Specific comorbidity risk adjustment was a better predictor of 5-year acute myocardial infarction mortality than general methods

OBJECTIVE: To compare methods of risk adjustment in a population of individuals with acute myocardial infarction (AMI), in order to assist clinicians in assessing patient prognosis. STUDY DESIGN AND SETTING: A historical inception cohort design was established, with follow-up of or=66 years who had an AMI in 1994 or 1995 were selected (n = 4,874). The three risk-adjustment methods were the Ontario AMI prediction rule (OAMIPR), the D'Hoore adaptation of the Charlson Index, and the total number of distinct comorbidities. Logistic regression models were built including each of the adjustment methods, age, sex, socioeconomic status, previous AMI, and cardiac procedures at time of AMI. RESULTS: The OAMIPR had the highest C-statistic and R(2). CONCLUSION: Clinicians are advised to consider the specific comorbidities that are present, not merely their number, and those that emerge over time, not merely those present at the time of the infarct.     

绝经期前、后女性急性心肌梗死患者临床特点及危险因素

目的:探讨绝经期前、后女性急性心肌梗死(acutem yocardial infarction,AMI)患者的危险因素、发病特点、预后。方法:2007年1月～2011年1月北华大学附属医院收治的女性AMI患者310例,依据是否绝经及绝经年限分组并对危险因素、临床表现、并发症和入院30天病死率进行比较。结果:绝经前女性AMI患者与绝经后患者相比,高脂血症的发生率更低(OR=8.151,P=0.005);典型胸痛症状的发生与年龄(OR=0.881,P=0.001)及绝经年限(OR=2.600,P=0.025)差异有统计学意义;绝经年限与严重心律失常和心力衰竭(>KillipⅡ级)差异无统计学意义(P>0.05)。合并糖尿病和心力衰竭(>KillipⅡ级)是预测绝经后女性心肌梗死患者死亡率的独立危险因素(OR=1.081,P=0.043;OR=12.339,P<0.001)。结论:绝经期前、后女性心肌梗死患者具有不同的临床特点,应结合其临床特点,采取不同的预防和诊疗措施。     

农村居民急性心肌梗死住院及死亡人数变化趋势

目的 估价农村居民急性心肌梗死（ＡＭＩ）发病率与与死亡率的变化趋势。方法 回顾性调查了１９７６￣１９９５年ＡＭＩ住院及死亡病例,以每５年为一个阶段进行统计、对比。结果 第４阶段与第１阶段比较,农村ＡＭＩ住院人数增另了２６４．６％,死亡例数另了１２９．４％,住院病死率下降了３７．２％,女性住院人数显著高于男性,分别为３７５．０％和２０７．４％;女性住院病死率也高于男性住院病死率也高于男分别为１９．８     

Managing and analysing a large health-care system database for predicting in-hospital mortality among acute myocardial infarction patients.

There is increasing interest in the identification of predictors of risk for in-hospital mortality due to acute myocardial infarction (AMI). This study identified significant predictors of in-hospital mortality among AMI patients using a patient level clinical database. The study population consisted of 4167 cases admitted between October 1999 and April 2001 with a principal diagnosis of AMI to 36 hospitals in three US states. Of the 182 available variables in the clinical data set, 30 variables were used as candidate predictors, and 19 showed significant univariate association with AMI in-hospital mortality. By applying multiple logistic regression and stepwise selection, a final prediction model for AMI in-hospital mortality was developed. Variables included in the final model were age, arrived from cardiac rehabilitation centre, cardiopulmonary resuscitation (CPR) on arrival, Killip class, AMI with co-morbid conditions, AMI with complications, percutaneous transluminal coronary angioplasty (PTCA) performed, beta-blockers given, angiotensin-converting enzyme (ACE) inhibitors given, Plavix given. A 10-variable in-hospital mortality prediction model for AMI patients, which includes both risk factors and beneficial treatment procedures, was developed. chi(2) goodness of fit test suggested a good fit for the model.     

