Gout not induced by diuretics in a case-control study in general practice

OBJECTIVE: To determine the relation between diuretics and the development of gout, taking into account the possible confounding by hypertension and cardiovascular diseases. DESIGN: Case-control study. METHOD: With the aid of the data on morbidity and medication from the electronic medical files ofa dispensing general practitioner, all patients with a first gout registration during the period from October 1994 to September 2002 were identified as cases; in the same practice, for each patient, 3 controls of the same age and sex who were known not to have gout were selected at random. Conditional logistic regression analyses were carried out to estimate the odds ratio (OR) for gout in patients who had used diuretics for at least 3 months and in patients suffering from hypertension, heart failure, or myocardial infarction. The statistical interaction between variables was investigated after stratification for diuretic use. RESULTS: Via the medical files, 70 gout patients (59 men), with a mean age of 55.1 years (SD: 13.5) were identified, plus 210 matched controls. When assessed without correction, the use ofdiuretics seemed to be associated with a definite risk of gout: OR: 2.8 (95% CI: 1.2-6.6). But after adjustment for the cardiovascular variables hypertension, heart failure and myocardial infarction, the risk of gout associated with diuretic use disappeared: OR: 0.6 (95% CI: 0.2-2.0). An independent risk of gout was demonstrated for hypertension (OR: 3.9; 95% CI: 1.6-10.0), and to a lesser degree for myocardial infarction (OR: 1.5; 95% CI: 0-5-4.1). The risk of gout associated with heart failure was also calculated (OR: 40.1; 95% CI: 3.8-437.2), but diuretic independency could not be proven as all patients with heart failure were on diuretics and there was no heart failure among those not using diuretics. CONCLUSION: In this case-control study, the use of diuretics did not increase the risk of gout. The cardiovascular indications for prescribing diuretics were significant confounders.     

All-cause Mortality and Mortality of Myocardial Infarction for 989 Legally Castrated Men

Background: Male gender is an independent coronary risk factor. Method: Long-term follow-up of 989 Danish men who underwent legal castration between 1929 and 1968. Results: The legally castrated men were unmarried and belonged to social class IV and V more often than were Danish men in general. During the follow-up until 2000, 835 of the 989 (85%) castrated men died, including 148 who died of myocardial infarction. In multiple Poisson regression analyses, the men had a standardized mortality rate (SMR) for all-cause mortality of 1.30 (95% CI: 1.26–1.36) and a SMR for mortality of myocardial infarction of 1.08 (95% CI: 1.04–1.16). Thus, the castrated men had a lower proportion of deaths of myocardial infarction (148/792, 18.7% (95% CI: 16.0–21.6%)) than was expected based on the mortality rates for the Danish male population (136/608, 22.4%). The castrated men had discordant changes for the SMR for all-cause mortality and mortality of myocardial infarction whereas subgroups of the Danish population previously has been found to have concordant changes for the two SMRs. Conclusion: The castrated men had fewer deaths of myocardial infarction than expected, so men may not have increased risk of coronary heart disease from unphysiologically low levels of endogenous androgens. An erratum to this article is available at .     

Air pollution and emergency admissions in Boston, MA

STUDY OBJECTIVE: Many studies have shown that ambient particulate air pollution (PM) is associated with increased risk of hospital admissions and deaths for cardiovascular or respiratory causes around the world. In general these have been analysed in association with PM(10) and ozone, whereas PM(2.5) is now the particle measure of greatest health and regulatory concern. And little has been published on associations of hospital admissions and PM components. DESIGN: This study analysed hospital admissions for myocardial infarction (15 578 patients), and pneumonia (24 857 patients) in associations with fine particulate air pollution, black carbon (BC), ozone, nitrogen dioxide (NO(2)), PM not from traffic, and carbon monoxide (CO) in the greater Boston area for the years 1995-1999 using a case-crossover analysis, with control days matched on temperature. MAIN RESULTS: A significant association was found between NO(2) (12.7% change (95% CI: 5.8, 18)), PM(2.5) (8.6% increase (95% CI: 1.2, 15.4)), and BC (8.3% increase (95% CI: 0.2, 15.8)) and the risk of emergency myocardial infarction hospitalisation; and between BC (11.7% increase (95% CI: 4.8, 17.4)), PM(2.5) (6.5% increase (95% CI: 1.1, 11.4)), and CO (5.5% increase (95% CI: 1.1, 9.5)) and the risk of pneumonia hospitalisation. CONCLUSIONS: The pattern of associations seen for myocardial infarction and pneumonia (strongest associations with NO(2), CO, and BC) suggests that traffic exposure is primarily responsible for the association with heart attacks.     

