Absence of sex differences in pharmacotherapy for acute myocardial infarction

BACKGROUND: Previous studies have indicated that sex differences may exist in the pharmacological management of acute myocardial infarction (AMI), with female patients being treated less aggressively. OBJECTIVES: To determine if previously reported sex differences in AMI medication use were also evident among all AMI patients treated at hospitals in an urban Canadian city. METHODS: All patients who had a primary discharge diagnosis of AMI from all three adult care hospitals in Calgary, Alberta, in the 1998/1999 fiscal year were identified from hospital administrative records (n=914). A standardized, detailed chart review was conducted. Information collected from the medical charts included sociodemographic and clinical characteristics, comorbid conditions, and cardiovascular medication use during hospitalization and at discharge. RESULTS: Similar proportions of female and male patients were treated with thrombolytics, beta-blockers, angiotensin-converting enzyme inhibitors, nitrate, heparin, diuretics and digoxin. Among patients aged 75 years and over, a smaller proportion of female patients received acetylsalicylic acid in hospital than did male patients (87% versus 95%; P=0.026). Multivariable logistic regression analysis revealed that, after correction for age, use of other anticoagulants/antiplatelets and death within 24 h of admission, sex was no longer an independent predictor for receipt of acetylsalicylic acid in hospital. Medications prescribed at discharge were similar between male and female patients. CONCLUSION: The results from this Canadian chart review study, derived from detailed clinical data, indicate that the pattern of pharmacological treatment of female and male AMI patients during hospitalization and at discharge was very similar. No sex differences were evident in the treatment of AMI among patients treated in an urban Canadian centre.     

Long-term Mortality after Acute Myocardial Infarction in Relation to Prescribed Dosages of a Beta-Blocker at Hospital Discharge

This study was designed to describe the 5-year mortality rate in relation to the dose of metoprolol prescribed at hospital discharge after hospitalisation for acute myocardial infarction (AMI). All patients discharged alive after being hospitalized for AMI at Sahlgrenska Hospital (covering half of the community of Göteborg, with 500,000 inhabitants) during 1986–1987 (period I) and all patients discharged alive after hospitalization for AMI at Sahlgrenska Hospital and östra Hospital (covering the whole area of the community of Göteborg) in 1990–1991 (period II) were included. Overall mortality was retrospectively evaluated over 5 years of follow-up. In all there were 2161 patients who were discharged after AMI. Seventy-three percent of these patients were prescribed a beta-blocker and 59% were prescribed metoprolol. Of the patients prescribed metoprolol, 34% were on 200 mg, 46% on 100 mg, and 20% on 50 mg or less. Information on 5-year mortality was available for 2142 of the 2161 patients (99.1%). The 5-year mortality was 24% among patients prescribed 200 mg, 33% among patients prescribed 100 mg, and 43% among patients prescribed 50 mg (P < 0.0001). Patients prescribed another beta-blocker had a 5-year mortality of 39%, and patients prescribed no beta-blocker at all had a 5-year mortality of 61%. When correcting for dissimilarities at baseline, patients who were prescribed 100 mg had an adjusted risk ratio for death of 0.79 (95% confidence limit 0.64–0.96; P = 0.021) as compared with patients not prescribed a beta blocker. The corresponding figure for patients prescribed >100 mg was 0.63 (95% confidence limit 0.48–0.84; P = 0.001). Both patients prescribed high and low doses of metoprolol after AMI appeared to benefit from treatment. There was a trend indicating more benefit when larger doses were prescribed.     

Uncovering a multitude of sins: medication management in the home post acute hospitalisation among the chronically ill

