Diagnostic Value of Chest Radiographs in Bedridden Patients Suspected of Having Pneumonia

Objectives

To assess the diagnostic value of the chest radiograph for the diagnosis of pneumonia in bedridden patients, using non-contrast-enhanced high-resolution chest computed tomography (CT) as the gold standard.

Methods

We prospectively evaluated bedridden patients hospitalized with moderate to high clinical probability of pneumonia. Chest radiographs were interpreted in a blinded fashion by 3 observers and classified as definite, normal, or uncertain for pneumonia. Chest CT was obtained within 12 hours of chest radiograph. We applied Bayesian analysis to assess the accuracy of chest radiograph in the diagnosis of pneumonia.

Results

In a 5-month period, 58 patients were evaluated, 31 (53%) were female. Their chest radiographs were interpreted as negative, uncertain, or positive for pneumonia in 31 (53%), 15 (26%), and 12 (21%) patients, respectively, while CT confirmed pneumonia in 11 (35%), 10 (67%), and in 10 (83%). The sensitivity of the chest radiograph to diagnose pneumonia was 65%, the specificity was 93%, the positive and negative predictive values were, respectively, 83% and 65%, while the overall accuracy was 69% (95% confidence interval, 50%-79%).

Conclusions

In bedridden patients with suspected pneumonia, a normal chest radiograph does not rule out the diagnosis, hence, a chest CT scan might provide valuable diagnostic information.     

Significance of Cardiac Computed Tomography Incidental Findings in Acute Chest Pain

Background

Coronary computed tomography angiography might improve the management of patients presenting to the emergency department with acute chest pain; however, noncoronary incidental findings are frequently detected. The prevalence and clinical significance of these findings have not been well described.

Methods

Consecutive patients presenting to the emergency department with acute chest pain and inconclusive initial evaluation between May 2005 and May 2007 underwent 64-slice coronary computed tomography angiography before hospital admission with noncoronary incidental findings immediately reported. An expert panel adjudicated which incidental findings changed in-hospital patient management, and projections for additional testing were based on standard medical practice.

Results

Among 395 patients (37.0% were female, mean age 53 ± 12 years), incidental findings were detected in 44.8% (n = 177): noncalcified pulmonary nodules (n = 94, 23.8%), simple liver cysts (n = 26, 6.6%), calcified pulmonary nodules (n = 16, 4.1%), and contrast-enhancing liver lesions (n = 9, 2.3%). In-hospital management was changed because of incidental finding reporting in 5 patients (1.3%), and a potential alternative diagnosis was offered in another 16 patients (4.1%). Subsequent diagnostic imaging tests were recommended in 81 patients (20.5%), including 74 chest computed tomography scans. After 6 months, biopsy was performed in 3 patients, revealing cancer in 2 (0.5%) who underwent successful tumor resection.

Conclusion

Clinically important findings are detected in up to 5% of patients with a lead symptom of acute chest pain and low to intermediate likelihood of acute coronary syndrome, but only few directly change patient management; 21% are recommended for further imaging tests, resulting in invasive procedures and detection of cancer in few patients.     

Differences in care-seeking behavior for acute chest pain in the United States and Japan

Background

Delay from onset of acute myocardial infarction symptoms to the delivery of medical care is a major determinant of prognosis. Although studies have explored patient factors for delay in seeking care, there are limited data on international differences in care-seeking behavior.

Methods

We surveyed 1032 people in the United States and 1422 people in Japan in January 1997 on decision-making responses to a chest pain scenario representing acute MI. Participants were asked about how they would seek initial care and how promptly they would seek care.

Results

The mean age was 43.6 years in the United States and 48.3 years in Japan. For the hypothetical scenario, US respondents were more likely to seek care at an emergency department (22.9% vs 16.2% in Japan) or through emergency medical services/911 (55.9% vs 32.9% in Japan, P = .001). American subjects were also more likely to seek care immediately (83.1% vs 56.4% in Japan, P = .001).