Cost-Effectiveness of Treatments Reducing Coronary Heart Disease Mortality in Ireland, 2000 to 2010

Objective:  Coronary heart disease (CHD) is associated with a large burden of disease in Ireland and is responsible for more than 6000 deaths annually. This study examined the cost-effectiveness of specific CHD treatments in Ireland.
Methods:  Irish epidemiological data on patient numbers and median survival in specific groups, plus the uptake, effectiveness, and costs of specific interventions, all stratified by age and sex, were incorporated into a previously validated CHD mortality model, the IMPACT model. This model calculates the number of life-years gained (LYGs) by specific cardiology interventions to generate incremental cost-effectiveness ratios (ICERs) per LYG for each intervention.
Results:  In 2000, medical and surgical treatments together prevented or postponed approximately 1885 CHD deaths in patients aged 25 to 84 years, and thus generated approximately 14,505 extra life-years (minimum 7270, maximum 22,475). In general, all the cardiac interventions investigated were highly cost-effective in the Irish setting. Aspirin, beta-blockers, ACE inhibitors, spironolactone, and warfarin for specific conditions were the most cost-effective interventions (<€3000/LYG), followed by the statins for secondary prevention (<€6500/LYG). Revascularization for chronic angina and primary angioplasty for myocardial infarction, although still cost-effective, had the highest ICER (between €12,000 and €20,000/LYG).
Conclusions:  Using a comprehensive standardized methodology, cost-effectiveness ratios in this study clearly favored simple medical treatments for myocardial infarction, secondary prevention, angina, and heart failure.     

Myocardial infarction and acute cholecystitis: an application of sequence symmetry analysis

Using a statewide hospital discharge database and a novel epidemiology method, sequence symmetry analysis (Epidemiology. 1996;7:478-84), I examined the relative risk for hospital admission for acute cholecystitis after admission for myocardial infarction. In sequence symmetry analysis, the ratio of the number of subjects in a fixed population who experienced two events in a "causal" vs "noncausal" temporal sequence estimates the incidence rate ratio (IRR). Of 514 patients admitted for both myocardial infarction and acute cholecystitis during a 3-year window period, 295 were admitted for myocardial infarction first and 219 for acute cholecystitis first, yielding a null sequence-adjusted IRR of 1.45 [95% confidence interval (CI) = 1.28-1.64]. A similar analysis for a known relation (myocardial infarction-->congestive heart failure, N = 27,850) showed the expected association [adjusted IRR = 1.92 (95% CI = 1.88-1.95)], whereas an analysis for a relation hypothesized not to be strong (congestive heart failure-->acute cholecystitis, N = 775) showed only a small association [adjusted IRR = 1.16 (95% CI = 1.05-1.28)]. Subgroup analysis revealed time courses that supported each relation as causal. Hospitalization for myocardial infarction may increase the risk for subsequent hospitalization for acute cholecystitis.     

Assessing the impact of heart failure specialist services on patient populations

Background

The assessment of the impact of healthcare interventions may help commissioners of healthcare services to make optimal decisions. This can be particularly the case if the impact assessment relates to specific patient populations and uses timely local data. We examined the potential impact on readmissions and mortality of specialist heart failure services capable of delivering treatments such as b-blockers and Nurse-Led Educational Intervention (N-LEI).

Methods

Statistical modelling of prevented or postponed events among previously hospitalised patients, using estimates of: treatment uptake and contraindications (based on local audit data); treatment effectiveness and intolerance (based on literature); and annual number of hospitalization per patient and annual risk of death (based on routine data).

Results

Optimal treatment uptake among eligible but untreated patients would over one year prevent or postpone 11% of all expected readmissions and 18% of all expected deaths for spironolactone, 13% of all expected readmisisons and 22% of all expected deaths for b-blockers (carvedilol) and 20% of all expected readmissions and an uncertain number of deaths for N-LEI. Optimal combined treatment uptake for all three interventions during one year among all eligible but untreated patients would prevent or postpone 37% of all expected readmissions and a minimum of 36% of all expected deaths.