Background: Sub-optimal use of prescribed medication is often associated with unplanned hospitalisation among the chronically ill.
Aims: To examine the extent of sub-optimal use of prescribed medication in a 'high risk' patient cohort recently discharged from acute hospital care.
Methods: Chronically ill patients discharged from acute hospital care ( n =342) were studied. At one week post discharge a home visit was performed by a nurse and a pharmacist during which medication management (including compliance and medication—related knowledge) was assessed.
Results: During the majority of home visits at least one medication-related problem was detected: approximately half of the cohort subject to a 'reliable' pill-count were found to be mal-compliant and almost all demonstrated inadequate medication-related knowledge. Mal-compliance was correlated with ≥ five prescribed medications (Odds ratio [OR] 2.6: p <0.002). Comparatively, lower medication-related knowledge was correlated with age >75 years (OR 2.2: p <0.001), exacerbation of a pre-existing chronic illness (OR 2.7: p =0.044) and six years formal education (OR 1.9: p ≥0.004). Neither were modulated by extent of in-hospital counselling. Other previously unknown problems detected during the home visit included hoarding of previously prescribed medication (35%) and reducing medication intake to minimise costs (21%).
Conclusions: Management of prescribed medications among chronically ill patients recently discharged from acute hospital care is often sub-optimal. Assessment of medication management in the home provides an invaluable opportunity to detect and address problems likely to result in poorer health outcomes.     

Occurrence of angina pectoris prior to acute myocardial infarction and its relation to prognosis

In 917 patients with acute myocardial infarction (AMI) we evaluatedthe impact of previous angina pectoris on the prognosis. Thirty-fourpercent of the patients had chronic angina prior to AMI, and22% had angina pectoris of short duration. Patients with chronicangina pectoris differed from the remaining patients havinga more frequent previous history of AMI, diabetes mellitus,hypertension, and congestive heart failure. They less frequentlydeveloped a Q-wave AMI, and had smaller infarcts according tomaximum serum-enzyme activity as compared with the remainingpatients. They had a higher one-year mortality rate (36%) ascompared with those having angina pectoris of short duration(22%), and those with no angina pectoris (26%). Their reinfarctionrate was also higher (26%) as compared with that in the othertwo groups (15% and 9% respectively). In a multivariate analysisconsidering age, sex, clinical history, initial symptoms, initialelectrocardiogram and estimated infarct size, previous chronicangina pectoris was not an independent risk factor for death,but was independently associated with the risk of reinfarction(P<0.001) Among patients with a history of angina pectoristhe outcome was related to medication prior to onset of AMIand at discharge from hospital. Patients in whom beta-blockerswere prescribed at discharge had a one-year mortality of 13%as compared with 30% in the remaining patients (P<0.001).     

Prediction of mortality after myocardial infarction by simple clinical variables recorded during hospitalization

Simple clinical variables obtainable in any coronary care unit and in any patient were recorded in 769 consecutive patients who were admitted with acute myocardial infarction (AMI) and who were discharged from the hospital and followed for up to 3 years. To identify the patients at highest and lowest risk of posthospital mortality, a prognostic index was established from a stepwise logistic discriminant analysis of variables obtained in a consecutive series of 418 patients discharged alive from one of two coronary care units admitting new patients on alternate days. This prognostic index was validated by applying it to a comparison group of 351 consecutive control patients discharged from the other coronary care unit. In the training group, 59 of the 418 patients (14%) died during the first year after hospital discharge and 34 (8%) died during the second or third year. The stepwise logistic discriminant analysis made it possible to distinguish between 1-year survivors and nonsurvivors, but not between the patients who died during the second and third years and the 3-year survivors. Four variables were selected for obtaining a 1-year prognostic index: the maximum grade of left ventricular function during hospitalization (0 to 4), history of previous AMI (1 or 0), predischarge cardiothoracic ratio (0 to 0.99), and complete bundle branch block (1 or 0). Prognostic index = 7.0196-0.6515 function - 1.6623 previous AMI - 0.0729 cardiothoracic ratio - 1.0813 bundle branch block. This index was validated in the comparison group.(ABSTRACT TRUNCATED AT 250 WORDS)     

One-year prognosis in patients hospitalized with a history of unstable angina pectoris

