Disparities in use of same-day percutaneous coronary intervention for patients with ST-elevation myocardial infarction in Florida, 2001-2005

Primary percutaneous coronary intervention (PCI) is the recommended treatment for ST-elevation myocardial infarction (STEMI), according to American College of Cardiology and American Heart Association guidelines published in 1999 and 2004. In this study, hospital and patient predictors of same-day primary PCI use for STEMI were examined across the period from 2001 to 2005. Inpatient discharge data for adults aged > or =18 years with primary diagnoses of STEMI who were admitted to Florida hospitals through emergency departments (ED) from 2001 to 2005 (n = 58,308) were analyzed. Hierarchical (multilevel) logistic regression models were used to assess hospital PCI volume and individual characteristics as predictors of same-day PCI use for patients at PCI-capable hospitals. The percentage of ED-admitted patients with a STEMI who received same-day PCI in Florida increased from 20% in early 2001 to 43% in late 2005. At PCI-capable hospitals, 50% of these patients received same-day PCI in late 2005. Patients admitted on weekends, women, patients aged > or = 75 years, patients with chronic obstructive pulmonary disease, and patients with end-stage renal disease were all significantly less likely to receive same-day PCI. Black patients were less likely to receive same-day PCI in early 2001 (adjusted odds ratio [OR] 0.7, 95% confidence interval 0.5 to 0.9, p <0.0001), but this racial disparity was not evident by late 2005 (adjusted OR 1.0). Men were more likely than women to receive same-day PCI, with a significant association remaining in late 2005 (adjusted OR 1.2, 95% confidence interval 1.1 to 1.4, p <0.0001). Throughout the study period, the strongest predictor of same-day PCI was admission to a high- or medium-volume PCI-capable hospital; the adjusted OR in late 2005 was 4.6 (95% confidence interval 2.8 to 7.6, p <0.0001). In conclusion, weekend admission, female gender, older age, and serious co-morbidities were all significant barriers to receiving same-day PCI. Among patients admitted to PCI-capable hospitals, total PCI volume (high or medium vs low) was associated with significantly greater odds of receiving primary PCI, independent of patient sociodemographics, risk factors, or co-morbidities. Statewide, despite an increase in the use of PCI over time, most ED-admitted patients with a STEMI in Florida did not receive primary PCI in late 2005.     

The effect of weekend versus weekday admission on outcomes of esophageal variceal hemorrhage

BACKGROUND

Hospital staffing is often lower on weekends than weekdays, and may contribute to higher mortality in patients admitted on weekends. Because esophageal variceal hemorrhage (EVH) requires complex management and urgent endoscopic intervention, limitations in physician expertise and the availability of endoscopy on weekends may be associated with increased EVH mortality.

OBJECTIVE

To assess the differences in mortality, hospital length of stay (LOS), and costs between patients admitted on weekends versus patients who were admitted on weekdays.

METHODS

The United States Nationwide Inpatient Sample database was used to identify patients hospitalized for EVH between 1998 and 2005. Differences in mortality, LOS, and costs between patients admitted on weekends and weekdays were evaluated using regression models with adjustment for patient and clinical factors, including the timing of endoscopy.

RESULTS

Between 1998 and 2005, 36,734 EVH admissions to 2207 hospitals met the inclusion criteria. Compared with patients admitted on weekdays, individuals admitted on the weekend were slightly less likely to undergo endoscopy on the day of admission (45% versus 43%, respectively; P=0.01) and by the second day (81% versus 75%; P<0.0001). However, mortality (11.3% versus 10.8%; P=0.20) and the requirement for endoscopic therapy (70% versus 69%; P=0.08) or portosystemic shunt insertion (4.4% versus 4.7%; P=0.32) did not differ between weekend and weekday admissions. After adjusting for confounding factors, including the timing of endoscopy, the risk of mortality was similar between weekend and weekday admissions (OR 1.05; 95% CI 0.97 to 1.14). Although LOS was similar between groups, adjusted hospital charges were 4.0% greater (95% CI 2.3 to 5.8%) for patients hospitalized on the weekend.

CONCLUSIONS

In patients with EVH, admission on the weekend is associated with a small delay in receiving endoscopic intervention, but no difference in mortality or the requirement for portosystemic shunt insertion. The weekend effect observed for some medical and surgical conditions does not apply to patients with EVH.     

