy for STEMI and new antithrombotic drugs are not widely available. However, treatment of ACS in Mexico is rapidly evolving. Dual oral antiplatelet therapy with the combination of clopidogrel and aspirin (acetylsalicylic acid) is becoming the new standard of care for the management of patients with NSTEMI and those undergoing percutaneous coronary intervention. Results from controlled clinical studies strongly support the use of early and aggressive treatment with this combination. The addition of clopidogrel to the national formulary represents an important step in the evolution of care for ACS patients in Mexico. Local and regional leadership is required to foster the widespread adoption of this highly beneficial treatment strategy. The main objectives of this review are to highlight the recommendations of the Mexican guidelines for the management of ACS and provide some perspective regarding challenges to optimal management of ACS patients in Mexico.

Pharmacists' role in the post-discharge management of patients with heart failure: a literature review

BACKGROUND AND OBJECTIVE

The incidence of heart failure is increasing in developed countries. In the aged population, heart failure is a common cause of hospitalization and hospital readmission, which in conjunction with post-discharge care, impose a significant cost burden. Inappropriate medication management and drug-related problems have been identified as major contributors to hospital readmissions. In order to enhance the care and clinical outcomes, and reduce treatment costs, heart failure disease management programmes (DMPs) have been developed. It is recommended that these programmes adopt a multi-disciplinary approach, and pharmacists, with their understanding and knowledge of medication management, can play a vital role in the post-discharge care of heart failure patients. The aim of this literature review was to assess the role of pharmacists in the provision of post-charge services for heart failure patients.

METHOD

An extensive literature search was undertaken to identify published studies and review articles evaluating the benefits of an enhanced medication management service for patients with heart failure post-discharge.

RESULTS

Seven studies were identified evaluating 'outpatient' or 'post-discharge' pharmacy services for patients with heart failure. In three studies, services were delivered prior to discharge with either subsequent telephone or home visit follow-up. Three studies involved the role of a pharmacist in a specialist heart failure outpatient clinic. One study focused on a home-based intervention. In six of these studies, positive outcomes, such as decreases in unplanned hospital readmissions, death rates and greater compliance and medication knowledge were demonstrated. One study did not show any difference in the number of hospitalizations between intervention and control groups. The quality of evidence of the randomized controlled trials was assessed using the Jadad scoring method. None of the studies achieved a score of more than 2, out of a maximum of 5, indicating the potential for bias.

DISCUSSION

The DMPs carried out by pharmacists have contributed to positive patient outcomes, which has highlighted the value of extending the traditional roles of pharmacists from the provision of professional guidance to the delivery of continuity of care through a more holistic and direct approach.

CONCLUSION

This review has demonstrated the effectiveness of pharmacists' interventions to reduce the morbidity and mortality associated with heart failure. However, there is an on-going need for the development and evaluation of pharmacy services for these patients.

Outcomes of patients in clinical trials with ST-segment elevation myocardial infarction among countries with different gross national incomes

AIMS

To evaluate whether there is an association between 30-day mortality in patients with ST-segment elevation myocardial infarction (STEMI) included in clinical trials and country gross national income (GNI).

METHODS AND RESULTS

A retrospective analysis of the databases of five randomized trials including 50 310 patients with STEMI (COBALT 7169, GIK-2 2931, HERO-2 17,089, ASSENT-2 17,005, and ASSENT-3 6116 patients) from 53 countries was performed. Countries were divided into three groups according to their GNI based on the World Bank data: low (less than 2900 US dollars), medium (between 2900 US dollars and 9000 US dollars), and high GNI (more than 9000 US dollars per capita). Baseline characteristics, in-hospital management variables, and 30-day outcomes were evaluated. A previously defined logistic regression model was used to adjust for differences in baseline characteristics and to predict mortality. The observed mortality was higher than the predicted mortality in the low (12.1 vs. 11.8%) and in the medium income groups (9.4 vs. 7.9%), whereas it was lower in the high income group (4.9 vs. 5.6%).