The prognosis during 1 year of follow-up in 715 patients admitted to one single hospital due to suspected acute myocardial infarction (AMI) with a history of unstable angina pectoris immediately preceding hospitalization is described. AMI developed in 192 patients (27%) during the first three days and in 255 patients (38%) during the first year. The mortality during hospitalization was 7% (50 patients) and during 1 year 19% (130 patients). Of the nonsurvivors, 54% died of AMI, 28% of congestive heart failure, and 20% of cardiogenic shock. Based on simple clinical parameters on admission to the emergency room, risk indicators for death during the following year could be identified as follows, in the order of significance: high age (p < 0.001), ST-segment depression on admission (p < 0.001), and a history of diabetes mellitus (p < 0.05). At admission to the emergency room, risk indicators for development of AMI during the following year were as follows: initial degree of suspicion of AMI (p < 0.001), electrocardiographic signs of acute ischemia on admission (p < 0.001), ST-segment elevation on admission (p < 0.01), age (p < 0.05), and lack of a previous history of chronic stable angina pectoris (p < 0.05). We conclude that, among patients admitted to hospital due to suspected AMI with a history of unstable angina pectoris immediately preceding hospitalization, 38% developed a confirmed infarction and 19% died during the following year.     

Need for better severity indexes of acute myocardial infarction under diagnosis-related groups

Clinical, demographic and administrative data, including length of stay and institutional charges, were examined for 219 patients hospitalized for acute myocardial infarction (AMI). Neither length of stay nor charges differed among AMI patients with or without cardiovascular complications as defined by Medicare's diagnosis-related group (DRG) categories (DRG 121 and 122, respectively) for patients who are discharged alive. Myocardial enzyme peak levels are the best predictors of hospital resource consumption for patients with AMI when considered alone or in combination with other factors. The "cardiovascular complications" designated by discharge diagnoses did not reflect resource consumption in our patient population. Sixteen percent of the patients studied underwent cardiac catheterization during hospitalization. These patients stayed in the hospital longer and incurred 70% higher charges; nevertheless, they were grouped with the remaining AMI patients in the current DRG formulation. Clinical evaluations such as cardiovascular complications are subject to interpretation, and are therefore less credible than enzyme measurements for recognizing the severity of a patient's AMI. Reimbursement based on objective measurements may avoid payment inequities.     

急性心肌梗死患者心室膨胀瘤的影响因素及其对患者预后的预测价值研究

背景心室膨胀瘤是急性心肌梗死(AMI)患者常见且危险的并发症,可增加主要不良心血管事件(MACE)发生风险,影响患者预后,但目前国内外鲜有关于AMI患者心室膨胀瘤影响因素的研究报道。目的探讨AMI患者心室膨胀瘤的影响因素及其对患者预后的影响。方法选取2017年7月—2018年7月空军军医大学第一附属医院收治的AMI患者104例,根据心室膨胀瘤发生情况分为发生组(n=30)和未发生组(n=74)。比较两组患者一般资料〔包括年龄,性别,体质指数(BMI),发病至治疗时间,入院时心率(HR),高血压、高脂血症、糖尿病发生情况,纽约心脏病协会(NYHA)分级,前壁梗死情况,病变血管支数,贫血发生情况,冠状动脉溶栓或介入治疗情况,药物使用史〕、白细胞计数(WBC)及心功能指标〔包括左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、左心室收缩末期内径(LVESD)〕、住院期间及出院后1年预后;AMI患者心室膨胀瘤的影响因素分析采用多因素Logistic回归分析;绘制受试者工作特征曲线(ROC曲线)以评价AMI患者心室膨胀瘤的影响因素对AMI患者预后的预测价值。结果(1)两组患者男性比例、BMI、入院时HR、高血压发生率、高脂血症发生率、糖尿病发生率、NYHA分级>Ⅱ级及病变血管支数≥3支者所占比例、贫血发生率、行冠状动脉溶栓或介入治疗及有药物使用史者所占比例、LVEDD、LVESD比较,差异无统计学意义(P>0.05);发生组患者年龄大于未发生组,发病至治疗时间长于未发生组,前壁梗死发生率、WBC高于未发生组,LVEF低于未发生组(P<0.05)。(2)多因素Logistic回归分析结果显示,年龄〔OR=2.849,95%CI(2.157,3.365)〕、发病至治疗时间〔OR=3.019,95%CI(2.053,4.162)〕、前壁梗死〔OR=2.408,95%CI(2.214,2.685)〕、WBC〔OR=2.680,95%CI(1.985,2.931)〕、LVEF〔OR=3.047,95%CI(2.013,4.121)〕是AMI患者心室膨胀瘤的影响因素(P<0.05)。(3)发生组患者住院期间预后不良者所占比例高于未发生组(P<0.05)。绘制ROC曲线发现,年龄、发病至治疗时间、前壁梗死、WBC、LVEF预测AMI患者住院期间预后不良的曲线下面积(AUC)分别为0.798、0.745、0.712、0.823、0.861。(4)发生组患者出院后1年预后不良者所占比例高于未发生组(P<0.05)。绘制ROC曲线发现,年龄、发病至治疗时间、前壁梗死、WBC、LVEF预测AMI患者出院后1年预后不良的AUC分别为0.701、0.734、0.796、0.772、0.812。结论高龄、发病至治疗时间延长、前壁梗死、高WBC、低LVEF是AMI患者心室膨胀瘤的危险因素,且上述因素对AMI患者短期预后具有一定预测价值。     

