The effects of quality improvement interventions on inhospital mortality after acute myocardial infarction.

OBJECTIVE: To evaluate the effects of quality improvement interventions on inhospital mortality after admission for acute myocardial infarction (AMI). DESIGN: Before-and-after study (with concurrent controls) based on hospital discharge data from a routinely maintained, administrative database. SETTING: All Queensland public hospitals, July 1991 - June 1999. STUDY POPULATION: Patients with AMI admitted through the emergency department. Intervention: Development and promulgation of clinical practice guidelines at one hospital, combined with regular audit and feedback, commencing November 1995. MAIN OUTCOME MEASURES: Inhospital mortality (adjusted for age, sex and comorbidities) for four-year periods before (1991-92 to 1994-95) and after (1995-96 to 1998-99) initiation of quality improvement interventions. RESULTS: Before the intervention, the adjusted odds ratio (OR) for inhospital death at the intervention hospital was about the same as at other public hospitals (adjusted OR, 0.99; 95% CI, 0.80-1.24), but was more than 40% lower after the intervention (adjusted OR, 0.59; 95% Cl, 0.45-0.78). After the intervention, the risk of death at the intervention hospital was lower compared with hospitals with cardiologists as admitting practitioners (adjusted OR, 0.63; 95% CI, 0.48-0.83), with onsite revascularisation facilities (adjusted OR, 0.66; 95% CI, 0.49-0.88), and with large numbers (> or = 250 per year) of annual admissions of patients with AMI (adjusted OR, 0.72; 95% CI, 0.54-0.97). CONCLUSIONS: Quality improvement interventions lower the risk of inhospital death in patients with AMI. Implementation of such interventions in all hospitals may confer a risk of death lower than that achieved by admitting all patients under the care of cardiologists, or to hospitals with revascularisation facilities or a high volume of admissions of patients with AMI.     

Clinical outcomes of percutaneous coronary intervention for chronic total occlusion lesions in remote hospitals without on-site surgical support

Background The safety of percutaneous coronary intervention （PCI） for chronic total occlusion （CTO） lesions in remote hospitals without surgical facilities remains unknown. This study aimed to evaluate three-year outcomes after CTO for PCI in ten centers around China where no on-site coronary artery bypass grafting （CABG） support was available. Methods A total of 152 patients from 10 Chinese hospitals without on-site surgical facilities were prospectively studied. Intra-procedural and in-hospital events were assessed. Angiographic follow-up was indexed eight months after the initial procedure. Clinical follow-up was extended to three years. The primary outcome was the rate of major adverse cardiac events （MACE）, defined as cardiac death, myocardial infarction and target-vessel revascularization （TVR）. Results The incidence of CTO was 7.9% in patients who underwent PCI, Successful recanalization was achieved in 132 patients （86.8%）. Compared with patients in the PCI success group, patients with PCI procedural failure had longer lesion lengths （（42.32±22.08） mm vs （27.61±22.85） mm, P=0.023）, a higher rate of perforation （25.0% vs 0, P=0.014）, and a greater need for pericardial puncture. There were significant differences in MACE in-hospital and at one year and three years between the failure （10.0%, 30.0% and 35.0%） and the success （3.0%, 12.1% and 14.4%） groups （P=0.037, 0.034 and 0.040, respectively）. These led to a significant decrease in the MACE-free survival rate at one and three years in the failure group, compared with the success group （P=0.031 and 0.023, respectively）. Stump was the only predictor of recanalization success （HR 0.158, 95% Cl 0.041-0.612, P=0.008）, whereas procedural failure （OR 13.023, 95% CI 6.67-13.69, P=0.002）, incomplete revascularization （OR 9.71, 95% CI 2.93-5.59, P=0.005）, and total stent length （OR 6.02, 95% Cl 1.55-11.93, P=0.027） were three independent predictors of MACE. Conclusions PCI for CTO was unsafe in remote hospitals without CABG facilities. Paying attention to coronary perforation is important for successful procedures.     

Differences in mortality and use of revascularization in black and white patients with acute MI admitted to hospitals with and without revascularization services