Effect of Weekend Admissions on the Treatment Process and Outcomes of Internal Medicine Patients: A Nationwide Cross-Sectional Study

Many studies address the effect of weekend admission on patient outcomes. This population-based study aimed to evaluate the relationship between weekend admission and the treatment process and outcomes of general internal medicine patients in Taiwan.A total of 82,340 patients (16,657 weekend and 65,683 weekday admissions) aged ≥20 years and admitted to the internal medicine departments of 17 medical centers between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. A generalized estimating equation (GEE) analysis was used to compare patients admitted on weekends and those admitted on weekdays.Patients who were admitted on weekends were more likely to undergo intubation (odds ratio [OR]: 1.27; 95% confidence interval [CI]: 1.16–1.39; P < 0.001) and/or mechanical ventilation (OR, 1.25; 95% CI, 1.15–1.35; P < 0.001), cardio-pulmonary resuscitation (OR: 1.45; 95% CI: 1.05–2.01; P = 0.026), and be transferred to the intensive care unit (ICU) (OR: 1.16; 95% CI: 1.03–1.30; P = 0.015) compared with those admitted on weekdays. Weekend-admitted patients also had higher odds of in-hospital mortality (OR: 1.19; 95% CI: 1.09–1.30; P < 0.001) and hospital treatment cost (OR: 1.04; 95% CI: 1.01–1.06; P = 0.008) than weekday-admitted patients.General internal medicine patients who were admitted on weekends experienced more intensive care procedures and higher ICU admission, in-hospital mortality, and treatment cost. Intensive care utilization may serve as early indicator of poorer outcomes and a potential entry point to offer preventive intervention before proceeding to intensive treatment.     

Factors predicting success rate and recurrence of atrial fibrillation after first electrical cardioversion in patients with persistent atrial fibrillation

BACKGROUND: The recurrence rate of atrial fibrillation (AF) after elective cardioversion is high. HYPOTHESIS: The study aimed to identify clinical predictors for successful electrical cardioversion and maintenance of sinus rhythm after a first electrical cardioversion in patients with persistent AF without concomitant antiarrhythmic drugs of class I and III. METHODS: Consecutive outpatients (n = 166) with persistent AF for > 1 month, scheduled for elective cardioversion, were prospectively included in the study. A clinical investigation, echocardiographic assay, and Holter electrocardiogram (ECG) before and ECG 4 weeks after cardioversion, were performed in all patients. RESULTS: The mean age of the patients was 68 years (range 45-83) and duration of AF was 5 (1-48) months. Sinus rhythm was established in 124 (75%) patients. In multivariate analysis, only duration of AF < 6 months (p < 0.04, odds ratio [OR] 2.2, 95% confidence interval [CI] 1.1 to 4.7) and patients weight (p < 0.03, OR 2.3, 95% CI 1.1 to 4.8 for weight < 80 kg) were identified as independent predictors of successful cardioversion. At 4 weeks after cardioversion, only 46 (37%) of 124 patients maintained sinus rhythm. Independent factors for maintenance of sinus rhythm, in multivariate analysis, were AF <3 months (p < 0.04, OR 2.5, 95% CI 1.1 to 5.6), treatment with beta blockers (p < 0.00001, OR 7.0, 95% CI 3.0 to 16.3) or verapamil/diltiazem (p < 0.04, OR 3.6, 95% CI 1.1 to 12.1), and right atrial dimension < 37 mm (p < 0.02, OR 5.9, 95% CI 1.4 to 25.4). CONCLUSIONS: In patients with persistent AF, the patient's weight and the duration of AF are independent predictors for a successful cardioversion. Short duration of AF, treatment with beta blockers or verapamil/diltiazem, and right atrial area/dimension are independent predictors for maintenance of sinus rhythm.     

Restrictive left ventricular filling pattern and risk of new-onset atrial fibrillation after acute myocardial infarction