Outcome after cardiac arrest during acute myocardial infarction

A community-wide study of acute myocardial infarction (AMI) was conducted in all 16 acute-care general hospitals in the Worcester, Massachusetts, metropolitan area during the years 1975, 1978, 1981 and 1984. The in-hospital and long-term prognoses of 667 patients with AMI complicated by cardiac arrest (CA) was compared with that of 2,596 AMI patients without CA. The incidence of CA complicating AMI was similar (21%) during each of the 4 study years. Among patients with AMI who had CA, 36% had CA within the first day of hospitalization and 48% within the first 2 days. The in-hospital case-fatality rate was much higher for AMI patients with CA (78%) than for those without CA (4%) (p less than 0.001). For patients discharged alive from the hospital, a trend toward a higher mortality rate was seen at 1 and 2 years after hospital discharge for patients with CA; however, long-term survival rates were not significantly different between AMI patients with and without CA. When time of occurrence of CA relative to in-hospital survival was examined, patients with early CA (within 1 day or within 2 days of hospital admission) had a significantly greater in-hospital survival (39% and 34%) than did those with late CA (after 1 day or after 2 days) (13% and 12%). Similarly, patients discharged from the hospital after early CA had a significantly better chance of long-term survival than patients discharged after late CA.     

Academic affiliation with a nursing home. Impact on patient outcome

In a prospective study, 46 patients discharged from a teaching hospital to a "teaching unit" nursing home, where primary medical care was provided by faculty geriatricians, medical students, and medical housestaff, were compared with 78 similar patients discharged to one of five community nursing homes without a teaching affiliation. At the time of hospital discharge, patients were determined to have a terminal, rehabilitative, or long stay prognosis based on a review of hospital discharge summaries using specific criteria. Among 34 study and 55 control patients with a long stay prognosis, ten of the study group compared with seven of the control group returned home (P = .03). Seven of 34 long stay patients in the study group were rehospitalized, while 15 of a matched control group of 34 required hospitalization (P = .04). There was no increase in mortality or emergency service use in the study population. Patients considered to be terminal or rehabilitative showed no difference in ultimate outcome or hospital use. In the study group patients experienced an average reduction in total medications prescribed from 6.2 to 5.3, while patients in the control group had an increase from 5.4 medications prescribed to 7.6 (P less than .001). Of 16 study patients discharged from the teaching unit nursing home, all remained home at least three months after discharge; only 12 of 18 control group patients discharged from the nursing home remained at home at three months (P less than .01). Long-term care by geriatric faculty, students, and housestaff appeared to have favorably influenced patient outcomes.     

Amiodarone and mortality among elderly patients with acute myocardial infarction with atrial fibrillation