Chest pain in acute myocardial infarction among diabetic and non-diabetic patients

Considering that diabetic patients suffering from Acute Myocardial Infarction (AMI) may or may not have chest pain, this study aimed to compare the presence and intensity of chest pain in AMI between diabetic and non-diabetic patients. We conducted a cross-sectional study that included patients with AMI, aged ≥ 18 years, both sexes. We used a verbal numeric scale for assessing the presence and intensity of pain. The study included 88 patients, of whom 77 (87.5%) non-diabetic patients and 11 (12.5%) diabetics. The pain was present in 11 (100%) of diabetics and in 76 (98.7%) of non-diabetics. The intensity of pain in diabetics was 8.91 versus 8.23 in non-diabetic patients. The study showed similarity in the presence and intensity of chest pain between diabetic and non diabetic patients suffering from AMI.     

Pizza and risk of acute myocardial infarction

OBJECTIVES: Pizza eating has been favourably related to the risk of cardiovascular disease, but the data are limited. To evaluate the potential role of pizza consumption on the risk of acute myocardial infarction (AMI), we considered data from an Italian study. DESIGN: We conducted a hospital-based case-control study on 507 cases of nonfatal AMI and 478 controls in Milan, Italy, between 1995 and 1999. RESULTS: The multivariate odds ratios were 0.78 for occasional, 0.62 for regular and 0.44 for frequent eaters. The estimates were similar across strata of age, sex, smoking and other major covariates. CONCLUSIONS: Some of the ingredients of pizza have been shown to have a favourable influence on the risk of cardiovascular disease. However, there is no single explanation for the present findings. Pizza may in fact represent a general indicator of Italian diet, that has been shown to have potential cardiovascular benefits.     

老年急性ST抬高型心肌梗死院内死亡风险预警模型

目的分析老年急性ST抬高型心肌梗死(STEMI)患者短期预后风险，建立其院内死亡预警模型，早期识别胸痛中心老年高危人群，指导救治策略。 方法回顾性收集2019年11月至2020年1月经喀什地区第一人民医院胸痛中心入院的60岁及以上的老年STEMI患者252例，按7∶3比例随机分为建模队列和验证队列，以多因素回归分析筛出院内死亡风险因素，以R语言构建基于多因素回归分析结果的老年STEMI院内死亡风险预警列线图模型。 结果多因素回归分析筛出院内死亡风险因素血清肌酐、院内新发心衰、未用β受体阻滞剂、未行冠脉介入治疗(PCI)与院内死亡密切相关，并最终进入预测模型。模型队列和验证队列的AUC值分别为0.927(95% CI 0.846~0.947)和0.885(95% CI 0.816~0.893)。校准曲线显示该模型有良好的拟合度。 结论基于血清肌酐、院内新发心衰、未用β受体阻滞剂、未行PCI介入治疗等4个因素上建立的老年人STEMI院内死亡预测列线图模型，预测效能强，简单易用，可较准确、方便地预测老年STEMI患者院内死亡风险。     

Underuse of invasive procedures among Medicaid patients with acute myocardial infarction.

OBJECTIVES: The purpose of this study was to determine whether underuse of cardiac procedures among Medicaid patients with acute myocardial infarction is explained by or is independent of fundamental differences in age, race, or sex distribution; income, coexistent illness; or location of care. METHODS: Administrative data from 226 hospitals in New York were examined for 11,579 individuals hospitalized with a primary diagnosis of acute myocardial infarction. Use of various cardiac procedures was compared among Medicaid patients and patients with other forms of insurance. RESULTS: Medicaid patients were older, were more frequently African American and female, and had lower median household incomes. They also had a higher prevalence of hypertension, diabetes, lung disease, renal disease, and peripheral vascular disease. After adjustment for these and other factors, Medicaid patients were less likely to undergo cardiac catheterization, percutaneous transluminal coronary angioplasty, and any revascularization procedure. CONCLUSIONS: Factors other than age, race, sex, income, coexistent illness, and location of care account for lower use of invasive procedures among Medicaid patients. The influence of Medicaid insurance on medical practice and process of care deserves investigation.     