Mechanisms for atrial arrhythmias that occur in the context of acute myocardial infarction (AMI) have not been well characterized. AMI often leads to alterations in left ventricular (LV) filling dynamics, which may result in advanced diastolic dysfunction. Diastolic dysfunction may produce increased left atrial (LA) pressure and initiate LA remodeling, promoting the progression to atrial fibrillation (AF). We studied 1,169 patients admitted with AMI. Advanced diastolic dysfunction was defined as a restrictive filling pattern (RFP), defined as ratio of early to late transmitral velocity of mitral inflow >1.5 or deceleration time <130 ms. The relation between RFP and the primary end point of new-onset AF occurring within 6 months was analyzed using multivariable Cox models. Of 1,169 patients (70% men, mean ± SD 64 ± 10 years of age), 110 (9.4%) developed new-onset AF (19.6% and 7.5% in patients with and without RFP, respectively, p <0.0001). RFP was associated with a hazard ratio of 2.72 for AF (95% confidence interval 1.83 to 4.05, p <0.0001). After multivariable adjustments for clinical variables, LV ejection fraction (EF) and LA size, RFP remained an independent predictor of AF (hazard ratio 2.17, 95% confidence interval 1.42 to 3.32, p <0.0001). Risk of AF was higher in patients with RFP for preserved (≥45%, hazard ratio 2.14, 95% confidence interval 1.09 to 4.20, p = 0.03) or decreased (hazard ratio 2.80, 95% confidence interval 1.63 to 4.82, p <0.0001) LVEF. In contrast, decreased LVEF in the absence of RFP was similar to that of patients with preserved LVEF and without RFP. In conclusion, in patients with AMI, presence of advanced diastolic dysfunction was independently associated with new-onset AF, suggesting that increased filling pressures may contribute to the development of AF after AMI.     

Comparison of 30-day outcomes in patients <75 years of age versus >or=75 years of age with acute myocardial infarction treated by primary coronary angioplasty

We reviewed 1,087 consecutive patients treated by primary coronary angioplasty for acute myocardial infarction; 309 were >or=75 and 778 were <75 years of age. Compared with the younger group, the older group had higher 30-day (8.1% vs 4.0%, p = 0.0057) and cardiac (6.5% vs 3.6%, p = 0.038) mortality rates. Successful reperfusion was achieved in the 2 groups at a similarly high rate (91.6% and 92.9%, p = 0.45). Successful compared with unsuccessful angioplasty decreased 30-day mortality rates in the older group (6.0% vs 30.8%, p <0.0001) and in the younger group (3.2% vs 14.5%, p <0.0001). When reperfusion was successful, the cardiac mortality rate in older patients was not significantly greater than that in younger patients (4.6% vs 2.8%, p = 0.14). By multivariate analysis in all 1,087 patients, overt cardiogenic shock on admission (odds ratio 44.7, 95% confidence interval 22.0 to 91.1, p <0.0001) and unsuccessful reperfusion (odds ratio 9.40, 95% confidence interval 4.11 to 21.5, p <0.0001) were found to be independent predictors of 30-day mortality, whereas age >or=75 years (odds ratio 1.79, 95% confidence interval 0.91 to 3.50, p = 0.090) was not. In conclusion, aggressive angioplasty in older patients improves prognosis.     

High-sensitivity C-reactive protein is predictive of successful cardioversion for atrial fibrillation and maintenance of sinus rhythm after conversion

BACKGROUNDS: Cardioversion for atrial fibrillation (AF) is the most effective treatment for the restoration of sinus rhythm (SR). Recently, an elevated level of hs-CRP has been shown to be associated with AF burden, suggesting that inflammation increases the propensity for persistence of AF. We examined whether the level of high-sensitivity C-reactive protein (hs-CRP) was predictive of the outcome of cardioversion for AF. METHODS AND RESULTS: One hundred and six patients with a history of symptomatic AF lasting > or =1 day (age 63+/-14 years, mean+/-S.D.) underwent cardioversion. Echocardiography and hs-CRP assay were performed immediately prior to cardioversion. SR was restored in 84 patients (79%). By using selected cutoff values, multiple discriminant analysis revealed significant associations between successful cardioversion and a shorter duration of AF (AF duration< or =36 days, odds ratio (OR), 0.98; 95% confidence interval (CI), 0.97-0.99), smaller left atrial diameter (left atrial diameter< or =40 mm, OR 0.82, 95% CI 0.71-0.94), better-preserved left ventricular ejection fraction (left ventricular ejection fraction> or =60%, OR 0.92, 95% CI 0.86-0.99), and lower hs-CRP level (hs-CRP< or =0.12 mg/dL, OR 0.33, 95% CI 0.21-0.51). During a follow-up period of 140+/-144 days, AF recurred in 64 patients (76%). By using a cutoff value of hs-CRP> or =0.06 mg/dL, Cox proportional-hazards regression model found that only hs-CRP level was an independent predictor of AF recurrence (OR 5.30, 95% CI 2.46-11.5) after adjustment for coexisting cardiovascular risks. When patients were divided by the hs-CRP level of 0.06 mg/dL, percentage of maintenance of SR below and above the cutoff was 53% and 4%, respectively (log-rank test, p<0.0001). CONCLUSIONS: hs-CRP level determined prior to cardioversion represents an independent predictor of both successful cardioversion for AF and the maintenance of SR after conversion.     