Conclusion

In a population of previously hospitalised patients with low previous uptake of b-blockers and no uptake of N-LEI, optimal combined uptake of interventions through specialist heart failure services can potentially help prevent or postpone approximately four times as many readmissions and a minimum of twice as many deaths compared with simply optimising uptake of spironolactone (not necessarily requiring specialist services). Examination of the impact of different heart failure interventions can inform rational planning of relevant healthcare services.     

Estimating utility values for health states of type 2 diabetic patients using the EQ-5D (UKPDS 62).

PURPOSE: The aim of this study was to analyze quality-of-life data from the United Kingdom Prospective Diabetes Study (UKPDS) to estimate the impact of diabetes-related complications on utility-based measures of quality of life. METHODS: The EuroQol EQ-5D instrument was administered in 1996 to 3667 UKPDS patients with type 2 diabetes. Tobit and censored least absolute deviations (CLAD) regression analysis based on data from the 3192 respondents was used to estimate the impact of major complications on (1) the visual analog scale (VAS) and (2) the EQ-5D utilities derived from population-based time trade-off values. RESULTS: Using the tobit model, the effect on tariff values was as follows: myocardial infarction = -0.055 (95% confidence interval [CI] = -0.067, -0.042), blindness in 1 eye = -0.074 (95% CI= -0.124, -0.052), ischemic heart disease = -0.090 (95% CI = -0.126, -0.054), heartfailure = -0.108 (95% CI= -0.169, -0.048), stroke = -0.164 (95% CI = -0.222, -0.105), and amputation = -0.280 (95% CI = -0.389, -0.170). The impact on the VAS scores was smaller, but the ranking was identical. Estimates of these effects, based on the nonparametric CLAD estimator, are also reported and compared. CONCLUSION: These results demonstrate the magnitude of the impact of 6 complications on utility-based measures of quality of life, which can be used to estimate the outcome of interventions that reduce these diabetes-related complications.     

Quantifying risk of adverse clinical events with one set of vital signs among primary care patients with hypertension

BACKGROUND: Hypertension is often uncontrolled. One reason might be physicians' reticence to modify therapy in response to single office measurements of vital signs. METHODS: Using electronic records from an inner-city primary care practice, we extracted information about vital signs, diagnoses, test results, and drug therapy available on the first primary care visit in 1993 for patients with hypertension. We then identified multivariable predictors of subsequent vascular complications in the ensuing 5 years. RESULTS: Of 5,825 patients (mean age 57 years) previously treated for hypertension for 5.6 years, 7% developed myocardial infarctions, 17% had strokes, 24% developed ischemic heart disease, 22% had heart failure, 12% developed renal insufficiency, and 13% died in 5 years. Controlling for other clinical data, a 10-mmHg increase in systolic blood pressure was associated with 13% increased risk (95% confidence interval [CI], 6%-21%) of renal insufficiency, 9% (95% CI, 3%-15%) increased risk of ischemic heart disease, 7% (95% CI, 3%-11%) increased risk of stroke, and 6% (95% CI, 2%-9%) increased risk of first stroke or myocardial infarction. A 10-mmHg elevation in mean blood pressure predicted a 12% (95% CI, 5%-20%) increased risk of heart failure. An increase in heart rate of 10 beats per minute predicted a 16% (95% CI, 2%-5%) increased risk of death. Diastolic blood pressure predicted only a 13% (95% CI, 4%-23%) increased risk of first stroke. CONCLUSIONS: Vital signs-especially systolic blood pressure-recorded routinely during a single primary care visit had significant prognostic value for multiple adverse clinical events among patients treated for hypertension and should not be ignored by clinicians.     

Unjustified variations in patient management for acute myocardial infarction in the Rhône-Alpes region of France. PRIMA Group

OBJECTIVES: To examine determinants of use of cardiac procedures after acute myocardial infarction and identify variation factors. METHODS: Observational prospective cohort study of 2,519 patients in 48 centers with a two-level logistic-regression analysis. RESULTS: Elderly patients were less likely to undergo pre- and inhospital thrombolysis (odds ratios, 0.71 and 0.64; 95% CI, 0.62-0.81 and 0.58-0.69, respectively). The elderly, females, and patients with heart failure on admission were less likely to undergo noninvasive tests (0.74, 0.62, and 0.51; 95% CI, 0.67-0.81, 0.46-0.83, and 0.38-0.68, respectively) and coronary angiography (0.38, 0.53, and 0.67; 95% CI, 0.34-0.42, 0.38-0.74, and 0.52-0.86, respectively) but not revascularization. Hospital factors were more difficult to interpret. CONCLUSIONS: Elderly, women, and heart failure patients underwent fewer cardiac procedures than lower-risk patients. Physicians should change their attitude toward these groups and use advanced procedures, bearing in mind the patients' needs rather than good procedural outcomes.     