Occupational exposure to noise and mortality from acute myocardial infarction

BACKGROUND: Exposure to noise is highly prevalent in the workplace, and an etiologic association with cardiovascular disease has been hypothesized. Although there is evidence of hypertension among noise-exposed workers, evidence of heart disease has been less conclusive. METHODS: We identified a cohort of 27,464 blue-collar workers from 14 lumber mills in British Columbia who worked at least 1 year between 1950 and 1995 and who were followed up over the same period. Cumulative noise exposure was quantitatively assessed. Vital status was ascertained from the Canadian Mortality Database. We estimated standardized mortality ratios using the general population as referents, and we estimated relative risks using an internal low-exposure group as controls. To examine acute effects of noise, we assessed relative risks during subjects' working years in lumber mills. Because of the possibility of exposure misclassification as a result of hearing-protector use, we investigated a subgroup that had been employed before widespread use of protectors. RESULTS: During the follow-up period, 2510 circulatory disease deaths occurred. Relative risks for acute myocardial infarction mortality were elevated in the full cohort, with a stronger association in the subgroup without hearing protection. There was an exposure-response trend, with a relative risk in the highest exposed group of 1.5 (95% confidence interval=1.1-2.2). The highest relative risks (2.0-4.0) were observed during subjects' working years. Smoking did not appear to confound these associations. CONCLUSIONS: Chronic exposure to noise levels typical of many workplaces was associated with excess risk for acute myocardial infarction death. Given the very high prevalence of excess noise exposure at work, this association deserves further attention.     

急性心肌梗死患者近期预后的危险因素分析

目的探讨影响急件心肌梗死患者近期预后的危险因素,为改善急性心肌梗死患者的预后提供科学依据。方法选取2003-2008年山东省菏泽市牡丹区中医院419例急性心肌梗死患者作为研究对象,对相关危险因素进行单因素和多因素Logistic回归分析。结果2003-2008年笔者所在医院共收治419例急性心肌梗死患者,其中抢救无效死亡19例,病死率为4.53％。高龄、心肌梗死面积大、未及时溶栓、糖尿病、高血压、高血脂是影响心肌梗死患者近期预后的主要危险因素,OR值分别为1.462、3.205、2.390、2.401、2.133和1.650。结论影响急性心肌梗死患者近期预后的原因很多,及时给予尿激酶进行溶栓治疗,有效控制患者的血压、血糖和血脂浓度,可以改善急性心肌梗死患者的近期预后,降低病死率。     

急性心肌梗死住院患者发生医院感染的相关危险因素分析

目的 分析急性心肌梗死(AMI)住院患者发生医院感染的相关危险因素,以便制定相应预防措施.方法 对医院收治的AMI并发医院感染患者的病历资料进行回顾性分析.结果 整理、查阅AMI患者病历1739例,发生医院感染148例,AMI医院感染发病率为8.51％;发生感染部位呼吸道感染59例、尿路感染36例、皮肤软组织感染28例、消化道感染13例,其他12例,其中单一部位感染143例,≥2个部位感染5例;对148例AMI医院感染患者相关因素分析中,年龄、性别、住院天数、合并慢性基础疾病、抗菌药物应用、侵入性操作和免疫抑制剂、激素应用与医院感染发病明显相关,差异有统计学意义(P＜0.01).结论 AMI患者发生医院感染危险因素较多,发生率较高,对AMI患者的侵入性操作和抗菌药物应用等危险因素等应引起高度重视.     

青年与老年急性心肌梗死病变特点及其危险因素的对照研究

目的探讨青年(年龄≤40岁)急性心肌梗死(AMI)的相关因素.方法将36例年龄≤40岁的青年AMI与60例同期收治的年龄＞65岁的老年AMI进行回顾性对比,对其性别、危险因素、临床症状、并发症及预后等相关因素进行分析.结果青年组男性病例33例(占91.7%),有诱发因素20例(占55.5%),表现为典型心前区剧烈疼痛24例(占66.6%),高血脂10例(占27.8%),均高于老年组(P＜0.05).青年组多支冠脉病变仅9例(占25.0%),死亡仅1例(占2.8%),均低于老年组(P＜0.05).结论青年AMI男性发病率高,可有诱发因素,胸痛典型,死亡率低,预后好.     