Background Amiodarone has been shown to be safe in patients with acute myocardial infarction (AMI) who are at risk for sudden cardiac death. However, there is limited data concerning the safety of amiodarone in patients who experience AMI complicated by atrial fibrillation. Methods To determine the safety of amiodarone therapy, we conducted a retrospective analysis of elderly patients hospitalized with AMI who experienced atrial fibrillation and had survived to hospital discharge (n = 17,597). Amiodarone prescribed at discharge was evaluated for its association with short-term and long-term mortality in crude and adjusted analyses employing propensity score methods. Results Of the 17,597 patients, 550 patients (3.1%) were prescribed amiodarone, 2317 patients (13.2%) were prescribed other antiarrhythmic agents (excluded from analysis), and 14,730 (83.7%) were prescribed no antiarrhythmic medication at discharge. Thirty-day mortality rates were similar for patients prescribed amiodarone and those not prescribed amiodarone (6.8% amiodarone vs 5.4% no amiodarone, P = .21), but mortality at 1 year was higher among patients prescribed amiodarone (35.6% vs 31.6%, P = .001). However, amiodarone was not associated with mortality at 30 days (odds ratio 0.80, 95% CI 0.53-1.20) or at long-term follow-up (mean duration 612 days, hazard ratio 1.04, 95% CI 0.92-1.18) after multivariable modeling. Conclusions Amiodarone was not independently associated with short-term or long-term mortality in elderly patients discharged after a hospitalization for AMI complicated by atrial fibrillation. Although our data suggest that amiodarone may be safe to use in this population, randomized controlled trial data are needed to confirm this finding. (Am Heart J 2002;144:1095-101.)     

Which factors determine the long-term outcome among patients with a very small or unconfirmed AMI

AIM: To describe various factors associated with the very long-term prognosis for patients with a very small or an unconfirmed acute myocardial infarction (AMI). METHODS: Patients below 76 years of age, hospitalized due to suspected AMI who either developed a very small AMI (enzyme elevation相似文献   

Calcium channel blockers and mortality in elderly patients with myocardial infarction.

BACKGROUND: Although calcium channel blockers are a useful therapy in relieving angina, lowering blood pressure, and slowing conduction of atrial fibrillation, growing evidence has cast doubt on their safety in patients with coronary disease. OBJECTIVE: To examine the association between calcium channel blocker therapy at hospital discharge and mortality in a population-based sample of elderly patients hospitalized with acute myocardial infarction. DESIGN: Retrospective cohort study using data from medical charts and administrative files. SETTING: All acute care hospitals in 46 states. PATIENTS: All Medicare patients with a principal diagnosis of acute myocardial infarction consecutively discharged from the hospital alive during 8-month periods between 1994 and 1995 (N = 141,041). MAIN OUTCOME MEASURE: Mortality at 30 days and 1 year. RESULTS: Calcium channel blockers were widely prescribed at hospital discharge to elderly patients with myocardial infarction between 1994 and 1995 (n = 51,921), the most commonly prescribed being diltiazem (n = 21,175), nifedipine (n = 12,670), amlodipine (n = 11,683), and verapamil (n = 3639). After adjusting for illness severity and concomitant medication use, patients who were prescribed calcium channel blockers at hospital discharge did not have increased risk for 30-day or 1-year mortality, with the exception of the few (n = 116) treated with bepridil. Bepridil differs from other calcium channel blockers because of its tendency to prolong repolarization, and its association with proarrhythmic effects in elderly patients. CONCLUSION: We did not identify a mortality risk in a large consecutive sample of elderly patients with myocardial infarction, which supports the need for additional prospective trials examining calcium channel blocker therapy for ischemic heart disease.     

Warfarin use and long-term outcomes in patients with acute myocardial infarction and atrial fibrillation

Warfarin use in patients with acute myocardial infarction (AMI) and atrial fibrillation (AF) remains challenging. We describe use of warfarin up to 1 year after hospitalization among patients with AMI and AF according to stroke and bleeding risk, and identify factors associated with long-term mortality in this population. Patients with AMI and AF who underwent cardiac catheterization during their AMI hospitalization in 1995–2007 were identified from the Duke Databank for Cardiovascular Disease. Warfarin use at discharge, 6 months, and 1 year as well as long-term vital status were assessed by surveys. Rates of warfarin use were presented according to CHADS₂ and CHA₂DS₂VASc stroke and ATRIA bleeding risk scores. Cox proportional hazards modeling was used to determine whether warfarin use at discharge was independently associated with 1-year mortality. A total of 879 patients hospitalized with AMI with AF were identified. Median age was 72 (25th, 75th percentiles: 64, 79), and median follow-up was 4.1 years (1.3, 7.4). The rate of warfarin use at discharge was 24 % and did not differ by CHADS₂, CHA₂DS₂VASc, or ATRIA risk scores. Warfarin use remained similar at 6 months (26 %) and 1 year (27 %). Long-term mortality was high and did not differ by whether warfarin was or was not prescribed at discharge (72 and 71 %, respectively). Factors associated with 1-year mortality were history of heart failure (HR 1.58, 95 % CI 1.32–1.90), higher Charlson comorbidity index (HR 1.19, 95 % CI 1.11–1.28), and older age (HR 1.03 per 1-year increase, 95 % CI 1.02–1.05). Warfarin use at discharge among patients hospitalized for AMI who had comorbid AF was low and remained low at 1 year. Warfarin use at hospital discharge was not associated with either 1-year mortality or long-term mortality.     

