Mortality from acute myocardial infarction before and after establishment of a coronary care unit

Ineffectiveness of the measurement of 'routine' vital signs for adult inpatients with community-acquired pneumonia

More frequent vital sign evaluation does not result in a statistically significant difference in survival or the number of transfers to the intensive care unit (for progression of disease) after adjusting for age, gender, duration of intravenous antibiotics and comorbid conditions.

Ineffectiveness of measuring routine vital signs in adult inpatients with deep venous thrombosis

The purpose of this study was to evaluate the benefit, if any, of routine monitoring of vital signs on clinical outcomes in hospitalized patients with deep venous thrombosis (DVT). One hundred forty-nine patients with DVT included in this study were categorized into two groups: those that underwent measurement of vital signs every 6 hours or those that had vital signs measured every 8 hours. Vital signs included pulse, blood pressure, respiratory rate, and temperature. Frequency of measurement of vital signs did not alter average length of star, for patients with every-4-hours measurement, this was 5.16 days and was not statistically significant from patients with every-8-hours measurement, who stayed an average of 4.85 days (p = 0.507). Similarly, more frequent vital sign evaluation did not result in a statistically significant difference in survival, progression of disease, nor did it predict the disposition of the patient. These results suggest that present frequency of measurement of vital signs is not cost or time effective because they do not result in a favorable outcome, length of stay, or disposition. The study further serves to highlight the need for an individualized assessment of vital sign measurement, because this will also lead to a more efficient allocation of hospital resources.

Early mortality of acute myocardial infarction in patients with and without prior coronary revascularization surgery. A Coronary Artery Surgery Study Registry Study

BACKGROUND

The Coronary Artery Surgery Study (CASS) Registry is used to evaluate the effect of various baseline clinical and angiographic factors on mortality after acute out-of-hospital myocardial infarction (MI) in patients with and without prior coronary bypass surgery.

METHODS AND RESULTS

Among the CASS Registry patients, there were 985 medical and 369 surgical patients who had an MI out of the hospital within 3 years after enrollment. In the medical group, 20% died before hospitalization. Medical patients with baseline three-vessel disease or left ventricular (LV) dysfunction were at high risk of immediate death. For medical patients who were hospitalized with MI, mortality was higher for older patients and those with severe angina as well as for those with extensive disease and LV dysfunction. The total 30-day mortality for medical patients was 36%. In the surgical group, 12% died before hospitalization. Surgical patients with LV dysfunction or prior MI were at highest risk of immediate death. For surgical patients hospitalized with MI, mortality was significantly increased only for patients with baseline LV dysfunction. Mortality was not significantly higher for surgical patients with multivessel disease. The total 30-day mortality for surgical patients was 21%. The prior use of aspirin or beta-blockers was not associated with reduced mortality from subsequent MI for either medical or surgical patients. Although the prevalence of cigarette smoking was high among patients who had an MI, cigarette smoking did not alter the infarct-related mortality rate.

CONCLUSIONS

The surgical group had lower mortality rates than the medical group both immediately (p = 0.001), after hospitalization (p less than 0.0001), and at 30 days (p less than 0.0001).

Validation of a coronary prognostic index for the Chinese--a tale of three cities

In order to confirm the efficacy of a new coronary prognostic index for the prediction of mortality of acute myocardial infarction in the Chinese in general, this index was applied to 886 patients from six general hospitals in Hong Kong (435 patients), Guangzhou (212 patients) and Shanghai (239 patients), respectively. They could be successfully stratified into seven clinical subsets with stepwise increasing mortality. The overall mortality tallied with that predicted by the original coronary prognostic index. The efficacy of this prognostic index for the prediction of mortality from acute myocardial infarction among the Chinese is verified and its application in the objective assessment of patients with acute myocardial infarction is recommended.

Management of acute myocardial infarction

This article presents plans of therapy based on current knowledge of pathophysiologic mechanisms, taking into consideration the rapid changes in availability of new drugs (or new experiences with old drugs) and new therapeutic interventions. Persistence of ischemic pain in the acute phase, or its recurrence during early convalescence, is a signal of a high-risk state for additional coronary events, and aggressive measures are required to prevent them. The indications, and the role of invasive hemodynamic monitoring in the treatment of left ventricular failure and/or hypotension, are discussed.