Conclusion

Respondents in the United States and Japan differed substantially in their responses to a hypothetical chest pain scenario. Whether these differences result from cultural or health care system factors and whether these apparent attitudes produce gaps in real responses to acute coronary syndromes must be explored in further studies.     

The utility of gestures in patients with chest discomfort

Purpose

Patient gestures are thought to be useful in determining the etiology of chest discomfort. We sought to determine the utility of certain patient gestures in the diagnosis of ischemic chest discomfort or myocardial infarction.

Methods

We performed a prospective observational study of 202 patients admitted with chest discomfort. Patients were observed for the Levine Sign (clenched fist to the chest), the Palm Sign (palm of the hand to the chest), the Arm Sign (touching the left arm), and, as an indicator of nonischemic chest discomfort, the Pointing Sign (pointing with 1 finger).

Results

Prevalences of the Levine, Palm, Arm, and Pointing Signs were 11%, 35%, 16%, and 4%, respectively. Using troponin levels and results of functional studies and coronary angiograms as reference standards, none of the sensitivities of the signs exceeded 38%. Specificities of the Levine and Arm Signs ranged between 78% and 86%, but the positive predictive values did not exceed 55%. The Pointing Sign had a specificity of 98% for evidence of nonischemic chest discomfort, and the positive predictive value of a negative troponin was 88%. The diameter of discomfort significantly correlated with certain gestures. Larger chest pain diameters were associated with evidence of myocardial ischemia.

Conclusions

Although certain gestures are exhibited by patients presenting with chest discomfort, they generally have poor test characteristics. The Pointing Sign has a high specificity for nonischemic chest discomfort, but a low prevalence. The gestures may communicate the size of the chest discomfort, with larger areas suggestive of ischemia.     

Diagnosis of Pulmonary Malignancy after Hospitalization for Pneumonia

Background

Many physicians recommend that patients receive follow-up chest imaging after the diagnosis of pneumonia to ensure that a pulmonary malignancy is not missed. However, there is little research evidence to support this practice. Our aims were to assess the frequency of the diagnosis of pulmonary malignancy, and to identify risk factors for pulmonary malignancy following hospitalization for pneumonia.

Methods

By excluding patients with a prior diagnosis of pulmonary malignancy, we examined the incidence of a new pulmonary malignancy diagnosis in inpatients aged ≥65 years with a discharge diagnosis of pneumonia in fiscal years 2002-2007, and at least 1 year of Department of Veterans Affairs outpatient care before the index admission.

Results

Of 40,744 patients hospitalized with pneumonia, 3760 (9.2%) patients were diagnosed with pulmonary malignancy after their index pneumonia admission. Median time to diagnosis was 297 days, with only 27% diagnosed within 90 days of admission. Factors significantly associated with a new diagnosis of pulmonary malignancy included history of chronic pulmonary disease, any prior malignancy, white race, being married, and tobacco use. Increasing age, Hispanic ethnicity, need for intensive care unit admission, and a history of congestive heart failure, stroke, dementia, or diabetes with complications were associated with a lower incidence of pulmonary malignancy.

Conclusion

A small, but clinically important, proportion of patients are diagnosed with pulmonary malignancy posthospitalization for pneumonia. Additional research is needed to examine whether previously undiagnosed pulmonary malignancies might be detected at admission, or soon after, for those hospitalized with pneumonia.     

Elective percutaneous coronary intervention using broad-spectrum antiplatelet therapy (eptifibatide, clopidogrel, and aspirin) alone, without scheduled unfractionated heparin or other antithrombin therapy

Background

Adjunctive pharmacotherapy during percutaneous coronary intervention (PCI) has historically consisted of a regimen of antiplatelet agents accompanied by an antithrombin agent, typically unfractionated heparin. Paradoxically, unfractionated heparin may activate platelets, induce other pro-thrombotic activities, increase bleeding complications, and cause thrombocytopenia. To optimize patient care and avoid the potential risks of unfractionated heparin in patients undergoing elective PCI, one of the authors began to use adjunctive pharmacotherapy consisting of broad-spectrum antiplatelet therapy alone, without scheduled unfractionated heparin or other antithrombin therapy.