Secondary prevention after myocardial infarction

The management of acute myocardial infarction has been revolutionized in the past decade. Advances in pharmacological and mechanical reperfusion therapy have improved the survival of patients who experience myocardial infarction. Although revascularisation techniques have been shown to reduce infarct size and in-hospital mortality, patients recovering from myocardial infarction are still at increased risk for reinfarction, congestive heart failure, and sudden death. Despite impressive technological advances, lifestyle modification and pharmacological interventions remain the key components of secondary prevention after myocardial infarction. Although the concept of secondary prevention of reinfarction and death has been investigated vigorously for several decades, preventive therapy has been seriously underused by physicians. The aim of this paper is to provide a comprehensive, evidence-based overview of secondary prevention postmyocardial infarction clinical trials, in the hope of improving the utilization of effective therapies in patients with coronary heart disease.     

Family history of coronary heart disease, a strong risk factor for myocardial infarction interacting with other cardiovascular risk factors: results from the Stockholm Heart Epidemiology Program (SHEEP)

We explored the relation between family history of coronary heart disease and the risk of myocardial infarction in a case-control study of subjects, 45 to 70 years of age, living in Stockholm, Sweden. Our cases comprised 1091 male and 531 female first-time acute myocardial infarction patients who had survived at least 28 days after their infarction. Referents were randomly selected from the population from which the cases were derived. The adjusted odds ratio (OR) of myocardial infarction was 2.0 (95% confidence interval [CI] = 1.6-2.6) for men reporting > or = 1 affected parent or sibling, compared with men with no family history of coronary heart disease, and 3.4 (95% CI = 2.1-5.9) for those reporting > or = 2 affected parents or siblings. The corresponding OR for women were 2.1 (95% CI = 1.5-3.0) and 4.4 (95% CI = 2.4-8.1). We found evidence for synergistic interactions in women exposed to family history of coronary heart disease in combination with current smoking and with a high quotient between low-density lipoprotein and high-density lipoprotein cholesterol (>4.0), respectively, which yielded adjusted synergy index scores of 2.9 (95% CI = 1.2-7.2) and 3.8 (95% CI = 1.5-9.7), respectively. Similarly, in men we found evidence for interaction for the co-exposure of family history of coronary heart disease and diabetes mellitus. Our study shows that family history of coronary heart disease is not only a strong risk factor for myocardial infarction in both sexes, but that its effect is synergistic with other cardiovascular risk factors as well.     

气温热浪与居民心脑血管疾病死亡关系的病例交叉研究

目的 探讨北京市气温热浪(热浪)对当地居民每日心脑血管疾病死亡人数的影响.方法 运用病例交叉设计方法,分析北京市1999年1月1日至2000年6月30日期间热浪对居民每日心脑血管疾病死亡人数的影响,同时研究其对每日急性心肌梗死(AMI)死亡人数的影响.选择死亡发生前第7天作为自身对照,分别计算不同长度的危险期OR值,以最高OR值及其对应的危险期来反映热浪过程对居民心脑血管疾病死亡人数影响的大小、滞后天数及持续时间.结果 研究期间共发生5次热浪.第1次持续9 d,最高气温为38.8℃,平均湿度为46.7%,居民每日心血管疾病死亡、脑血管疾病死亡和AMI死亡的OR值分别为1.384(95%CI:1.128～1,697)、1.776(95%CI:1.456～2.167)和1.276(95%CI:0.905～1.799);第2次热浪持续3 d,最高气温为36.8℃,平均湿度为61.0%,3种死因每日死亡的OR值分别为1.385(95%CI:0.678～2.826)、1.300(95%CI:0.726～2.329)和2.000(95%CI:0.684～5.851);第3次热浪持续7 d,最高气温为41.5℃,平均湿度为58.5%,3种死因每日死亡的OR值分别为2.613(95%CI:2.116～3.228)、2.317(95%CI:1.875～2.863)和3.088(95%CI:2.098～4.546);第4次持续3 d,最高气温为39.6℃,平均湿度为31.9%,3种死因每日死亡的OR值分别为1.333(95%CI:0.724～2.457)、2.429(95%CI:1.007～5.856)和3.333(95%CI:0.917～12.112);第5次热浪持续4d,最高气温为37.4℃,平均湿度为42.0%,3种死因每日死亡OR值分别为2.333(95%CI:1.187～4.588)、1.727(95%CI:0.822～3.630)和1.800(95%CI:0.603～5.371).结论 (1)热浪对居民心脑血管疾病死亡有影响,且存在滞后效应,滞后期为2～4d,其中AMI死亡的滞后期较短,为0～2d;(2)热浪开始当天日最高气温较前一天升温的幅度越大,对居民心脑血管疾病死亡人数影响的滞后期越短,死亡风险越大,对脑血管疾病死亡影响更大;(3)热浪期间日最高气温的波动可以增加居民心脑血管疾病死亡的风险.     