CONCLUSION

An inverse relationship between mortality and GNI was observed in STEMI clinical trials. Most of the variability in mortality can be explained by differences in baseline characteristics; however, after adjustment, lower income countries have higher mortality than the expected.

Overview of acute decompensated heart failure in Argentina: lessons learned from 5 registries during the last decade

BACKGROUND

The acute decompensated heart failure (ADHF) is not as well characterized as the chronic phase, particularly in Latin American countries. Thus, the aim of this overview was to describe the clinical profile, treatment, and inhospital course of ADHF during the last decade in Argentina.

METHODS

Results obtained from 5 Argentinean prospective and multicenter registries, involving 2974 patients admitted for ADHF, were assessed. These registries were performed and published between 1992 and 2004.

RESULTS

The mean age was 65 to 70 years, and nearly 40% were female. Coronary artery disease was the main etiology in nearly 30% of the patients. Between 1992 and 2004, the use of angiotensin-converting enzyme inhibitors increased from 29.9% to 53.4% before admission and from 48.5% to 69.3% before discharge; the use of beta-blockers rose from 4.2% to 33.2% at admission and from 2.5% to 42.4% at predischarge (all P < .0001). Inhospital mortality rates in the first to the fifth registries were 12.1%, 4.6%, 10.5%, 8.9%, and 4.7% (P [trend] = .006). However, there were 98 (7.7%) deaths among 1272 patients before 2002, compared with 129 (7.6%) among 1702 since 2002 (P = .9).

CONCLUSIONS

The clinical profile of this largest sample of ADHF reported from a Latin American country is different from that observed in clinical trials and comparable to registries worldwide. Although an improvement in the use of recommended drugs was observed in the last decade, the average mortality has not changed. These findings might have implications in the design of multinational clinical trials.

'Lost in translation': accounting for between-country differences in the analysis of multinational cost-effectiveness data

Cost-effectiveness analysis has gained status over the last 15 years as an important tool for assisting resource allocation decisions in a budget-limited environment such as healthcare. Randomised (multicentre) multinational controlled trials are often the main vehicle for collecting primary patient-level information on resource use, cost and clinical effectiveness associated with alternative treatment strategies. However, trial-wide cost effectiveness results may not be directly applicable to any one of the countries that participate in a multinational trial, requiring some form of additional modelling to customise the results to the country of interest. This article proposes an algorithm to assist with the choice of the appropriate analytical strategy when facing the task of adapting the study results from one country to another. The algorithm considers different scenarios characterised by: (a) whether the country of interest participated in the trial; and (b) whether individual patient-level data (IPD) from the trial are available. The analytical options available range from the use of regression-based techniques to the application of decision-analytic models. Decision models are typically used when the evidence base is available exclusively in summary format whereas regression-based methods are used mainly when the country of interest actively recruited patients into the trial and there is access to IPD (or at least country-specific summary data). Whichever method is used to reflect between-country variability in cost-effectiveness data, it is important to be transparent regarding the assumptions made in the analysis and (where possible) assess their impact on the study results.

Disease management programmes for older people with heart failure: crucial characteristics which improve post-discharge outcomes

AIMS

Disease management programmes (DMPs) have evolved as an innovative clinical practice system to enhance the discharge outcomes of older people with heart failure. Yet, clinical trials which have examined their effectiveness have reported inconsistent findings. This may be explained by variations in the design of DMPs. The aim is to identify the characteristics of DMPs which are crucial to reducing hospital readmission and/or mortality of older people with heart failure.

METHODS AND RESULTS

A systematic computerized search was conducted to identify randomized controlled trials of the last 10 years, which examined the effects of DMPs on hospital readmission and mortality of older people with heart failure. The identified DMPs were classified as effective and ineffective, according to statistically significant changes in discharge outcomes. Twenty-one trials were identified, 11 (52.4%) of which reported DMPs improving the discharge outcomes of older people with heart failure. The results indicate that an effective DMP should be multi-faceted and consists of an in-hospital phase of care, intensive patient education, self-care supportive strategy, optimization of medical regimen, and ongoing surveillance and management of clinical deterioration. Cardiac nurse and cardiologist should be actively involved and a flexible approach should be adopted to deliver the follow-up care.