Methods

Five hundred consecutive patients undergoing scheduled, elective PCI (stent deployment, cutting balloon atherotomy, conventional balloon angioplasty, or high-speed rotational atherectomy) received adjunctive pharmacotherapy consisting of eptifibatide, clopidogrel, and aspirin.

Results

The technical success rate was 100%. During the first 24 hours, there were no major adverse clinical events. Non-Q-wave myocardial infarction occurred in 1.6% of patients, major and minor bleeding complications in 0.2% and 0.6%, respectively, and thrombocytopenia in 0.6%. During the first 30 days, there was 1 (0.2%) major adverse clinical event.

Conclusions

For elective PCI, adjunctive pharmacotherapy consisting of broad-spectrum antiplatelet therapy alone, without scheduled unfractionated heparin or other antithrombin therapy, appears to be safe and may prove to be efficacious.     

Tubercular mastitis in men: case report and systematic review

Background

Tuberculous mastitis is usually reported in multiparous postpartum women and is an unusual cause of gynecomastia in adolescent men.

Methods

We describe an illustrative case and review all cases of tubercular mastitis reported in men in the English literature.

Results

Our search yielded 24 cases of male tubercular mastitis. Most presented with an isolated breast lump. Constitutional symptoms were rare (21.4%), and associated tuberculosis foci, mostly inactive, were seen in 43.8%. Breast parenchymal involvement, chest wall masses, pectoral muscle abscesses, cold abscesses tracking through the chest wall, and empyema necessitatis presented as breast lumps. Fine-needle aspiration cytology was the most common diagnostic modality, and acid-fast bacilli were demonstrable in a minority (33%). A combination of granulomatous mastitis, necrosis, and clinical response to antitubercular therapy was the most common mode of establishing the diagnosis. Most patients responded to antitubercular therapy alone.

Conclusion

Tubercular mastitis is a rare cause of breast masses in men, and a high index of suspicion can prevent diagnostic delays. Most patients respond to antitubercular therapy alone.     

Complication rates on weekends and weekdays in US hospitals

Purpose

Recent studies and anecdotal evidence suggest that patient safety may be compromised on weekends. Our objective was to determine whether rates of complications in hospitals are higher on weekends than on weekdays.

Methods

We examined records from 4,967,114 admissions to acute care hospitals in 3 states and analyzed complication rates using the Patient Safety Indicators. We selected 8 indicators that could be assigned to a single day: complications of anesthesia, retained foreign bodies, postoperative hemorrhage, accidental cuts and lacerations during procedures, birth trauma, obstetric trauma during vaginal deliveries with and without instrumentation, and obstetric trauma during cesarean delivery. Odds ratios (ORs) comparing weekends versus weekdays were adjusted for demographics, type of admission, and admission route. In a subgroup analysis of surgical complications, we restricted the population to patients who underwent cardiac or vascular procedures.

Results

Four of the 8 complications occurred more frequently on weekends: postoperative hemorrhage (OR 1.07, 95% confidence interval [CI], 1.01-1.14), newborn trauma (OR 1.06, 95% CI, 1.03-1.10), vaginal deliveries without instrumentation (OR 1.03, 95% CI, 1.02-1.04), and obstetric trauma during cesarean sections (OR 1.36, 95% CI, 1.29-1.44). Complications related to anesthesia occurred less frequently on weekends (OR 0.86). Among patients undergoing vascular procedures, surgical complications occurred more frequently on weekends (OR 1.46, 95% CI, 1.16-1.85).

Conclusions

Rates of complications are marginally higher on weekends than on weekdays for some surgical and newborn complications, but more significantly for obstetric trauma and for surgical complications involving patients undergoing vascular procedures. Hospitals should work toward increasing the robustness of safeguards on weekends.     