Context  Racial differences in the use of coronary revascularization after acute myocardial infarction (AMI) have been widely reported. However, few studies have examined patterns of care for AMI patients admitted to hospitals with and without revascularization services. Objective  To compare rates of hospital transfer, coronary revascularization, and mortality after AMI for black and white patients admitted to hospitals with and without revascularization services. Design, Setting, and Participants  Retrospective cohort study of 1 215 924 black and white Medicare beneficiaries aged 68 years and older, admitted with AMI between January 1, 2000, and June 30, 2005, to 4627 US hospitals with and without revascularization services. Main Outcome Measures  For patients admitted to nonrevascularization hospitals, transfer to another hospital with revascularization services; for all patients, risk-adjusted rates of 30-day coronary revascularization and 1-year mortality. Results  Black patients admitted to hospitals without revascularization were less likely (25.2% vs 31.0%; P<.001) to be transferred. Black patients admitted to hospitals with or without revascularization services were less likely to undergo revascularization than white patients (34.3% vs 50.2% and 18.3% vs 25.9%; P<.001) and had higher 1-year mortality (35.3% vs 30.2% and 39.7% vs 37.6%; P<.001). After adjustment for sociodemographics, comorbidity, and illness severity, blacks remained less likely to be transferred (hazard ratio [HR], 0.78; 95% confidence interval [CI], 0.75-0.81; P<.001) and undergo revascularization (HR, 0.71; 95% CI, 0.69-0.74; P<.001; and HR, 0.68; 95% CI, 0.65-0.70; P<.001 in hospitals with and without revascularization, respectively). Risk-adjusted mortality was lower for blacks during the first 30 days after admission (HR, 0.91; 95% CI, 0.88-0.93; P<.001; and HR, 0.90; 95% CI, 0.87-0.92; P<.001 in hospitals with and without revascularization, respectively) but was higher (P<.001) thereafter. Conclusions  Black patients admitted to hospitals with and without coronary revascularization services are less likely to receive coronary revascularization. The higher long-term mortality of black patients may reflect the lower use of revascularization or other aspects of AMI care.      

Guideline-discordant care in acute myocardial infarction: predictors and outcomes

OBJECTIVES: To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care. DESIGN: Retrospective cohort study. SETTING: Two community general hospitals. PARTICIPANTS: 607 consecutive patients admitted with AMI between July 1997 and December 2000. MAIN OUTCOME MEASURES: Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay. RESULTS: At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% CI, 1.7-3.6), silent infarction (OR, 2.7; 95% CI, 1.6-4.6), anterior infarction (OR, 2.5; 95% CI, 1.7-3.8), a history of heart failure (OR, 6.3; 95% CI, 3.7-10.7), chronic atrial fibrillation (OR, 3.2; 95% CI, 1.5-6.4); and heart rate >/= 100 beats/min (OR, 2.1; 95% CI, 1.4-3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% CI, 1.22-4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% CI, 0.90-7.1). CONCLUSIONS: Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI. Such care appears to increase the risk of inhospital death.     

药物洗脱支架与金属裸支架置入术后对糖尿病患者远期死亡、心肌梗死和支架血栓发生情况的影响

目的本研究通过比较糖尿病患者置入金属裸支架(bare metal stents,BMS)vs药物洗脱支架(drug eluting stents,DES)后发生死亡、心肌梗死(myocardial infarction,MI)、再次血运重建和支架血栓的情况,以评价糖尿病患者置入DES后的远期安全性和有效性。方法本研究于2003年7月～2005年12月连续入选了834例因冠心病合并糖尿病在首都医科大学附属北京安贞医院心内科行经皮冠状动脉介入治疗(percutaneous coronary intervention,PCI)的患者,按置入支架类型将患者分为DES组(n=583)和BMS组(n=251)。主要终点事件为24个月时全因病死率;次要终点事件为24个月时非致死性MI、再次血运重建以及主要不良心血管事件(major adverse cardiac events,MACE)的发生率。结果本研究结果经多因素回归分析显示,DES组明显降低了24个月时死亡[3.2%vs 5.1%,危险比(hazard ratio,HR)0.34,95%可信区间(confidential interval,CI)0.12～0.94,P=0.038]和心性死亡的风险(2.2%vs 4.4%,HR=0.29,95%CI:0.13～0.87,P=0.027),非致死性MI和心性死亡与非致死性MI复合终点发生风险比较差异无统计学意义;明确和可能的支架血栓的发生风险比较差异也没有统计学意义(1.9%vs 2.0%,HR=0.96,95%CI:0.51～2.17,P=0.351)。DES明显降低了再次血运重建的风险(10.5%vs 20.7%,HR=0.24,95%CI:0.11～0.78,P<0.001)和靶血管再次血运重建的风险(8.9%vs 17.1%,HR=0.33,95%CI:0.16～0.87,P<0.001);与BMS组比较DES组的MACE的风险也明显降低,差异有统计学意义(15.8%vs 27.9%,HR=0.19,95%CI:0.09～0.85,P<0.001);其主要与DES组患者的死亡和靶血管再次血运重建的风险降低有关。结论与BMS相比,DES可显著降低糖尿病患者的24个月时死亡、再次血运重建和MACE的风险,而未增加非致死性MI和支架血栓的风险。置入DES后死亡风险的降低原因,主要与DES降低再狭窄后的死亡和MI风险,获得更高的完全血运重建率以及未增加支架血栓的风险相关。     