CONCLUSION

This study defines precisely the characteristics of the care team and the organization content and delivery method of the DMP which are crucial to enhance the discharge outcomes of older people with heart failure.

Are international differences in the outcomes of acute coronary syndromes apparent or real? A multilevel analysis

STUDY OBJECTIVE

International variation in the outcomes of patients with acute coronary syndromes (ACS) has been well reported. The relative contributions of patient, hospital, and country level factors on clinical outcomes, however, remain unclear, and thus, was the objective of this study.

DESIGN

Multilevel logistic regression models were developed for death/(re)infarction (MI) at 30 days and death in one year, with patients (1st level) nested in hospitals (2nd level) and hospitals in countries (3rd level).

SETTINGS

The GUSTO IV ACS clinical trial was carried out at 458 hospital sites in 24 countries.

PATIENTS

7800 non-ST segment elevation (NSTE) ACS patients.

MAIN RESULTS

There were substantial variations among countries in the processes and outcomes of care at 30 days, ranging from 5.4% to 50.0% for percutaneous coronary intervention, 4.3% to 21.2% for coronary artery bypass graft surgery, 5.0% to 13.9% for 30 day death/(re)MI, and 4.9% to 14.8% for one year mortality. However, the residual inter-country variations in 30 day death/(re)MI and one year mortality became non-significant and nearly disappeared (p > 0.500 for both) after adjusting for key baseline patient characteristics and hospital factors, which became significant (p < 0.01 for both). Patient level factors accounted for 96%-99% of total variation in these end points, leaving the remaining 1% and 4% of variance attributable to hospital level factors.

CONCLUSION

The international differences in clinical outcomes in this study of NSTE ACS are primarily accounted for by the patient level factors, with hospital level factors playing a minor part, and the country level factors a negligible one. These findings have significant policy and research implications involving international collaboration and comparisons.

Metaanalysis and review of heart failure disease management randomized controlled clinical trials

BACKGROUND

The medical community has turned to disease management (DM) to bridge the gap between proven therapies and clinical practice for patients with heart failure (HF). The aim of this study was to assess the effectiveness of DM programs in reducing hospitalization and mortality in patients with HF on the basis of the results of existing trials.

METHODS

We compared the published results from 19 randomized controlled clinical trials evaluating HF DM programs. A random effects model was used to combine the hazards ratio for all-cause hospitalization across the studies evaluating specific types of HF DM programs.

RESULTS

We identified 19 relevant studies, with 5752 enrolled patients, which assessed the benefits of HF DM programs. The overall effect was a significant decrease in all-cause hospitalization for patients with HF. There was significant heterogeneity in the results (P < .0001).

CONCLUSIONS

The results of this analysis indicate that HF DM is an intervention that could significantly decrease hospitalization for patients with HF. However, due to differences in the types of strategies and the variety of health care settings in which they were evaluated, further studies of HF DM programs with multiple participating centers are required.

Eptifibatide

Eptifibatide (Integrilin) is a highly specific, reversible, intravenously administered glycoprotein (GP) IIb/IIIa receptor antagonist that acts at the final common step of the platelet aggregation pathway. Data from large clinical trials indicate that intravenous eptifibatide as adjunctive therapy to standard care is effective in patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) and/or undergoing percutaneous coronary intervention (PCI). In the ESPRIT (Enhanced Suppression of the Platelet glycoprotein IIb/IIIa Receptor with Integrilin Therapy) trial in patients undergoing PCI with stenting, eptifibatide, compared with placebo, achieved significant reductions in death and ischaemic complications and was better than a strategy of reserving treatment for the bailout situation. In the large PURSUIT (Platelet IIb/IIIa in Unstable angina: Receptor Suppression Using Integrilin Therapy) trial in patients with NSTE ACS, eptifibatide was associated with a significant reduction in the incidence of death or myocardial infarction (MI) compared with placebo. Eptifibatide is well tolerated in these trials. Ongoing trials are currently investigating the efficacy and tolerability of regimens that include this agent in other indications, including ST-segment elevation MI (STEMI).