Association of inflammation with atrial fibrillation in hyperthyroidism

Objectives The aim of this study was to evaluate the relationship between inflammation and development of atrial fibrillation (AF) in patients with hyperthyroidism. Methods A total of 65 patients with newly diagnosed hyperthyroidism, 35 of whom were in sinus rhythm and 30 of whom in AF. Thirty five age- and gender-matched patients in a control group were included in the study. Factors associated with the development of AF were evaluated by multivariate regression analysis. Results Factors associated with AF in multivariate analysis included high sensitivity C reactive protein [(HsCRP); odds ratio (OR): 11.19; 95% confidence interval (95% CI): 1.80-69.53; P = 0.003], free T4 (OR: 8.76; 95% CI: 2.09–36.7; P = 0.003), and left atrial diameter (OR: 1.25; 95% CI: 1.06–1.47; P = 0.008). Conclusions The results of the present study suggest that high sensitivity C reactive protein, an indicator of inflammation, free T4 and left atrial diameter are associated with the development AF in patients with hyperthyroidism.     

Increased dispersion of refractoriness in patients with atrial fibrillation in the early postoperative period after coronary artery bypass grafting

INTRODUCTION: Increased atrial effective refractory period (AERP) dispersion is well correlated with vulnerability to atrial fibrillation (AF). However, the preoperative electrophysiologic characteristics of atrial abnormalities that may play an important role in the development of AF postoperatively in patients with coronary artery bypass grafting (CABG) have not been investigated in detail. METHODS AND RESULTS: Fifty-six consecutive patients who underwent CABG were enrolled in this study. Eighteen patients (14 men and 4 women; mean age 57.7 +/- 5.2 years) with AF in the early postoperative period and 38 patients (28 men and 10 women; mean age 56.3 +/- 6.4 years) without AF were compared with regard to preoperative clinical, echocardiographic, angiographic, and electrophysiologic parameters. Preoperative PA interval and AERP dispersion values were higher (P < 0.05) in patients who developed AF in the early postoperative period. PA interval (P < 0.05, odds ratio = 1.64, 95% confidence interval 1.17-2.30), AERP in the high right atrium (AERP(HRA); P < 0.05, odds ratio = 0.94, 95% confidence interval 0.91-0.97), AERP in the right posterolateral atrium (AERP(RPL); P < 0.05, odds ratio = 0.79, 95% confidence interval 0.63-0.98), AERP in the distal coronary sinus (AERP(DCS); P < 0.05, odds ratio = 0.84, 95% confidence interval 0.74-1.02), and AERP dispersion (P < 0.001, odds ratio = 1.29, 95% confidence interval 1.12-1.47) were independently related to post-CABG AF in univariate analysis. Increases in preoperative PA interval and AERP dispersion were found to be associated with a high risk for development of post-CABG AF. CONCLUSION: AERP dispersion is a suitable electrophysiologic indicator for atrial vulnerability. The presence of increased preoperative AERP dispersion and PA interval may indicate patients at high risk for development of AF in the early postoperative period after coronary artery bypass grafting.     

Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals

Objectives. This study sought to compare the use of invasive procedures and length of stay for patients admitted with acute myocardial infarction to health maintenance organization (HMO) and fee-for-service hospitals.Background. The HMOs have reduced costs compared with fee-for-service systems by reducing discretionary admissions and decreasing hospital length of stay. It has not been established whether staff-model HMO hospitals also reduce the rate of procedure utilization.Methods. Using data from a retrospective cohort, we performed univariate and multivariate comparisons of the use of cardiac procedures, length of stay and hospital mortality in 998 patients admitted to two staff-model HMO hospitals and 7,036 patients admitted to 13 fee-for-service hospitals between January 1988 and December 1992.Results. The odds of undergoing coronary angiography were 1.5 times as great for patients admitted to fee-for-service hospitals than for those admitted to HMO hospitals (odds ratio 1.5, 95% confidence interval [CI] 1.3 to 1.9). Similarly, the odds of undergoing coronary revascularization were two times greater in fee-for-service hospitals (odds ratio 2.0, 95% Cl 1.6 to 2.5). However, higher utilization was strongly associated with the greater availability of on-site cardiac catheterization facilities in fee-for-service hospitals. The length of hospital stay, by contrast, was ∼1 day shorter in the fee-for-service cohort (7.3 vs. 8.0 days, p < 0.05).Conclusions. Physicians in staff-model HMO hospitals use fewer invasive procedures and longer lengths of stay to treat patients with acute myocardial infarction than physicians in fee-for-service hospitals. This finding, however, appears to be associated with the lack of on-site catheterization facilities at HMO hospitals.     