Coronary angiography and coronary artery revascularisation rates in public and private hospital patients after acute myocardial infarction

OBJECTIVE: To determine the rates of coronary angiography or coronary artery revascularisation procedures in patients with acute myocardial infarction (AMI) managed in private versus public hospitals. DESIGN: Case record linkage analysis of data from the Victorian Inpatient Minimum Dataset for admissions for AMI in the 12 months after the index admission. SETTING: Victorian acute care hospitals from July 1995 to December 1997. PATIENTS: Victorian residents aged 15-85 years admitted to hospital with AMI. MAIN OUTCOME MEASURES: Rates of coronary angiography or coronary artery revascularisation procedures after AMI. RESULTS: Compared with public patients in public hospitals, patients with AMI managed in private hospitals were more likely to undergo coronary angiography (rate ratio [RR], 2.17; P< 0.001; 95% CI, 2.06-2.29), coronary angioplasty or stenting (RR, 3.05; P<0.001; 95% CI, 2.82-3.31), and coronary artery bypass grafting (RR, 1.95; P<0.001; 95% CI, 1.79-2.14). Once coronary angiography had been performed, patients in private hospitals were more likely to undergo angioplasty or stenting (RR, 1.94; P<0.001; 95% CI, 1.79-2.11), but were only marginally more likely to undergo coronary artery bypass grafting (RR, 1.17; P<0.001; 95% CI, 1.07-1.28). CONCLUSIONS: In Victoria, management of patients with acute myocardial infarction is influenced by the public or private status of the patient, and by whether management occurs in private or public hospitals. Patients are more likely to undergo coronary angiography and coronary artery revascularisation procedures in private hospitals.     

Primary coronary angioplasty vs thrombolysis for the management of acute myocardial infarction in elderly patients.

CONTEXT: Despite evidence from randomized trials that, compared with early thrombolysis, primary percutaneous transluminal coronary angioplasty (PTCA) after acute myocardial infarction (AMI) reduces mortality in middle-aged adults, whether elderly patients with AMI are more likely to benefit from PTCA or early thrombolysis is not known. OBJECTIVE: To determine survival after primary PTCA vs thrombolysis in elderly patients. DESIGN: The Cooperative Cardiovascular Project, a retrospective cohort study using data from medical charts and administrative files. SETTING: Acute care hospitals in the United States. PATIENTS: A total of 20683 Medicare beneficiaries, who arrived within 12 hours of the onset of symptoms, were admitted between January 1994 and February 1996 with a principal discharge diagnosis of AMI, and were eligible for reperfusion therapy. MAIN OUTCOME MEASURES: Thirty-day and 1-year survival. RESULTS: A total of 80356 eligible patients had an AMI at hospital arrival and met the inclusion criteria, of whom 23.2% received thrombolysis and 2.5% underwent primary PTCA within 6 hours of hospital arrival. Patients undergoing primary PTCA had lower 30-day (8.7% vs 11.9%, P=.001) and 1-year mortality (14.4% vs 17.6%, P=.001). After adjusting for baseline cardiac risk factors and admission and hospital characteristics, primary PTCA was associated with improved 30-day (hazard ratio [HR] of death, 0.74; 95% confidence interval [CI], 0.63-0.88) and 1-year (HR, 0.88; 95% CI, 0.73-0.94) survival. The benefits of primary coronary angioplasty persisted when stratified by hospitals' AMI volume and the presence of on-site angiography. In patients classified as ideal for reperfusion therapy, the mortality benefit of primary PTCA was not significant at 1-year follow-up (HR, 0.92; 95% CI, 0.78-1.08). CONCLUSION: In elderly patients who present with AMI, primary PTCA is associated with modestly lower short- and long-term mortality rates. In the subgroup of patients who were classified as ideal for reperfusion therapy, the observed benefit of primary PTCA was no longer significant.     