Factors affecting practice nurse involvement in follow-up care of patients following myocardial infarction

BACKGROUND: Preventive care can reduce the morbidity and mortality of patients following myocardial infarction. Recent evidence has shown that such care is not being provided effectively. The involvement of practice nurses has been proposed as a means of improving the completeness of follow-up and the quality of preventive care. OBJECTIVES: We aimed to determine the extent to which follow-up care for people discharged from hospital after a myocardial infarction is currently being undertaken by practice nurses and to assess the factors influencing the provision of such care and the nurses' attitudes towards this extended role. METHOD: Postal questionnaires were sent to 183 practice nurses working in general practices in the Southampton and South-West Hampshire Health District; 121 nurses responded (66%), representing 58 out of 64 practices surveyed (91%). RESULTS: The majority of responding practice nurses (55%, 95% CI 47-64%) had hospital experience of caring for patients with ischaemic heart disease, and most (83%, 95% CI 76-89%) believed that they played a key role in follow-up care of patients following myocardial infarction. In the absence of external support from a cardiac liaison nurse, few nurses (26%, 95% CI 16-41%) provide such care at present and only 21% work in practices with a register of myocardial infarction patients. Factors predicting the provision of follow-up care are having adequate time (odds ratio 4.59, 95% CI 1.66-12.7), the support of a cardiac liaison nurse (odds ratio 3.07, 95% CI 1.28-7.34) and GP colleagues (odds ratio 3.38, 95% CI 1.38-8.23), training in consultation skills (odds ratio 7.25, 95% CI 2.08-25.3), fundholding (odds ratio 3.11, 95% CI 1.26-7.69) and the confidence and knowledge of the practice nurse (odds ratios and 95% CIs respectively: 2.84, 1.18-6.83 and 2.80, 1.13- 6.89). CONCLUSION: Most practice nurses are enthusiastic and have some of the necessary experience to provide follow-up care for patients who have experienced a myocardial infarction. Yet few currently provide it. The most important organizational incentives for providing such care are further training and the support of GPs and the cardiac liaison nurse.      

The incidence of coronary heart disease among Palestinians and Israelis in Jerusalem

BACKGROUND: Lifestyle factors relevant to coronary risk factors differ between Palestinians and Israelis. Both have been exposed, albeit differently, to the stressors of the long-term conflict. We determined the incidence of coronary heart disease, previously unreported in Palestinians, in these Mediterranean populations and made international comparisons with the MONICA Programme. METHODS: We applied the rigorous World Health Organization MONICA protocol, which enables standardized international population-based comparisons, to determine all acute myocardial infarction events and coronary deaths among Palestinians and Israelis aged 25-74, residents of the Jerusalem district in 1997. RESULTS: We confirmed a total of 265 coronary events among 76,200 Arabs and 698 among 226,500 Jews. Rates among Arabs were substantially higher than in Jews, particularly so in women. Age-adjusted rate ratios (RRs) for coronary events were 1.58 [95% confidence interval (95% CI) 1.34-1.87] among men and 2.37 (95% CI 1.81-3.10) among women. When restricted to coronary deaths, Arab: Jewish RRs were 2.79 (95% CI 2.09-3.73) in men and 2.66 (95% CI 1.77-4.00) in women. Compared with MONICA populations in 20 countries, Arabs ranked first in total coronary event rates and first in non-fatal myocardial infarction rates, exceeded populations in Finland, Scotland, and Northern Ireland, and showed striking differences from the participating Mediterranean centres. CONCLUSIONS: Coronary risk appears to be particularly high in Palestinian Arabs. Determinants of these unexpected findings should be sought and prevention programmes initiated.     