Incidental pulmonary nodules on cardiac computed tomography: prognosis and use

Background

Small asymptomatic lung nodules are found frequently in the course of cardiac computed tomography (CT) scanning. However, the utility of assessing and reporting incidental findings in healthy, asymptomatic subjects is unknown.

Methods

The sample comprised 1023 60- to 69-year-old subjects free of clinical cardiovascular disease and cancer who participated in the Atherosclerotic Disease, VAscular functioN and genetiC Epidemiology Study. All subjects underwent cardiac CT for determination of coronary calcium between 2001 and 2004, and the first 459 subjects were assessed for incidental pulmonary findings. We used health plan clinical databases to ascertain 24-month health care use and clinical outcomes.

Results

Noncalcified pulmonary nodules were reported in 81 of 459 subjects (18%). Chest CT was performed on 78% of participants in the 24 months after notification, compared with 2.5% in the previous 24 months. Chest x-ray use increased from 28% to 49%. The mean number of chest CT scans per subject was 1.3 (range, 0-5). Although no malignant lesions were diagnosed in the group who had pulmonary findings read, 1 lung cancer case was diagnosed in the group who did not have lung findings read. Among the 63 participants followed up by CT, the original lesion was not identified in 22 participants (35%), the lesion had decreased or remained stable in 39 participants (62%), and there was interval growth in 2 participants (3%).

Conclusion

Reporting noncalcified pulmonary nodules resulted in substantial rescanning that overwhelmingly revealed resolution or stability of pulmonary nodules, arguing for benign processes.     

Predictors of intracranial hemorrhage with fibrinolytic therapy in unselected community patients: a report from the FASTRAK II project

Background

Patients at high risk for intracranial hemorrhage (ICH) are generally excluded from thrombolytic trials. Because the frequency and predictors of ICH reported from these studies may not be widely applicable, we sought to examine this matter further in unselected patients with acute myocardial infarction in the community.

Methods

FASTRAK II is a prospective ongoing registry of acute coronary syndromes involving 111 Canadian hospitals. Trained medical personnel recorded admission, treatment, and discharge data on patients admitted with acute coronary syndromes.

Results

From January 1, 1998, to December 31, 2000, 12,739 patients received fibrinolytic therapy for acute myocardial infarction. Of these, 146 patients (1.15%) sustained strokes and 82 patients (0.65%) had an ICH. Advanced age, female sex, history of cerebrovascular event, and systolic hypertension on arrival (systolic blood pressure >160 mm Hg) were identified with a multivariate logistic regression model to be important independent risks factors for ICH. Patients receiving streptokinase had a lower risk of ICH. Among the patients at high risk for ICH, the ICH rates remained low, ranging from 0.7% to 1.8%.

Conclusion

ICH is an infrequent event after fibrinolytic therapy in ST-elevation MI; this low rate supports broad penetration of this therapy. Simple clinical characteristics are useful in predicting the risk of ICH and allow a clinician to individualize the risk-benefit assessment of this therapy.     

Relation of admission QRS duration with development of angiographic no-reflow in patients with acute ST-segment elevation myocardial infarction treated with primary percutaneous interventions

Background

Although QRS-complex changes during ischemia have been described previously, their relation with no-reflow is not clear.

Purpose

To evaluate relation of admission QRS duration with angiographic no-reflow, we studied 162 patients who underwent primary angioplasty.

Methods

Twelve-lead electrocardiogram with a paper speed of 50 mm/s was recorded on admission and repeated after angioplasty. Patients were divided into reflow and no-reflow groups based on postangioplasty coronary thrombolysis in myocardial infarction flow grade.

Results

Patients in the no-reflow group (26 patients) were older (P = .001) and had significantly longer pain-to-balloon interval (P = .007). The patients in the no-reflow group had significantly longer QRS duration on admission electrocardiogram compared with patients in the reflow group (interquartile range, 80-93 [median, 84] milliseconds vs 60-80 [median, 76] milliseconds, respectively; P < .001). After adjusting all variables, QRS duration on admission was found to be independently related to angiographic no-reflow (odds ratio, 1.07; 95% confidence interval, 1.02-1.12; P = .003).