Sex differences in evaluation and outcome of unstable angina

CONTEXT: The existence of sex bias in the delivery of cardiac care is controversial, and little is known about the association between sex and delivery of care and outcomes at an early point in the diagnostic sequence, such as when patients present for the evaluation of chest pain. OBJECTIVE: To test the hypothesis that female sex is negatively associated with care delivered to and outcomes of persons diagnosed as having unstable angina. DESIGN: Inception population-based cohort study with an average of 6 years of follow-up. SETTING: Emergency departments (EDs) in Olmsted County, Minnesota. PATIENTS: A total of 2271 Olmsted County residents (1306 men and 965 women) who presented to the ED for the first time with symptoms meeting criteria for unstable angina between 1985 and 1992. MAIN OUTCOME MEASURES: Use of cardiac procedures within 90 days of ED visit, overall mortality, and cardiac events (cardiac death, nonfatal myocardial infarction, nonfatal cardiac arrest, and congestive heart failure), compared by sex and Agency for Health Care Policy and Research cardiovascular risk category (low, intermediate, or high). RESULTS: Women were older (P<.001), more likely to have a history of hypertension (P = .001), and less likely to present with typical angina (P = .004) than men. Men were more likely than women to undergo noninvasive cardiac tests (relative risk [RR], 1.27; 95% confidence interval [CI], 1.14-1.40) as well as invasive cardiac procedures (RR, 1.72; 95% CI, 1.51-1.97). After adjustment, male sex was associated with a 24% increase in the use of cardiac procedures. Survival of both men and women in the high and intermediate risk categories was significantly lower than expected per the general population (P<.001). Women had a worse outcome than men, but after multivariate adjustment, male sex was associated with a trend toward an increase in the risk of death (RR, 1.23; 95% CI, 0.99-1.54) and significantly associated with increased risk of cardiac events (RR, 1.21; 95% CI, 1.03-1.42). CONCLUSIONS: Our population-based data indicate that after an ED visit for symptoms of unstable angina, the use of cardiac procedures was lower in women, but after taking into account baseline characteristics, men experienced worse outcomes.     

Diagnostic and therapeutic procedures among Australian hospital patients identified as indigenous

OBJECTIVES: To determine whether hospital patients identified as Indigenous are less likely than other inpatients to have a principal procedure recorded, and the extent to which any disparity in procedure use can be explained by differences in patient, episode and hospital characteristics. DESIGN: Retrospective analysis of routinely collected administrative data from the National Hospital Morbidity Database (NHMD). SETTING: Australian public and private hospitals. PATIENTS: All patients included in the NHMD whose episode type was recorded as acute and whose separation occurred between 1 July 1997 and 30 June 1998. Patients admitted for routine dialysis treatment were excluded. MAIN OUTCOME MEASURE: Whether a principal procedure was recorded. RESULTS: In public hospitals, patients identified as Indigenous were significantly less likely than other patients to have a principal procedure recorded, even after adjusting for patient, episode and hospital characteristics (adjusted odds ratio [OR], 0.67; 95% CI, 0.66-0.68). This disparity was apparent for most diseases and conditions. In private hospitals, no significant difference was observed (adjusted OR, 0.94; 95% CI, 0.83-1.06). CONCLUSIONS: The disparity in procedure use after adjustment for relevant factors indicates that in Australian public hospitals there may be systematic differences in the treatment of patients identified as Indigenous.     

Queuing for coronary angiography during severe supply-demand mismatch in a US public hospital: analysis of a waiting list registry.

CONTEXT: Adverse cardiac events have been reported in patients waiting for either coronary surgery or angioplasty. However, data on the risk of adverse events while awaiting coronary angiography are limited, and none are available from a US population. OBJECTIVE: To quantify cardiac outcomes in patients waiting for elective coronary angiography. DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 381 adult outpatients (mean [SD] age, 55 [12] years; 64% male; 61% white) on a waiting list for coronary angiography at a US tertiary care public teaching hospital during 1993-1994. MAIN OUTCOME MEASURES: Rates of cardiac death, nonfatal myocardial infarction, and hospitalizations for unstable angina or heart failure as a function of amount of time spent on a waiting list. RESULTS: Sixty-six patients were dropped from the waiting list but were included in the study analysis. During a mean (SD) follow-up of 8.4 (6.5) months, cardiac death, myocardial infarction, and hospitalization occurred in 6 (1.6%), 4 (1.0%), and 26 (6.8%) patients, respectively. The probability of events was minimal in the first 2 weeks and increased steadily between 3 and 13 weeks. By Cox multivariate analysis, 2 variables independently identified an increased risk of adverse events: a strongly positive treadmill exercise electrocardiogram or positive stress imaging result at referral (odds ratio [OR], 2.32; 95% confidence interval [CI], 1.22-4.16; P=.01) and the use of 2 to 3 anti-ischemic medications (OR, 1.98; 95% CI, 1.19-3.96; P=.04). Among 311 patients who ultimately underwent angiography, those with adverse events had a higher prevalence of coronary disease (96% vs 60%; P<.001), more frequently required revascularization (93% vs 53%; P<.001), and had longer hospital stays (mean [SD], 6.2 [4.3] vs 1.3 [0.7] days; P=.001). CONCLUSION: Our data suggest that in a cohort referred for coronary angiography, delaying the procedure places some patients at risk for death, myocardial infarction, unplanned hospitalization, a longer hospital stay, and, potentially, a poorer prognosis. Waits longer than 2 weeks should be avoided, and patients with strongly positive stress test results and those who require 2 to 3 anti-ischemic medications should be prioritized for early intervention.     