Increased mortality in partners of female myocardial infarction patients

BACKGROUND: Many studies have been performed on the impact of Alzheimer's disease, stroke and cancer on carers. Information on the influence of a myocardial infarction in a patient on the health of the partner is still scarce. METHODS: Exposed and non-exposed partners were compared with respect to the occurrence of mortality and predefined diseases, using Cox proportional hazards survival analysis. RESULTS: None of the disease incidence rates differed between exposed partners and control partners. Over 12 times as many male partners of (female) heart patients died as compared to their male control partners, when they had a low educational level. CONCLUSION: When exposed to myocardial infarction in a patient, the risk of dying in low educated male partners was over 12 times as large as for male low educated unexposed partners.     

In-hospital mortality among rural Medicare patients with acute myocardial infarction: the influence of demographics, transfer, and health factors

Context/Purpose: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in‐hospital mortality predictors among rural transfer patients. Methods: Cross‐sectional retrospective analyses on 2003‐2005 Medicare hospital inpatient data from 5 states were conducted to compare predictors of in‐hospital AMI mortality between rural hospital transferred and nontransferred patients. A total of 9,690 rural hospital AMI patients were identified: 3,087 were transferred to receiving hospitals and 6,603 were not transferred. Separate logistic regressions were conducted for transferred and nontransferred patient cohorts and results were compared. Results: Transfer patients were younger, more likely male, had fewer comorbidities/complications, and were less likely to expire (5.3% vs 16.7%) in the hospital. Congestive heart failure and cardiac dysrhythmia were the most common comorbidities/complications among transfer and no‐transfer AMI patients, but shock (OR = 9.44) and acute renal failure (OR = 3.67) had the strongest associations with in‐hospital mortality for both cohorts. Undergoing a percutaneous coronary intervention (PCI) was associated with a 42% reduction in hospital mortality risk for transfer patients. Conclusions: Transfer was associated with a greater likelihood of in‐hospital AMI survival, largely but not fully explained by transfer patients being younger with fewer comorbidities/complications who are receiving advanced cardiac care. Additional studies are needed to clarify other factors that explain higher in‐hospital mortality among nontransfers, such as patients’ health care decision‐making.     

Impact of risk factors for non-fatal acute myocardial infarction

The impact of risk factors for acute myocardial infarction (AMI) strongly differs across populations and most studies do not consider age as an effect modifier. This study aims to estimate the population attributable fractions (PAFs) of established risk factors for non-fatal AMI, considering age stratification, within a population-based case–control study of Portuguese men. Cases were male patients consecutively admitted with an incident AMI, during 1999–2003 (n = 638) and controls were a representative sample of the non-institutionalized Porto, Portugal in-habitants (n = 851). PAFs were derived by the equation: PAF = 1 − Σ (ρ/R), in which ρ is the proportion of cases in each exposure stratum and R is the adjusted odds ratio. PAFs were obtained for the individual effect of each factor and for combinations of them, after allowance for confounding. High waist-to-hip ratio (>0.90), smoking and lower education levels (0–4 years) had the highest PAFs among men aged ≤45 years: 81.2% (95% CI: 71.2–88.2), 63.5% (95% CI: 42.0–80.6) and 53.8% (95% CI: 40.9–66.2), respectively. For the oldest men, high waist-to-hip ratio (PAF = 88.7%, 95% CI: 77.6–94.7) and lack of leisure-time physical activity (PAF = 44.8%, 95% CI: 32.0–58.2) were the risk factors with the highest impact. Lifestyles explained 77.2% (95% CI: 53.4–90.9) of young myocardial infarction cases and 77.6% (95% CI: 65.3–86.4) of the cases aged >45 years. Preventive targeted interventions to decrease the prevalence of such modifiable risk factors would likely reduce morbidity and mortality of cardiovascular events and related conditions.     