Conclusion

QRS duration on admission may be valuable in predicting no-reflow.     

Low-risk patients admitted with community-acquired pneumonia

Purpose

To describe the natural history of community-acquired pneumonia in the subset of a large cohort of patients at low risk for mortality who were admitted to the hospital.

Methods

Prospective observational study of all patients at low risk for mortality (risk classes I and II) who presented to 6 hospitals and 1 emergency department in Edmonton, Alberta, Canada with a diagnosis of possible community-acquired pneumonia from November 15, 2000, to November 14, 2002.

Results

A total of 586/3065 (19.1%) low-risk patients (Fine criteria) were admitted, 48.4% of whom stayed more than 5 days. Multivariate analysis revealed that patients who were admitted were more likely to be female, to have presented at Site B, which serves an inner city population, to have diminished premorbid functional status, to have comorbidities likely to be made worse by pneumonia (chronic obstructive pulmonary disease, asthma, heart disease, inflammatory bowel disease), and to suffer from substance abuse or psychiatric illness. A respiratory rate of ≥28 breaths per minute, and symptoms of shaking chills, shortness of breath, nausea or diarrhea were the remaining factors predicting admission. Nineteen percent of the patients suffered one or more complications, the most serious of which was progression of the pneumonia, resulting in respiratory failure necessitating mechanical ventilation in 2.4% and empyema in 1.4%. Four patients had lung cancer, and 1 had cancer of the vocal cords. Thirty-one percent of those who were admitted were still unable to eat or drink enough to maintain hydration by hospital day 5 or on discharge day.

Conclusions

One in 5 patients at low risk for mortality were admitted to the hospital and half stayed more than 5 days; 19% suffered 1 or more complications. Our data emphasize the need for better rules to guide the admission decision and the importance of physician judgment in this decision.     

La sténose radique de l’artère rénale : une complication inhabituelle de la radiothérapie

Introduction

Renal artery stenosis represented 1 to 5% of all arterial hypertensions and is the leading cause of secondary hypertension. Renovascular hypertension is more common among women less than 30 years old (fibrodysplasia, 33%) and men older than 50 years old (66% atherosclerosis). Other causes are rare, especially radiation-induced renal artery stenosis.

Materials and methods

We report the case of Mr. D., 49 years old, with severe high blood pressure (230/125 mmHg) seven years after abdominal radiotherapy for Hodgkin's disease. Echo-Doppler was performed and found a subocclusive right ostial renal artery stenosis probably radiation-induced taking into account the history of the patient. Renal angiography confirmed this diagnosis and percutaneous transluminal renal artery angioplasty was performed with a final acceptable result (residual stenosis < 50%).

Discussion

Radiation-induced renal artery stenosis is rare (0.5/1000 to 1%). Most of the cases are proximal and the median time from radiation to referral is nine years. Radiation-induced nephritis disease was often referred to occurrence high blood pressure after abdominal radiotherapy but various data shows that radiation can also cause damage to larger vessels sizes (such as renal arteries) induced by atherosclerosis radiation. Patients should be successful treated by percutaneous intervention, as demonstrated by Fakhouri et al. [Am J Kidney Dis 38 (2001) 302-309] in a study of 11 patients.

Conclusion

This case shows that radiation-induced renal artery stenosis may occur many years after initial treatment, and patients developing severe arterial hypertension after abdominal radiation should be investigated for renal artery stenosis.     

Cross-sectional epidemiology of hepatitis C virus detection and treatment in HIV-infected patients

Background

Sustained virologic response to peginterferon plus ribavirin reduces liver-related complications and mortality in patients co-infected with HIV and hepatitis C virus. Therefore, the presence of any barriers to start hepatitis C virus therapy should be identified and eliminated in order to recruit all eligible patients.