Ability of minor elevations of troponins I and T to predict benefit from an early invasive strategy in patients with unstable angina and non-ST elevation myocardial infarction: results from a randomized trial.

CONTEXT: Cardiac troponins I (cTnI) and T (cTnT) are useful for assessing prognosis in patients with unstable angina and non-ST-segment elevation myocardial infarction (UA/NSTEMI). However, the use of cardiac troponins for predicting benefit of an invasive vs conservative strategy in this patient population is not clear. OBJECTIVE: To prospectively test whether an early invasive strategy provides greater benefit than a conservative strategy in acute coronary syndrome patients with elevated baseline troponin levels. DESIGN: Prospective, randomized trial conducted from December 1997 to June 2000. SETTING: One hundred sixty-nine community and tertiary care hospitals in 9 countries. PARTICIPANTS: A total of 2220 patients with acute coronary syndrome were enrolled. Baseline troponin level data were available for analysis in 1821, and 1780 completed the 6-month follow-up. INTERVENTIONS: Patients were randomly assigned to receive (1) an early invasive strategy of coronary angiography between 4 and 48 hours after randomization and revascularization when feasible based on coronary anatomy (n = 1114) or (2) a conservative strategy of medical treatment and, if stable, predischarge exercise tolerance testing (n = 1106). Conservative strategy patients underwent coronary angiography and revascularization only if they manifested recurrent ischemia at rest or on provocative testing. MAIN OUTCOME MEASURE: Composite end point of death, MI, or rehospitalization for acute coronary syndrome at 6 months. RESULTS: Patients with a cTnI level of 0.1 ng/mL or more (n = 1087) experienced a significant reduction in the primary end point with the invasive vs conservative strategy (15.3% vs 25.0%; odds ratio [OR], 0.54; 95% confidence interval [CI], 0.40-0.73). Patients with cTnI levels of less than 0.1 ng/mL had no detectable benefit from early invasive management (16.0% vs 12.4%; OR, 1.4; 95% CI, 0.89-2.05; P<.001 for interaction). The benefit of invasive vs conservative management through 30 days was evident even among patients with low-level (0.1-0.4 ng/mL) cTnI elevation (4.4% vs 16.5%; OR, 0.24; 95% CI, 0.08-0.69). Directionally similar results were observed with cTnT. CONCLUSION: In patients with clinically documented acute coronary syndrome who are treated with glycoprotein IIb/IIIa inhibitors, even small elevations in cTnI and cTnT identify high-risk patients who derive a large clinical benefit from an early invasive strategy.     

Rates of percutaneous coronary interventions and bypass surgery after acute myocardial infarction in Indigenous patients

OBJECTIVE: To compare rates of percutaneous coronary interventions (PCI) and bypass surgery after acute myocardial infarction (AMI) in Indigenous and non-Indigenous patients. DESIGN: Cohort study of public-sector patients who were followed up for 1 year using administrative hospital data. PARTICIPANTS AND SETTING: We followed up 14 683 public-sector patients admitted to Queensland hospitals for AMI between 1998 and 2002. Of these, 558 (3.8%) identified as Indigenous. OUTCOME MEASURES: Rates of PCI and bypass surgery, adjusted for differences between the Indigenous and non-Indigenous cohorts according to age, sex, socioeconomic status, remote residence, hospital characteristics, and comorbidities. RESULTS: The adjusted rate for PCI during the index admission was significantly lower by 39% (rate ratio [RR], 0.61; 95% CI, 0.38-0.98) among Indigenous versus non-Indigenous patients with AMI; the adjusted rate for subsequent PCI was significantly lower by 28% (RR, 0.72; 95% CI, 0.54-0.96). Adjusted rates for bypass surgery were similar in the two cohorts. For any coronary procedure (ie, PCI or bypass surgery), the adjusted rate was significantly lower by 22% (RR, 0.78; 95% CI, 0.64-0.94) among Indigenous patients with AMI. Diabetes, chronic renal failure, pneumonia, and chronic rheumatic fever were at least twice as common among Indigenous patients with AMI as in the rest of the cohort, and chronic bronchitis and emphysema and heart failure were at least 60% more common. If a patient had at least one comorbidity, then their probability of having a coronary procedure was reduced by 40%. CONCLUSIONS: There are likely to be several reasons for the lower rates of coronary procedures among Indigenous patients, but their high rates of comorbidities and the association of comorbidities with lower procedure rates was an important finding. As investment in primary care can reduce the prevalence and severity of comorbidities, we suggest that adequate primary health care is a prerequisite for effective specialist care.     