Risk of cardiovascular events and celecoxib: a systematic review and meta-analysis

OBJECTIVES: To examine whether the increased risk of cardiovascular events with rofecoxib represents a class effect of cyclooxygenase-2 (COX-2) specific inhibitors. DESIGN: Systematic review and meta-analysis of randomized double-blind clinical trials of celecoxib of at least 6 weeks' duration and presented data on serious cardiovascular thromboembolic events. Data sources included six bibliographic databases, the relevant files of the United States Food and Drug Administration, and pharmaceutical company websites. MAIN OUTCOME MEASURES: Pooled fixed effects estimates of the odds ratios for risk of cardiovascular events with celecoxib compared with comparator treatment were calculated using the inverse variance weight method. The main outcome measure was myocardial infarction. RESULTS: Four placebo-controlled trials with 4422 patients were included in the primary meta-analysis comparing celecoxib with placebo. The odds ratio of myocardial infarction with celecoxib compared to placebo was 2.26 (95%confidence interval 1.0 to 5.1). For composite cardiovascular events [odd ratio 1.38 (95% CI 0.91 to 2.10)], cardiovascular deaths [OR 1.06 (95% CI 0.38 to 2.95)] and stroke [OR 1.0(95% CI 0.51 to 1.84)] there was no significant increase in risk with celecoxib. The secondary meta-analysis which included a total of six studies (with placebo, diclofenac, ibuprofen, and paracetamol as comparators) of 12 780 patients, showed similar findings with a significant increased risk with celecoxib for myocardial infarction [OR 1.88 (95% CI 1.15 to 3.08)] but not other outcome measures. CONCLUSION: The available data indicate an increased risk of myocardial infarction with celecoxib therapy, consistent with a class effect for COX-2 specific inhibitors.     

Cohort mortality study of Swedish pulp and paper mill workers-nonmalignant diseases

OBJECTIVES: The aim of this study was to determine mortality among pulp and paper mill workers according to the main mill pulping process, department, and gender, particular reference being given to diseases of the circulatory and respiratory systems. METHODS: The cohort of 18 163 men and 2 291 women employed between 1939 and 1999 and with >1 year of employment was followed for mortality from 1952 to 2001 (acute myocardial infarction from 1969). Standardized mortality ratios (SMR) with 95% confidence intervals (95% CI) were estimated by comparing the observed number of deaths with the expected number for the entire Swedish population. Exposure was assessed from personnel files in the mills. Data from an exposure measurement database are also presented. RESULTS: There were 5898 deaths in the cohort. Total mortality had an SMR of 1.02 (95% CI 0.98-1.06) for the men in the sulfate mills and an SMR of 0.93 (95% CI 0.90-0.97) for the men in the sulfite mills. Mortality from acute myocardial infarction was increased among the men in both the sulfate and sulfite mills [SMR 1.22 (95% CI 1.12-1.32) and SMR 1.11 (95% CI 1.02-1.21), respectively] and by department in sulfate pulping (SMR 1.29, 95% CI 1.07-1.54), paper production (SMR 1.26, 95% CI 1.06-1.49), and maintenance (SMR 1.16, 95% CI 1.02-1.30). Mortality from cerebrovascular disease, diabetes mellitus, and nonmalignant respiratory diseases was not increased. CONCLUSIONS: Death from acute myocardial infarction, but not cerebrovascular diseases, was increased in this cohort and was probably related to a combination of different occupational exposures (eg, dust, sulfur compounds, shift work, and noise).     

Impact of new biomarkers of myocardial damage on trends in myocardial infarction hospital admission rates from population-based administrative data

Use of troponin testing in the diagnosis of myocardial infarction substantially increases the number of cases diagnosed as myocardial infarction among suspected cases in comparison with previous criteria. However, the impact of troponin testing on rates reported in national statistics that use routinely collected hospital morbidity data is uncertain. The authors developed Poisson regression models to estimate the effect of troponin testing on long-term trends in hospital admission rates in Perth, Western Australia, from 1980 to 2004. Troponin tests were used for 10.5% of patients with suspected myocardial infarction in 1996, rising rapidly to more than 90% of patients from 2001 onward. Fitted models that assumed a continuing linear decline estimated that 100% use of troponin testing in cases of suspected myocardial infarction would lead to an apparent increase in hospital admission rates of 42% (95% confidence interval (CI): 28, 56) in men and 21% (95% CI: 4, 41) in women as compared with rates that would be expected if previous linear trends had continued. Smaller effects of 30% (95% CI: 14, 48) in men and -2% (95% CI: -21, 20) in women were found in fitted models that assumed an underlying attenuating trend in the rates. Similarly constructed logistic regression trend models found no significant effect of troponin testing on trends in 28-day case-fatality.     