Methods

Cross-sectional study. In a HIV referral clinic we assessed the proportion of patients eligible for hepatitis C virus evaluation and treatment according to consensus guidelines.

Results

We identified 134 patients with hepatitis C virus and HIV co-infection. Twenty-one patients were excluded from the analysis due to never attending the HIV clinic (n = 12) or having hepatitis C virus RNA not detectable (n = 9). In the remaining 113 patients, only 61% had identification of hepatitis C virus genotype and quantification of hepatitis C viral load. Thirty-six patients started peginterferon plus ribavirin, and 16 (44%) achieved sustained virologic response. Seventy-seven patients did not receive treatment for hepatitis C virus due to the presence of medical contraindications (n = 22), provider barriers (n = 15), or patient barriers (n = 40). Multivariate analysis identified lower education degree (odds ratio: 4.53; 95% confidence intervals: 1.36-15.16, p = 0.014) and patient civil status single, separated or widower (odds ratio: 4.81; 95% confidence intervals: 1.54-14.99, p = 0.007) as the independent determinants associated to not initiating therapy for hepatitis C virus infection in patients with barriers.

Conclusion

A minor proportion of HIV-infected patients received appropriate assessment and treatment for hepatitis C virus infection. Social disadvantages require multidisciplinary models of health care to improve hepatitis C virus treatment initiation and success.     

Fluoroquinolone-resistant Escherichia coli in the long-term care setting

Background

Prior studies have found fluoroquinolone exposure to be a risk factor for infection with fluoroquinolone-resistant gram-negative rods in the acute care setting. However, risk factors may be different in the long-term care setting.

Methods

A case-control study design was used to determine whether fluoroquinolone exposure is a risk factor for fluoroquinolone-resistant Escherichia coli urinary tract infections in a long-term care center. Cases had fluoroquinolone-resistant E. coli urinary tract infections; 4 controls were selected for each case.

Results

Thirty-three case patients were eligible; 132 controls were then selected. In the multivariable analysis, fluoroquinolone-resistant E. coli urinary tract infection was more common with prior fluoroquinolone use (odds ratio 21.8, 95% confidence interval, 3.7-127.1).

Conclusions

Prior fluoroquinolone use is a strong risk factor for fluoroquinolone-resistant E. coli urinary tract infection in the long-term care setting. Further studies are needed to examine the effect of interventions to decrease fluoroquinolone-resistant infections in the long-term care setting, including studying the effect of decreasing fluoroquinolone use.     

Effects of structured care by a pharmacist-diabetes specialist team in patients with type 2 diabetic nephropathy

Purpose

We developed a disease management program for patients with Type 2 diabetic nephropathy and evaluated its effects on the time to onset of end-stage renal disease or all-cause death compared with usual care.

Methods

In a 2-year, prospective cohort study, we compared the clinical outcomes of patients managed by a structured care protocol (n = 80) to a group receiving usual care (n = 80) in the same hospital. Patients aged ≤80 years with type 2 diabetes, serum creatinine 150-400 μmol/L, and micro- or macroalbuminuria were recruited. The structured care protocol was implemented by a pharmacist-diabetes specialist team with particular emphasis on periodic laboratory assessments, patient adherence, risk factors control, and use of renin-angiotensin system inhibitor. The primary endpoint was the composite of end-stage renal disease or all-cause death. Other endpoints were the rate of renal decline, processes-of-care measures, and control of risk factors.

Results

During 22.8 ± 7.9 months of follow-up, the primary endpoint developed in 24 and 40 patients in the structured care and usual care groups, respectively (adjusted risk reduction, 60%, P< .001). Structured care (hazard ratio [95% confidence interval (CI)], 0.40 [0.23-0.68]), age (0.95 [0.93-0.98]), baseline systolic blood pressure (BP) (1.014 [1.003-1.026]), logarithm (base 10) of baseline serum creatinine (34 441 [2290-517 915]), and macroalbuminuria (8.95 [1.22-65.38]) were independent predictors for the primary endpoint. Structured care slowed the rate of renal decline (P = .032). More intensive laboratory measurements, increased use of renin-angiotensin system inhibitor, and greater reductions in BP and low-density lipoprotein (LDL) cholesterol were reported by patients receiving structured care.