Hospital therapy traditions influence long-term survival in patients with acute myocardial infarction

BACKGROUND

Differences in therapy and outcome among hospitals have been reported, but these studies have seldom used adjustment for differences in patient characteristics. The objective was to investigate the differences in treatment of acute myocardial infarction (AMI) among different hospitals within 1 country and the possible causes and outcomes of these differences.

METHODS

Prospective cohort study using data from the Register of Information and Knowledge about Swedish Heart Intensive care Admissions (RIKS-HIA) on 32,954 consecutive primary admissions of patients with AMI admitted to the intensive coronary care units of 67 Swedish hospitals in 1999-2000. An activity index was calculated for each hospital based on the hospital's ranking regarding proportion of performed examination or given therapy among the AMI patients.

RESULTS

After adjustment for 24 background characteristics, there were few significant deviations among hospitals in the proportion treated with acute reperfusion, antiplatelets, beta-blockers, or angiotensin-converting enzyme (ACE) inhibitors. However, 3- to 10-fold differences existed among hospitals in the proportion of patients treated with intravenous beta-blockers, intravenous nitroglycerin, intravenous or subcutaneous anticoagulants, and lipid-lowering medication, and even larger discrepancies in echocardiography and revascularization within 14 days. There was a strong (r = 0.69, P < .001) correlation between hospital activity index between the years and a correlation between the hospital's activity index and 1-year mortality (r = -0.30, P = .014). There was no correlation between hospital size and activity index.

CONCLUSIONS

Even after adjustment for differences in patient characteristics, there are differences between the hospital treatment cultures for patients with AMI that persists over time. Concerning everywhere-available treatment options, the treatment activity is independent of the size of the center. A more active treatment tradition is associated with a lower short- and long-term mortality in AMI patients.

Utilization of eptifibatide for treatment of severe dissections as a bail-out procedure

BACKGROUND

It has been shown in several large trials that the inhibition of glycoprotein (GP) IIb/IIIa receptors of platelets can reduce the rate of ischemic complications following percutaneous transluminal coronary angioplasty (PTCA). We sought to determine the efficacy of eptifibatide in patients with severe dissections or threatened vessel closure after PTCA in small coronary arteries (< 2.5 mm).

METHODS

Eptifibatide was used in 51 patients after conventional balloon angioplasty complicated by severe dissections with or without threatened vessel occlusion. Eptifibatide was administered as a double-bolus of 180 microg/kg bodyweight, followed by a continuous infusion at a dosage of 2.0 microg/kg min over a time period of 20 h. In this situation, the implantation of a coronary stent was avoided if a prompt antegrade flow of contrast dye could be maintained.

RESULTS

Using the GP IIb/IIIa antagonist eptifibatide, it was possible to increase or to maintain antegrade blood flow in 28 (55%) patients. In 45% of the patient population, however, repeat PTCA was needed, and in four patients (7.8%) an intracoronary stent had to be implanted. During hospitalization three (6%) patients underwent target lesion revascularization (two Re-PTCAs, one coronary bypass graft operation). There were no myocardial infarctions and there was no intrahospital death. The cumulative event rate including acute and long term events was 25%.

CONCLUSIONS

The findings of our study indicate that eptifibatide is able to prevent vessel occlusion after PTCA complicated by severe dissections with or without threatened vessel occlusion associated with a low-in-hospital complication rate.

Poverty, process of care, and outcome in acute coronary syndromes

OBJECTIVES

We sought to determine whether income-based disparities in care processes and outcome exist in patients with acute coronary syndromes.