Comparison of effectiveness and safety of ranolazine versus amiodarone for preventing atrial fibrillation after coronary artery bypass grafting

Atrial fibrillation (AF) is common after coronary artery bypass grafting (CABG) and increases the morbidity and cost. Amiodarone reduces AF after CABG. Ranolazine, an antianginal agent, also prolongs atrial refractoriness and inhibits after depolarizations and triggered activity; effects that could decrease AF after CABG. The present study compared amiodarone versus ranolazine for the prevention of AF after CABG. A retrospective cohort study of patients undergoing CABG at Aspirus Hospital from June 2008 to April 2010. The patients received either amiodarone (400 mg preoperatively followed by 200 mg twice daily for 10 to 14 days) or ranolazine (1,500 mg preoperatively followed by 1,000 mg twice daily for 10 to 14 days). The primary end point was any identified AF after CABG. A total of 393 consecutive patients undergoing CABG (mean age 65 ± 10 years, 72% men) received either amiodarone (n = 211 [53.7%]) or ranolazine (n = 182 [46.3%]). AF occurred in 26.5% of the amiodarone-treated patients compared to 17.5% of the ranolazine-treated patient (p = 0.035). The univariate predictors of AF included amiodarone use, age, chronic lung disease, and congestive heart failure. The multivariate predictors of AF included amiodarone use (odds ratio 1.7, 95% confidence interval 1.01 to 2.91, p = 0.045 vs ranolazine), age (odds ratio 2.2 per 10 years, 95% confidence interval 1.63 to 2.95, p <0.001), and chronic lung disease (odds ratio 1.86, 95% confidence interval 1.00 to 3.43, p = 0.049). No difference was found in the risk of adverse events between the 2 therapies. In conclusion, ranolazine was independently associated with a significant reduction of AF compared to amiodarone after CABG, with no difference in the incidence of adverse events. Randomized studies should be conducted to confirm these results.     

Brain natriuretic peptide levels as a predictor for new atrial fibrillation during hospitalization in patients with acute ischemic stroke

The aim of this study was to investigate the relation between brain natriuretic peptide (BNP) levels and the detection rate of new documented atrial fibrillation (AF) after ischemic stroke. Consecutive patients with ischemic stroke prospectively enrolled within 24 hours of onset. Patients with AF on admission electrocardiography or with histories of AF were excluded. The plasma BNP level was measured on admission, and the factors associated with new documented AF were investigated by multivariate logistic regression analysis. Furthermore, the detection rates of AF according to BNP level were evaluated. A total of 584 patients were enrolled. AF was detected in 40 patients (new AF group; 6.8%). The median BNP level of the new AF group was significantly higher than for the non-AF group (186.6 pg/ml [interquartile range 68.7 to 386.3] vs 35.2 pg/ml [interquartile range 15.9 to 80.1], p <0.0001). The cut-off level, sensitivity, and specificity of BNP levels to distinguish the new AF group from the non-AF group were 65.0 pg/ml, 80%, and 70%, respectively. Multivariate logistic regression analysis demonstrated that National Institutes of Health Stroke Scale score >7 (odds ratio 3.4, 95% confidence interval 1.685 to 7.006, p = 0.0007) and a plasma BNP level >65.0 pg/ml (odds ratio 6.8, 95% confidence interval 2.975 to 15.359, p <0.0001) were independently associated with new AF. The detection rates of AF according to BNP level were as follows: 2% of patients with <50 pg/ml, 4% of those with 50 to <100 pg/ml, 12% of those with 100 to <200 pg/ml, 26% of those with 200 to <400 pg/ml, and 38% of those with ≥400 pg/ml. In conclusion, BNP levels can predict new AF in patients with acute ischemic stroke. Elevated BNP levels result in an increase in the frequency of detection of new AF.     