One-year survival following early revascularization for cardiogenic shock

CONTEXT: Cardiogenic shock (CS) is the leading cause of death for patients hospitalized with acute myocardial infarction (AMI). OBJECTIVE: To assess the effect of early revascularization (ERV) on 1-year survival for patients with AMI complicated by CS. DESIGN: The SHOCK (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) Trial, an unblinded, randomized controlled trial from April 1993 through November 1998. SETTING: Thirty-six referral centers with angioplasty and cardiac surgery facilities. PATIENTS: Three hundred two patients with AMI and CS due to predominant left ventricular failure who met specified clinical and hemodynamic criteria. INTERVENTIONS: Patients were randomly assigned to an initial medical stabilization (IMS; n = 150) group, which included thrombolysis (63% of patients), intra-aortic balloon counterpulsation (86%), and subsequent revascularization (25%), or to an ERV group (n = 152), which mandated revascularization within 6 hours of randomization and included angioplasty (55%) and coronary artery bypass graft surgery (38%). MAIN OUTCOME MEASURES: All-cause mortality and functional status at 1 year, compared between the ERV and IMS groups. RESULTS: One-year survival was 46.7% for patients in the ERV group compared with 33.6% in the IMS group (absolute difference in survival, 13.2%; 95% confidence interval [CI], 2.2%-24.1%; P<.03; relative risk for death, 0.72; 95% CI, 0.54-0.95). Of the 10 prespecified subgroup analyses, only age (<75 vs >/= 75 years) interacted significantly (P<.03) with treatment in that treatment benefit was apparent only for patients younger than 75 years (51.6% survival in ERV group vs 33.3% in IMS group). Eighty-three percent of 1-year survivors (85% of ERV group and 80% of IMS group) were in New York Heart Association class I or II. CONCLUSIONS: For patients with AMI complicated by CS, ERV resulted in improved 1-year survival. We recommend rapid transfer of patients with AMI complicated by CS, particularly those younger than 75 years, to medical centers capable of providing early angiography and revascularization procedures.     

影响北京市心肌梗死病人应用急救医疗服务的因素

目的 调查北京市急性心肌梗死(AMI)病人急救医疗服务(EMS)应用率并探讨其影响因素.方法 多中心现况调查.入选2006年1月1日至12月31日期间就诊于北京市19所医院的789例ST段抬高心肌梗死(STEMI)病人.入院1周内,通过与病人进行结构式访谈及查阅病例记录收集资料.根据到达首诊医院的转运方式将病人分为EMS组和自行转运组,对比分析两组资料.结果 仅260例(33.0%)通过EMS转运到达首诊医院,其余529例(77.0%)通过自行转运到达.多元Logistic回归分析显示,年龄≥65岁(OR 1.530,95%CI 1.050～2.230,P=0.027)、大学及以上受教育程度(OR 2.032,95%CI,1.257～3.284,P=0.004)、冠心病史(OR 0.474,95%CI 1.049～2.458,P=0.029)、症状不能耐受(OR 0.592,95%CI 1.090～2.520,P=0.008)、焦虑(OR 0.760,95%CI 1.238～3.695,P=0.006)以及将症状归于心脏病(OR 0.402,95%CI 1.020～2.171,P=0.041)是应用EMS的独立预测因素.而梗死前心绞痛显著较少了EMS应用(OR 0.626,95% CI 0.431～0.907,P=0.013).结论 北京市仅1/3的STEMI病人发病后选择EMS转运.社会人口学、冠心病史、症状特点和认知因素等影响了病人对EMS的应用.     

Racial differences in mortality among men hospitalized in the Veterans Affairs health care system

CONTEXT: Racial disparities in health care delivery and outcomes may be due to differences in health care access and, therefore, may be mitigated in an equal-access health care system. Few studies have examined racial differences in health outcomes in such a system. OBJECTIVE: To study racial differences in mortality among patients admitted to hospitals in the Veterans Affairs (VA) system, a health care system that potentially offers equal access to care. DESIGN, SETTING, AND PARTICIPANTS: Cohort study of 28 934 white and 7575 black men admitted to 147 VA hospitals for 1 of 6 common medical diagnoses (pneumonia, angina, congestive heart failure, chronic obstructive pulmonary disease, diabetes, and chronic renal failure) between October 1, 1995, and September 30, 1996. MAIN OUTCOME MEASURES: The primary outcome measure was 30-day mortality among black compared with white patients. Secondary outcome measures were in-hospital mortality and 6-month mortality. RESULTS: Overall mortality at 30 days was 4.5% in black patients and 5.8% in white patients (relative risk [RR], 0.77; 95% confidence interval [CI], 0.69-0.87; P =.001). Mortality was lower among blacks for each of the 6 medical diagnoses. Multivariate adjustment for patient and hospital characteristics had a small effect (RR, 0.75; 95% CI, 0.66-0.85; P<.001). Black patients also had lower adjusted in-hospital and 6-month mortality. These findings were consistent among all subgroups evaluated. CONCLUSIONS: Black patients admitted to VA hospitals with common medical diagnoses have lower mortality rates than white patients. The survival advantage of black patients is not readily explained; however, the absence of a survival disadvantage for blacks may reflect the benefits of equal access to health care and the quality of inpatient treatment at VA medical centers.     

Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study

CONTEXT: Right heart catheterization (RHC) is commonly performed before high-risk noncardiac surgery, but the benefit of this strategy remains unproven. OBJECTIVE: To evaluate the relationship between use of perioperative RHC and postoperative cardiac complication rates in patients undergoing major noncardiac surgery. DESIGN: Prospective, observational cohort study. SETTING: Tertiary care teaching hospital in the United States. PATIENTS: Patients (n = 4059 aged >/=50 years) who underwent major elective noncardiac procedures with an expected length of stay of 2 or more days between July 18, 1989, and February 28, 1994. Two hundred twenty one patients had RHC and 3838 did not. MAIN OUTCOME MEASURE: Combined end point of major postoperative cardiac events, including myocardial infarction, unstable angina, cardiogenic pulmonary edema, ventricular fibrillation, documented ventricular tachycardia or primary cardiac arrest, and sustained complete heart block, classified by a reviewer blinded to preoperative data. RESULTS: Major cardiac events occurred in 171 patients (4.2%). Patients who underwent perioperative RHC had a 3-fold increase in incidence of major postoperative cardiac events (34 [15.4%] vs 137 [3.6%]; P<.001). In multivariate analyses, the adjusted odds ratios (ORs) for postoperative major cardiac and noncardiac events in patients undergoing RHC were 2.0 (95% confidence interval [CI], 1.3-3.2) and 2.1 (95% CI, 1.2-3.5), respectively. In a case-control analysis of a subset of 215 matched pairs of patients who did and did not undergo RHC, adjusted for propensity of RHC and type of procedure, patients who underwent perioperative RHC also had increased risk of postoperative congestive heart failure (OR, 2.9; 95% CI, 1.4-6.2) and major noncardiac events (OR, 2.2; 95% CI, 1.4-4.9). CONCLUSIONS: No evidence was found of reduction in complication rates associated with use of perioperative RHC in this population. Because of the morbidity and the high costs associated with RHC, the impact of this intervention in perioperative care should be evaluated in randomized trials.     

Sex differences in cardiac catheterization: the role of physician gender.

CONTEXT: Many studies indicate that women are less likely than men to undergo cardiac procedures after an acute myocardial infarction (AMI), raising concerns of sexual bias in clinical care. However, no data exist regarding the relationship between patient sex, physician sex, and use of cardiac procedures. OBJECTIVE: To determine whether sex differences in cardiac catheterization after AMI were greater when patients were treated by male attending physicians compared with female attending physicians. DESIGN, SETTING, AND PATIENTS: Analysis of data from the Cooperative Cardiovascular Project, a retrospective medical record review. A total of 104 >231 Medicare fee-for-service beneficiaries who were hospitalized in US acute care hospitals for an AMI between January 1994 and February 1995. MAIN OUTCOME MEASURE: Use of cardiac catheterization within 60 days of admission, compared between the 4 groups of patient sex-physician sex combinations. RESULTS: Women underwent fewer cardiac catheterizations than men when treated by either male physicians (38.6% vs 50.8%; P =.001) or female physicians (34.8% vs 45.8%; P =.001). Sex differences in procedure use were not greater when a patient and physician were of different sexes (P for interaction =.85). After potential confounders in multivariable analysis were accounted for, women were less likely to undergo cardiac catheterization (risk ratio, 0.90 [95% confidence interval (CI), 0.88-0.92]), regardless of the treating physician's sex. Patients treated by male physicians were more likely to undergo cardiac catheterization (risk ratio, 1.06 [95%CI, 1.02-1.10]) than those treated by female physicians, regardless of patient sex. CONCLUSIONS: Women who have had an AMI undergo a cardiac catheterization less often than men, whether treated by a male or female physician. These results suggest that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.     