BACKGROUND

Using income proxies and limited clinical data, some observational studies have shown income disparities in outcome after acute myocardial infarction (MI).

METHODS

Using annual household income from the economic substudy of the PURSUIT (Platelet Glycoprotein IIB/IIIA In Unstable Angina: Receptor Suppression Using Integrilin Therapy) trial, patients were grouped into low-, middle-, and high-income categories based on the U.S. Census Bureau definition of poverty. Logistic regression analysis was used to examine the association between income category and the use of cardiac procedures and the prescription of evidence-based medications at hospital discharge. Cox regression analysis was used to examine the hazard of 30-day and six-month death or recurrent MI across income categories, after adjusting for baseline characteristics.

RESULTS

Low-income patients had more chronic medical conditions and were sicker at presentation. Among low-income patients, the use of some evidence-based medications and cardiac procedures was lower and the unadjusted rates of 30-day death and six-month death or MI was higher. After multivariable adjustment, there was no consistent pattern for disparity in care processes, but the trend for higher short and intermediate-term death or MI persisted for low-income patients.

CONCLUSIONS

Income level is associated with a trend toward worse outcome among patients with acute coronary syndromes. The disparity in 30-day and six-month death or MI between low and high-income patients could not be readily explained by differences in in-hospital medical or invasive treatment, suggesting that the poor outcomes may be due to differences occurring after hospital discharge.

Early revascularisation and 1-year survival in 14-day survivors of acute myocardial infarction: a prospective cohort study

BACKGROUND

Randomised trials of early revascularisation in acute coronary syndromes have yielded conflicting results with respect to effects on survival. We assessed the association between revascularisation within 14 days after the index event and 1-year mortality in individuals who survived for at least 14 days after an acute myocardial infarction.

METHODS

We studied a prospective cohort of patients admitted to the coronary care units of 61 Swedish hospitals between 1995 and 1998. We obtained 1-year mortality data from the Swedish National Cause of Death Register. We assessed 21,912 individuals with first registry-recorded acute myocardial infarction, who were younger than age 80 years, and alive at day 14. Relative risk of 1-year mortality in patients who had revascularisation (n=2554) or those who did not (n=19,358) within 14 days was calculated by Cox regression analysis, adjusting for multiple covariates that affect mortality and with a propensity score that adjusted for covariates that affected the likelihood of early revascularisation.

FINDINGS

At 1 year, unadjusted mortality was 9.0% (1751 deaths) in the conservative group and 3.3% (84 deaths) in the early revascularisation group. In the Cox regression analysis early revascularisation was associated with a reduction in 1-year mortality (relative risk 0.47; 95% CI 0.37-0.60; p<0.001). This relative reduction of mortality was similar in all subgroups irrespective of age, sex, baseline characteristics, previous disease manifestations, or treatment.

INTERPRETATION

Early revascularisation in individuals with acute myocardial infarction is associated with substantial reduction in 1-year mortality. Our findings lend support to the use of an invasive approach early after an acute myocardial infarction.

Risk stratification in non-ST segment elevation acute coronary syndromes with special focus on recent guidelines

Patients with unstable angina or non-ST segment elevation (non-Q-wave) myocardial infarction are a heterogeneous group with respect to their risk of developing clinically significant adverse events such as subsequent myocardial infarction and death. Recent guidelines promote risk stratification of these patients, targeting high-risk patients for maximal antithrombotic and antiischemic therapy and low-risk patients for early discharge. We reviewed current and future modalities for risk stratification of patients and the predictive value of these methods in context with available pharmacologic agents. Unfortunately, most of the data identifying a particular pharmacologic regimen as beneficial in high-risk patients are retrospectively derived from large trials. Until prospective studies that use markers to guide therapy are available, clinicians should be familiar with the use of these risk markers and their application to the role of a given management strategy, including pharmacologic therapy.