Value of preoperative echocardiography in the prediction of postoperative atrial fibrillation following isolated coronary artery bypass grafting

The value of echocardiography, especially tissue Doppler imaging (TDI), in the assessment of risk of postoperative atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is not clear. One hundred two consecutive patients (80 men; mean age 61 +/- 10 years) who underwent elective isolated CABG were included in the study. All patients underwent conventional transthoracic echocardiography and TDI of the left and right heart before surgery. Also, 24-hour Holter recordings were obtained for all patients. The study end point was the development of postoperative AF. The surgical mortality rate was 2%. Postoperative AF occurred in 18 patients (18%). Patients with postoperative AF have been significantly older than patients without postoperative AF (73 +/- 7 vs 58 +/- 9 years, respectively; p <0.001). Compared with patients without postoperative AF, a significantly higher proportion of patients with postoperative AF experienced paroxysmal AF before surgery (6% vs 33%, respectively; p = 0.001). Patients with postoperative AF had a significantly larger mean left atrial diameter compared with patients without postoperative AF (37 +/- 3 vs 35 +/- 3 mm, respectively; p = 0.012). Multivariate logistic regression analysis identified age as the most significant predictor of postoperative AF (odds ratio 1.254, 95% confidence interval 1.127 to 1.396; p <0.001). Of the echocardiographic variables, only left atrial diameter was identified as a significant predictor of postoperative AF (odds ratio 1.250, 95% confidence interval 1.055 to 1.562; p = 0.047). In conclusion, in the prediction of postoperative AF after isolated CABG, preoperative transthoracic echocardiography, including both conventional echocardiography and TDI, is of little value.     

The association between the on-site availability of cardiac procedures and the utilization of those services for acute myocardial infarction by payer group. The National Registry of Myocardial Infarction 2 Investigators.

BACKGROUND: Prior studies have suggested that in-hospital availability may be an important determinant for the use of invasive cardiac services; however, whether this association is influenced by payer status remains unclear. HYPOTHESIS: The interaction of payer status and the on-site availability of coronary arteriography is associated with increased utilization of this procedure. METHODS: In-hospital availability and utilization of coronary arteriography was ascertained in 275,046 patients with acute myocardial infarction (AMI) enrolled in the National Registry of Myocardial Infarction 2 from June 1994 to April 1996. Logistic regression analyses were performed to determine the association between the on-site availability of cardiac catheterization at the initial hospital and subsequent utilization of coronary arteriography. Similar analyses were performed within Medicare, Medicaid, Commercial, Health Maintenance Organization (HMO), and Uninsured payer groups. RESULTS: Patients initially admitted to hospitals having on-site cardiac catheterization facilities were almost twice as likely to receive coronary arteriography as patients admitted to hospitals without such facilities and later transferred out [un-adjusted odds ratio (OR) = 1.69, 95% confidence interval (CI) 1.66-1.73, p < 0.0001; adjusted OR = 2.08, 95% CI 2.01-2.15, p < 0.0001]. Furthermore, this relationship of increased utilization with greater availability was evident within each payer group, but was highest among those with Commercial insurance and lowest among Medicaid recipients: [Commercial insurance (OR = 2.19, 95% CI 2.07-2.31, p < 0.0001); Uninsured (OR = 1.74, 95% CI 1.57-1.92, p < 0.0001); HMO (OR = 1.67, 95% CI 1.54-1.82, p < 0.0001); Medicare 1.60, 95% CI 1.55-1.64, p < 0.0001); Medicaid (1.46, 95% CI 1.29-1.65, p < 0.0001)]. CONCLUSIONS: Our results show a strong association between in-hospital availability and subsequent utilization of invasive cardiac procedures following AMI among all patients, but the strength of these associations varied among payer status.     

Weekend/holiday versus weekday hospital discharge and guideline adherence (from the American Heart Association's Get with the Guidelines--Coronary Artery Disease database)

Most hospitals have reduced medical staff on weekends. Furthermore, a recent study on acute myocardial infarction suggested that weekend admissions were associated with higher mortality compared with weekday admissions. We sought to determine if compliance with guideline recommendations for acute coronary syndrome performance measures would be worse on weekends/holidays compared with weekdays. We utilized the American Heart Association's Get with the Guidelines (GWTG) - Coronary Artery Disease database. This study included 154,910 patients admitted to 515 various hospitals from January 14, 2000 to April 30, 2007 with acute coronary syndrome (ACS). Patients discharged on weekdays were older and were more likely to be women, have a history of atrial fibrillation, cerebral vascular accident/transient ischemic attack and chronic renal insufficiency, and present with unstable angina. Although patients discharged on the weekends/holidays were slightly less likely to receive angiotensin-converting enzyme inhibitors than those discharged on weekdays (68.3% vs 69.5%, p <0.0001), all other measures were similar, and a composite performance measure for 100% compliance was equal in both groups (81.5% vs 81.4%, p = 0.77). In conclusion, within GWTG participating hospitals, weekend/holiday staffing provides the same quality of care in ACS for discharge medications and counseling compared with full weekday staffing. However, there remain further opportunities to improve utilization of guideline-recommended therapies irrespective of discharge day.     