急性心肌梗死并发脑卒中的多因素Logistic回归分析

目的分析急性心肌梗死(AMI)后发生脑卒中的患者在接受或不接受溶栓疗法的情况下,其脑卒中的发生率以及危险因素和对疾病转归的影响。方法运用统计学方法对本院1995～2010年间,收治的1 232例AMI患者进行统计分析。结果本组有14例(1.1%)在住院期间发生了脑卒中,年龄>60岁(OR 5.5;95%CI 2.8～10.9;P<0.001),收缩压>21.3 kPa(160 mmHg)(OR 3.7;95%CI 1.5～8.7;P<0.05),是AMI后并发脑卒中的独立预测因素。结论脑卒中是AMI的一种罕见且严重的并发症,入院时,年龄较大、高收缩压是脑卒中的独立危险因素。     

Waiting for coronary revascularization in Toronto: 2 years' experience with a regional referral office.

OBJECTIVES: To determine the frequency of major adverse events among patients awaiting coronary revascularization; to assess the match between referring physicians' estimates of urgency, a computer-generated multifactorial urgency rating score and actual waiting times; to determine the changes in waiting times as capacity for bypass surgery increased; and to evaluate the influence of choice of procedure or operator on waiting times. DESIGN: Consecutive case series. SETTING: Greater Toronto region. SUBJECTS: All 571 patients referred to an organized referral office by cardiologists at hospitals without on-site revascularization facilities between Jan. 3, 1989, and June 30, 1991. MAIN OUTCOME MEASURES: Preoperative fatal or nonfatal myocardial infarction; proportions of patients waiting longer than the maximum period recommended for their urgency rating; mean waiting times for various subgroups; and correlations among referring physicians' urgency ratings, computer-generated multifactorial urgency scores and waiting times. RESULTS: Of the 496 patients accepted for a procedure 5 had fatal cardiac events and 3 nonfatal myocardial infarction. Events occurred three times more often in patients with left mainstem disease than in those in other anatomic categories (relative risk [RR] 3.05, 95% confidence interval [CI] 1.48 to 6.27, p = 0.03). Both the computer-generated scores and the referring physicians' scores were correlated with the actual waiting time (r = 0.46 and 0.57 respectively). Waiting times and the proportion of patients with excessive waiting times fell during the study period (p < 0.0001). However, urgent cases were much less likely to be done "on time" than those with a recommended waiting time of more than 2 weeks (RR 0.16, 95% CI 0.11 to 0.25, p < 0.0001). The mean wait for coronary artery bypass grafting (CABG) was 22.73 days if the referral office was allowed to find a surgeon or interventional cardiologist and 35.31 days if one was requested (p = 0.002 after adjustment for urgency scores). CONCLUSIONS: Death of a patient on the waiting list is uncommon in an organized referral system. Patients with left main-stem disease are at higher risk of death than those in other anatomic categories. There were significant correlations between referring physicians' ratings of urgency, multifactorial urgency scores and actual waiting times. Expansion of capacity for CABG led to shorter waiting times, but patients with unstable symptoms continued to wait longer than recommended. Requests for a specific surgeon caused significantly longer delays.     

Opening of specialty cardiac hospitals and use of coronary revascularization in medicare beneficiaries

Context  Although proponents argue that specialty cardiac hospitals provide high-quality cost-efficient care, strong financial incentives for physicians at these facilities could result in greater procedure utilization. Objective  To determine whether the opening of cardiac hospitals was associated with increasing population-based rates of coronary revascularization. Design, Setting, and Patients  In a study of Medicare beneficiaries from 1995 through 2003, we calculated annual population-based rates for total revascularization (coronary artery bypass graft [CABG] plus percutaneous coronary intervention [PCI]), CABG, and PCI. Hospital referral regions (HRRs) were used to categorize health care markets into those where (1) cardiac hospitals opened (n = 13), (2) new cardiac programs opened at general hospitals (n = 142), and (3) no new programs opened (n = 151). Main Outcome Measures  Rates of change in total revascularization, CABG, and PCI using multivariable linear regression models with generalized estimating equations. Results  Overall, rates of change for total revascularization were higher in HRRs after cardiac hospitals opened when compared with HRRs where new cardiac programs opened at general hospitals and HRRs with no new programs (P<.001 for both comparisons). Four years after their opening, the relative increase in adjusted rates was more than 2-fold higher in HRRs where cardiac hospitals opened (19.2% [95% confidence interval {CI}, 6.1%-32.2%], P<.001) when compared with HRRs where new cardiac programs opened at general hospitals (6.5% [95% CI, 3.2%-9.9%], P<.001) and HRRs with no new programs (7.4% [95% CI, 3.2%-11.5%], P<.001). These findings were consistent when rates for CABG and PCI were considered separately. For PCI, this growth appeared largely driven by increased utilization among patients without acute myocardial infarction (42.1% [95% CI, 21.4%-62.9%], P<.001). Conclusion  The opening of a cardiac hospital within an HRR is associated with increasing population-based rates of coronary revascularization in Medicare beneficiaries.