Conclusions

Structured care delivered by a pharmacist-diabetes specialist team reduced the incidence of end-stage renal disease or death compared with usual care in patients with type 2 diabetic nephropathy.     

Serious hemorrhages related to vitamin K antagonist treated by prothrombic complexes: retrospective study conducted in 2008

Purpose

Vitamin K antagonist are widely used and clearly useful in the prevention of thrombotic and embolic events. However, they expose to hemorrhagic risk. The aim of this retrospective study was to describe the serious hemorrhagic events that occurred in patients treated with vitamin K antagonist and that required administration of prothrombotic complexes concentrates.

Methods

A comparative analysis of the file of the central pharmacy (that dispensed the prothrombotic complexes concentrates) and patient data of the department of medical information was perform to ascertain the population of patients having received some prothrombotic complexes concentrates. Then, hospitalization reports were consulted to select the patients having presented a severe bleeding while receveiving vitamin K antagonist. We collected patients’ characteristics, bleeding location, INR values, emergency care, seriousness and medical issue. Imputability was determined with the French method of pharmacovigilance.

Results

In 2008, in Caen University hospital, 80 patients received prothrombotic complexes concentrates in the context of a serious hemorrhage due to vitamin K antagonist. Their mean age was 75 years and the most common presentation was a neurological hemorrhage (38,7%). For 63,8% of the patients, there was an overdose in vitamin K antagonist. Twenty-two patients died during their hospitalization and 10 others presented later sequelas. None of the patients included in this study had been spontaneously declared to the pharmacovigilance. High imputability scores were positively correlated with INR (P = 0.0002).

Conclusion

Quality of emergency care of hemorrhagic events due to vitamin K antagonist could be improved with a better application of the professional recommendations and a spontaneous declaration to pharmacovigilance.     

Recent and temporal trends (1975 to 1999) in the treatment, hospital, and long-term outcomes of Hispanic and non-Hispanic white patients hospitalized with acute myocardial infarction: a population-based perspective

Background

Extremely limited population-based data are available describing recent and temporal trends in the characteristics, treatment, and outcomes of Hispanic and non-Hispanic white patients hospitalized with acute myocardial infarction (AMI).

Methods

This was a community-based, observational study of 9649 greater Worcester residents hospitalized in all hospitals serving the Worcester, Massachusetts, metropolitan area in 12 one-year periods between 1975 and 1999. In the total study sample, 171 (2%) patients were Hispanic. Hispanic patients were matched with 395 non-Hispanic white patients on the basis of age, sex, and year of hospitalization.

Results

Hispanics were more likely to present to greater Worcester hospitals with a history of diabetes as compared with non-Hispanic whites. Hispanics were less likely to have an initial, Q-wave AMI during the index hospitalization. After controlling for a limited number of known potentially confounding factors, Hispanics were at lower risk for development of heart failure (OR, 0.63; 95% CI, 0.41, 0.96). Both Hispanics (13% vs 11%) and non-Hispanic whites (28% vs 9%), however, had declines in hospital case-fatality rates between 1975 and 1999. An overall similar treatment pattern and increasing trends in the use of effective cardiac medications over time were observed in both patient groups. However, Hispanics were significantly less likely to be treated with coronary angioplasty during the acute hospitalization. Trends of a worse long-term survival for discharged Hispanic patients were observed over a 10-year follow-up period.

Conclusions

The results of this community-wide study suggest encouraging hospital outcomes in Hispanic and non-Hispanic white patients hospitalized with AMI. Enhanced secondary prevention efforts remain needed to improve the hospital and long-term outcomes of patients with AMI, irrespective of race or ethnicity.