Stroke patients with atrial fibrillation have a worse prognosis than patients without: data from the Austrian Stroke registry.

AIMS: Stroke patients with atrial fibrillation (AF) have a poorer neurological outcome than stroke patients without AF. Whether stroke patients with AF also have a higher rate of medical complications is unknown. The aim of the study was to compare the in-hospital course of acute stroke patients with and without AF. METHODS AND RESULTS: The Austrian Stroke registry was a prospective multi-centre study involving 57 medical departments documenting the hospital course of consecutive stroke patients from June 1999 to October 2000. AF was diagnosed in 304 (31%) of 992 patients. Patients with AF were older (79 versus 75 years, p < 0.0004) than no-AF patients. There were more cases of pneumonia (23% versus 9%, p < 0.0004), pulmonary oedema (12% versus 6%, p < 0.0004) and symptomatic intracerebral haemorrhage (8% versus 2%, p < 0.0004) in AF compared to no-AF. In-hospital mortality was higher in AF (25% versus 14%, p < 0.0004), and neurological outcome was poorer (65 versus 90 Barthel index, p < 0.0004). On multivariable logistic regression analysis, however, AF was no predictor for mortality, but a Barthel index of zero (odds ratio 5.30, 95% CI 3.10-9.08, p < 0.0001), a National Institutes of Health Stroke Scale > 21 or comatose (odds ratio 3.13, 95% CI 2.26-4.32, p < 0.0001), age > 75 years (odds ratio 3.15, 95% CI 1.85-5.37, p < 0.0001), heart rate > 100 min(-1) (odds ratio 2.15, 95% CI 1.26-3.66, p = 0.0049), obstructive pulmonary disease (odds ratio 2.58, 95% CI 1.03-6.48, p = 0.0442) and creatinine > 125 micromol/l (odds ratio 1.84, 95% CI 1.00-3.37, p = 0.0479). CONCLUSION: Stroke in AF is associated with a poor prognosis, an increased rate of medical and neurological complications and a higher in-hospital mortality than in no-AF.     

Usefulness of P-wave dispersion in standard twelve-lead electrocardiography to predict transition from paroxysmal to persistent atrial fibrillation

A prospective study was conducted to investigate the validity of the hypothesis that P-wave dispersion (Pd) may be a clinically useful predictor of progression from paroxysmal to persistent atrial fibrillation (AF). Two hundred four consecutive patients with a diagnosis of paroxysmal AF were studied. Standard 12-lead electrocardiography and echocardiography were performed on all patients at the time of entry into the study. Pd was measured as the difference between maximum and minimum P-wave duration in any of the 12 leads. Mean follow-up was 66 +/- 8 months. Group I included patients (n = 132) in whom paroxysmal AF did not progress to persistent AF, and group II included those (n = 72) who developed persistent AF. In group II, age, percentage of men, percentage of patients with diabetes mellitus, maximum P-wave duration, Pd, and left atrial dimension were significantly higher than in group I (p <0.05). Multivariate logistic regression analysis using these 6 factors identified age (odds ratio 2.18, 95% confidence interval 1.41 to 3.41, p <0.01) and Pd (odds ratio 1.91, 95% confidence interval 1.51 to 2.44, p <0.01) as independent predictors of a transition to persistent AF. Pd >or=40 ms predicted progression to persistent AF with sensitivity of 71%, specificity of 77%, positive predictive value of 63%, negative predictive value of 83%, and accuracy of 75%. In conclusion, Pd was a clinically useful predictor of progression from paroxysmal to persistent AF.     

Trends in drug overdose deaths in England and Wales 1993-98: methadone does not kill more people than heroin