急性心肌梗死患者早期他汀类药物应用的意义

目的观察急性心肌梗死(AMI)患者早期(出院前)他汀类药物应用对长期服药率及预后的影响。方法入选1998~1999年从我院出院的AMI患者,根据出院前是否应用他汀类药物分为他汀组与非他汀组,随访两组主要终点即全因死亡、因心绞痛再住院、非致死性再梗、血管重建(冠状动脉介入治疗,冠状动脉旁路移植术)及脑卒中的发生率,同时观察两组目前他汀类药物的应用情况。结果(1)符合入选标准的患者260例,完成随访227例,其中在出院前应用他汀类药物的患者(他汀组)107例,未应用他汀类药物的患者(非他汀组)120例,随访(52.5±16.1)月。(2)随访期间他汀组主要终点发生率明显降低(31.8%比50.8%;P=0.004)。(3)应用logistic多因素回归分析,仅年龄和出院前应用他汀类药物和主要终点显著相关(P均为0.038)。(4)随访期间他汀组患者比非他汀组患者服药率明显提高(62%比19.4%;P<0.001)。结论AMI早期他汀类药物应用可以减少主要终点的发生率,提高长期服药率。     

Determinants of appropriate lipid management in patients with ischaemic heart disease. Cracovian Program for Secondary Prevention of Ischaemic Heart Disease

Although several randomised clinical trials have documented the efficacy of lipid-lowering therapy in improving clinical outcomes in hyperlipidemic subjects with ischaemic heart disease (IHD), such therapy is underutilized worldwide. Not much is known about the effects of the hospital setting (university vs. community) on lipid management in patients after hospitalization due to ischaemic heart disease. The combined effect of age, sex, education, risk factors, hospital as well as practice setting in the post-discharge period on lipid management in IHD patients is also unknown. Therefore the aim of this study was to evaluate factors influencing lipid management during and after hospitalization due to IHD. The primary outcome measure was "appropriate lipid management", defined as: (a) being discharged on lipid-lowering medication or having a documented LDL cholesterol level <3.4 microM/l within the first 24 h of hospitalization, and (b) (for patients with hypercholesterolemia) being prescribed a lipid-lowering drug at the time of the interview 6-18 months after discharge. METHODS AND RESULTS: We reviewed the hospital records of 1051 consecutive patients with a discharge diagnosis of acute myocardial infarction (N=290), unstable angina (N=247), percutaneous coronary intervention (N=259) or coronary artery bypass surgery (N=255) who were hospitalized at three university (N=533) or three community (N=518) cardiac departments. Overall, 42.2% of the study population met the criteria for appropriate lipid management during hospitalization. Admission to the university hospital, percutaneous coronary intervention, a history of myocardial infarction, the presence of hypertension, the absence of diabetes mellitus, and younger age were all associated with an increased probability of receiving proper treatment during hospitalization. During the follow-up interview (6-18 months after discharge), 10.4% patients had a LDL cholesterol level of <2.6 microM/l. The use of lipid-lowering agents in the group with hypercholesterolemia was 40.8%. Patients who met the criteria for appropriate lipid management during hospitalization were more often prescribed a lipid-lowering drug at the time of interview compared with persons who did not meet those criteria (62.5% vs. 23.5%; P<0.0001). Patients undergoing percutaneous coronary interventions, treated in hospital outpatient clinics, obese patients as well as those better educated were more likely to be treated appropriately than the other groups. CONCLUSIONS: Proper lipid management during hospitalization is the most important factor related to lipid management in the post-discharge period. There is the potential for a further reduction of coronary risk, especially in patients hospitalized in community hospitals, not undergoing coronary interventions and those being under the care of general practitioners.