Neighbourhood social interactions and risk of acute myocardial infarction

STUDY OBJECTIVE: Previous studies of neighbourhood effects on ischaemic heart disease (IHD) have used census or administrative data to characterise the residential context, most commonly its socioeconomic level. Using the ecometric approach to define neighbourhood social interaction variables that may be relevant to IHD, neighbourhood social cohesion and safety were examined to see how they related to acute myocardial infarction (AMI) mortality, after adjustment for individual and neighbourhood confounders. DESIGN: To construct social interaction variables, multilevel models were used to aggregate individual perceptions of safety and cohesion at the neighbourhood level. Linking data from the Health Survey in Scania, Sweden, and the Population, Hospital, and Mortality Registers, multilevel survival models were used to investigate determinants of AMI mortality over a three year and nine month period. PARTICIPANTS: 7791 Individuals aged 45 years and over. MAIN RESULTS: The rate of AMI mortality increased with decreasing neighbourhood safety and cohesion. After adjustment for individual health and socioeconomic variables, low neighbourhood cohesion, and to a lesser extent low safety, were associated with higher AMI mortality. Neighbourhood cohesion effects persisted after adjustment for various neighbourhood confounding factors (income, population density, percentage of residents from low-income countries, residential stability) and distance to the hospital. There was some evidence that neighbourhood cohesion effects on AMI mortality were caused by effects on one-day case-fatality, rather than on incidence. CONCLUSIONS: Beyond commonly evoked effects of the physical environment, neighbourhood social interaction patterns may have a decisive influence on IHD, with a particularly strong effect on survival after AMI.     

Fiber intake and risk of nonfatal acute myocardial infarction

OBJECTIVE: To investigate the association between fiber intake and risk of acute myocardial infarction (AMI), also according to type and source of fiber, in a Mediterranean country. DESIGN: Hospital-based case-control study. SETTING: Northern Italy. SUBJECTS: A total of 507 cases of first nonfatal AMI and 478 controls in hospital for acute conditions. INTERVENTIONS: Subjects were interviewed with a questionnaire that included a validated food frequency section. Odds ratios (OR) were obtained using multiple logistic regression, and adjusted for several recognized risk factors for AMI. Fiber was measured as non-starch polysaccharides. RESULTS: Compared with the lowest one, the OR in the highest tertile was 0.72 for total fiber, 0.64 for soluble fiber, 0.77 for total insoluble fiber, 0.71 for cellulose, 0.81 for insoluble non-cellulosic polysaccharides, 0.82 for vegetable fiber, 0.64 for fruit fiber and 1.11 for cereal fiber, and the estimates were statistically significant for soluble and fruit fiber. When further adjusted for beta-carotene, vitamin C and vitamin E intake, the fruit fiber still showed the strongest inverse relation, although the association was no longer significant. The protective effect of fiber was more marked in, or restricted to, subjects with other AMI risk factors, such as smokers, diabetics and hypertensives. CONCLUSIONS: Though an inverse association between fiber intake and AMI risk appears established, the causality of this association is still open to debate. In this population, cereal fiber derives chiefly from refined grains, and this may explain the lack of protection by this type of fiber.     

Swan-Ganz catheter use and mortality of myocardial infarction patients

Using the 1989 Medicare provider analysis and review (MEDPAR) file, we calculated a 30-day indirectly standardized mortality ratio (SMR) for all "fresh" acute myocardial infarction (AMI) Medicare aged cases (i.e., fresh AMI patients are those who had not reported an AMI in the prior 8 weeks) at 2,900 hospitals, as well as an indirectly standardized procedure ratio (SPR) of Swan-Ganz catheter (SGC) use for these AMI cases at each hospital. Cases at hospitals with higher SGC SPRs also had higher SMRs. This positive association persisted when hospitals were further stratified by their annual volume of fresh AMI cases. We believe that our use of cases as the unit of observation, stratified by the SGC SPR of their hospital, avoids some case selection bias in observational studies directly comparing risk-adjusted mortality of cases with and without SGC.