Role of age and sex in short-term and long term mortality after a first Q wave myocardial infarction

STUDY OBJECTIVE: The objective of this study was to analyse whether the risk of death within 28 days and three years after a first Q wave myocardial infarction was higher in hospitalised women than in men. DESIGN: Follow up study. PATIENTS AND SETTING: All consecutive first Q wave myocardial infarction patients aged 25 to 74 years (447 women and 2322 men) admitted to a tertiary hospital in Gerona, Spain, from 1978 to 1997 were registered and followed up for three years. MAIN RESULTS: Women were older, presented more comorbidity and developed more severe myocardial infarctions than men. A significant interaction was found between sex and age. Women aged 65-74 had higher early mortality risk than men of the same age (OR 1.62; 95% CI 1.01, 2.66) after adjusting for age, comorbidity and acute complications including heart failure. Women under 65 tended to be at lower risk of early mortality than men (0.45 (95% CI 0.19, 1.04). Three year mortality of 28 day survivors did not differ between sexes. CONCLUSIONS: These data support the idea that the higher 28 day mortality in hospitalised women with a first Q wave myocardial infarction is mainly attributable to the large number of patients aged 65 to 74 years in whom the risk is higher than that in men. Women under 65 with myocardial infarction do not seem to be a special group of risk.     

Validating recommendations for coronary angiography following acute myocardial infarction in the elderly: a matched analysis using propensity scores

We determined whether adherence to recommendations for coronary angiography more than 12 h after symptom onset but prior to hospital discharge after acute myocardial infarction (AMI) resulted in better survival. Using propensity scores, we created a matched retrospective sample of 19,568 Medicare patients hospitalized with AMI during 1994-1995 in the United States. Twenty-nine percent, 36%, and 34% of patients were judged necessary, appropriate, or uncertain, respectively, for angiography while 60% of those judged necessary received the procedure during the hospitalization. The 3-year survival benefit was largest for patients rated necessary [mean survival difference (95% CI): 17.6% (15.1, 20.1)] and smallest for those rated uncertain [8.8% (6.8, 10.7)]. Angiography recommendations appear to select patients who are likely to benefit from the procedure and the consequent interventions. Because of the magnitude of the benefit and of the number of patients involved, steps should be taken to replicate these findings.     

NSF for CHD: 3 years of 12-month follow-up audit after cardiac rehabilitation

BACKGROUND: The coronary heart disease (CHD) National Service Framework (NSF) sets standards and milestones. For acute myocardial infarction (AMI) or coronary revascularization, 'Milestone 3, of Standard 12 requires that, by April 2002, every hospital should have clinical audit data no more than 12 months old showing 'total number and % of those recruited to cardiac rehabilitation who, one year after discharge, report: regular physical activity of at least 30 minutes duration on average five times a week, not smoking and a Body Mass Index (BMI) of <30 kg/m2'. This study looked at cost, method and practicalities of retrieving this data. METHODS: A postal questionnaire was used to follow-up coronary patients who started our cardiac rehabilitation programme between 1 April 2001 and 31 March 2004. The project was costed. RESULTS: Three hundred and seventy-five (33 per cent) AMI patients, 412 (36 per cent) coronary artery bypass grafting (CABG) patients and 343 (30 per cent) percutaneous coronary intervention (PCI) patients entered the cardiac rehabilitation programme over 3 years. Completed questionnaires were received from 903 (80 per cent). Post-AMI patients or those stratified as high risk for further cardiac events were least likely to respond. Of responders, 74 per cent were exercising regularly, 95 per cent were not smoking and 79 per cent had a BMI <30 kg/m2. CONCLUSION: Targets for smoking and BMI set by the NSF are too low and were achieved by most patients before the start of cardiac rehabilitation. Patients who are post-AMI or are stratified as high risk need to be targeted if a high level of follow-up is to be achieved.