Hearts too good to die: an evaluation of coronary care

Intensive coronary care has become the standard treatment for acute myocardial infarction, and no self-respecting hospital would be without its coronary care unit. However, literature review to evaluate the contribution of coronary care shows that its promise may have been overstated and its benefits overestimated.

Myocardial ischemia. Towards better use of the coronary care unit

The coronary care unit is an expensive facility. Attempts to prove its value have not been successful, and the difficulty of doing so is considerable. In the absence of proof, it is nevertheless still necessary to establish a reasonable approach to the use of this facility. Such an approach and the evidence in its support are summarized. Pending the acquisition of more accurate predictors of risk, the following arbitrary guidelines are suggested. The coronary care unit is an appropriate environment for the management of dangerous arrhythmias and the major complications of infarction, for the management of resting angina until asymptomatic for 24 hours, and for the management of uncomplicated infarction in the absence of all predictors of risk for a period of 24 hours after the last episode of ischemic pain. Longer observation may be desirable for patients with certain predictors of short-term risk.

Acute myocardial infarction: survey of urban and rural hospital mortality

Mortality rates for acute myocardial infarction (AMI) in the province of Manitoba were studied by a retrospective, randomized survey of urban and rural hospital records. Urban hospitals had formal coronary care unit (CCU). Selected rural hospitals lacked CCUs but usually possessed portable monitoring and defibrillation equipment. Twenty-seven percent of 852 cases in the study population died. The mortality rate for unequivocal AMI was 14% to 15% to both urban and rural hospitals. Patients with possible AMI had high mortality rates in both facilities (41% to 45%). Subgroup analysis of the definite AMI population failed to reveal statistically significant differences in urban vs rural mortality, although a consistent trend toward superior performance in urban centers was found. The magnitude of the potential of a rural hospital intervention program to reduce the AMI mortality nevertheless appeared to be small.

A Marxian interpretation of the growth and development of coronary care technology

Cost containment efforts will fail if they continue to ignore the structural relationships between health care costs and private profit in capitalist society. The recent history of coronary care shows that apparent irrationalities of health policy make sense from the standpoint of capitalist profit structure. Coronary care units (CCUs) gained wide acceptance, despite high costs. Studies of CCU effectiveness, using random controlled trials and epidemiologic techniques, do not show a consistent advantage of CCUs over non-intensive ward care or simple rest at home. From a Marxian perspective, the proliferation of CCUs and similar innovations is a complex historical process that includes initiatives by industrial corporations, cooperation by clinical investigators at academic medical centers, support by private philanthropies linked to corporate interests, intervention by state agencies, and changes in the health care labor force. Cost-effective methodology obscures the profit motive as a basic source of high costs and ineffective practices. Health-policy alternatives curtailing corporate involvement in medicine would reduce costs by restricting profit.

Effect of a coronary care unit on mortality from acute myocardial infarction

The mortality from acute myocardial infarction was compared for 2 years before the introduction of a coronary care unit (C.C.U.), and three and a half years after. The difference was not significant statistically (18% before, and 15% after). There was no reduction in the incidence of cardiac arrest in the C.C.U. period, but resuscitation from cardiac arrest was more successful. The results are considered in the light of previous studies, and the current status of coronary care in district general hospitals is discussed.

Protecting the medical commons: who is responsible?

The resources for medical care are clearly finite, but demands on those resources are growing rapidly. Of particular concern are the demands on those resources for medical practices of three kinds: those that pose conflicts between the interests of the individual and those of society; those of no value or of undetermined value; and those for potentially preventable conditions. Such practices must be evaluated in terms of social and medical priorities, and this requirement will become more urgent with the establishment of national health insurance. Who will make decisions is less clear, but it is not likely to be physicians alone. It is imperative that physicians and other health providers work closely with professionals from many fields, and with consumers, to ensure the availability and dissemination of information that will permit decisions that are in the best interests of society.