Aims To test the hypothesis that methadone is responsible for a greater increase in overdose deaths than heroin, and causes proportionally more overdose deaths than heroin at weekends. Design and setting Multivariate analysis of 3961 death certificates mentioning heroin, morphine and/or methadone held on the Office for National Statistics drug‐related poisoning mortality database from 1993 to 1998 in England and Wales. Measurements Percentage increase in deaths by year by drug, odds ratio (OR) of dying at the weekend from methadone‐related overdose compared to dying from heroin/morphine overdose. Findings From 1993 to 1998, annual opiate overdose deaths increased from 378 to 909. There was a 24.7% (95% confidence interval (CI) 22–28%) yearly increase in heroin deaths compared to 9.4% (95% CI 6–13%) for methadone only. This difference was significant (P < 0.001 by test of interaction) after adjustment for sex, age group, polydrug use, area of residence and underlying cause of death. The largest number of deaths occurred on Saturday (673). The OR of death from methadone overdose on Saturday and Sunday was 1.48 (95% CI 1.29–1.71) for methadone‐only deaths compared to dying from heroin/morphine at the weekend after adjustment for other covariates, but the OR was not significant (1.09, 95% CI 0.95–1.25) if the weekend was defined as Friday and Saturday. Conclusions There was no evidence that the threefold increase in deaths over time was due to methadone. There was equivocal support only for the hypothesis that there was an excess of deaths from methadone at weekends. Increased interventions to prevent overdose among injectors in England and Wales are long overdue.     

Relation of C-reactive protein and new-onset atrial fibrillation in patients with acute myocardial infarction

Recent studies have implicated systemic inflammation in the genesis and maintenance of atrial fibrillation (AF). A robust inflammatory response is an integral component of the response to tissue injury during acute myocardial infarction (AMI). However, there is no information concerning the association between inflammation and AF in patients with AMI. We studied 1,209 patients admitted for AMI. C-reactive protein (CRP) was measured by a high-sensitivity assay within 12 to 24 hours after symptom onset. The relation between CRP and new-onset AF occurring during the hospital course and at 1 year was analyzed using multivariable logistic regression and Cox models, respectively. New-onset AF during hospitalization occurred in 6.5%, 10.4%, and 17.1% of patients in the first, second and third CRP tertiles, respectively (p trend <0.0001). In a multivariable logistic regression, adjusting for clinical variables and ejection fraction, compared with patients in the first CRP tertile, the odds ratios for AF were 1.5 (95% confidence interval 0.9 to 2.5, p = 0.15) and 2.0 (95% confidence interval 1.2 to 3.3, p = 0.008) in patients in the second and third CRP tertiles, respectively (p for trend = 0.007). In a Cox multivariate analysis, CRP remained an independent predictor of new-onset AF at 1 year. In conclusion, in a large cohort of patients with AMI, there was a graded positive association between increased CRP and new-onset AF. Inflammation may contribute to the development of AF in the setting of AMI.     

Clinical value of left atrial appendage flow for prediction of long-term sinus rhythm maintenance in patients with nonvalvular atrial fibrillation

OBJECTIVES: This study evaluated the role of various clinical and echocardiographic parameters, including the left atrial appendage (LAA) anterograde flow velocity, for prediction of the long-term preservation of sinus rhythm (SR) in patients with successful cardioversion (CV) of nonvalvular atrial fibrillation (AF). BACKGROUND: Echocardiographic parameters for assessing long-term SR maintenance after successful CV of nonvalvular AF are not accurately defined. METHODS: Clinical, transthoracic echocardiographic and transesophageal echocardiographic (TEE) data--measured in AF lasting >48 h--of 186 consecutive patients (116 men, mean age: 65 +/- 9 years) with successful CV (electrical or pharmacologic) were analyzed for assessment of one-year maintenance of SR. RESULTS: At one-year follow-up, 91 of 186 (49%) patients who underwent successful CV continued to have SR. Mean LAA peak emptying flow velocity was higher in patients remaining in SR for one year than in those with AF relapse (41.7 +/- 20.2 cm/s vs. 27.7 +/- 17.0 cm/s; p < 0.001). On multivariate logistic regression analysis, only the mean LAA peak emptying velocity >40 cm/s (p = 0.0001; chi(2): 23.9, odds ratio [OR] = 5.2, confidence interval [CI] 95% = 2.7 to 10.1) and the use of preventive antiarrhythmic drug treatment (p = 0.0398; chi(2): 4.2; OR = 2.0, CI 95% = 1.0 to 3.8) predicted the continuous preservation of SR during one year, outperforming other univariate predictors such as absence of left atrial spontaneous echocardiographic contrast during TEE, the left atrial parasternal diameter <44 mm, left ventricular ejection fraction >46% and AF duration <1 week before CV. The negative and positive predictive values of the mean LAA peak emptying velocity >40 cm/s for assessing preservation of SR were 66% (CI 95% = 56.9 to 74.2) and 73% (CI 95% = 62.4 to 83.3), respectively. CONCLUSIONS: In TEE-guided management of nonvalvular AF, high LAA flow velocity identifies patients with greater likelihood to remain in SR for one year after successful CV. Low LAA velocity is of limited value in identifying patients who will relapse into AF.