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Biomedical subjects

A Timmis

Publications and source records attributed to A Timmis.

15 recordsLinked to original sources
PubMed2005

Impact of the National Service Framework for coronary heart disease on treatment and outcome of patients with acute coronary syndromes.

OBJECTIVES: To evaluate the impact the National Service Framework (NSF) for coronary heart disease has had on emergency treatment and outcomes in patients presenting with acute coronary syndromes. DESIGN: Retrospective cohort study. SETTING: Coronary care units of two district general hospitals. RESULTS: Data from 3371 patients were recorded, 1993 patients in the 27 months before the introduction of the NSF and 1378 patients in the 24 months afterwards. After the introduction of the NSF in-hospital mortality was significantly reduced (95 patients (4.8%) v 43 (3.2%), p = 0.02). This was associated with a reduction in the development of Q wave myocardial infarction (40.6% v 33.3%, p < 0.0001) and in the incidence of left ventricular failure (15.9% v 12.3%, p = 0.003). The proportion of patients receiving thrombolysis increased (69.4% v 84.7%, p < 0.0001) with a decrease in the time taken to receive it (proportion thrombolysed within 20 minutes 12.1% v 26.6%, p < 0.0001). The prescription of beta blockers (51.9% v 65.8%, p < 0.0001), angiotensin converting enzyme inhibitors (37% v 66.4%, p < 0.0001), and statins (55.2% v 72.7%, p < 0.0001) improved and the proportion of patients referred for invasive investigation increased (18.3% v 27.0%, p < 0.0001). Trend analysis showed that improvements in mortality and thrombolysis were directly associated with publication of the NSF, whereas the improvements seen in prescription of beta blockers and statins were the continuation of pre-existing trends. CONCLUSIONS: In the two years that followed publication of the NSF the initial treatment and outcome of patients presenting with acute coronary syndromes improved. Some of the improvements can be attributed to the NSF but others are continuations of pre-existing trends.

Adrenergic beta-Antagonists↗
PubMed2001

Hypothetical ratings of coronary angiography appropriateness: are they associated with actual angiographic findings, mortality, and revascularisation rate? The ACRE study.

OBJECTIVE: To determine whether ratings of coronary angiography appropriateness derived by an expert panel on hypothetical patients are associated with actual angiographic findings, mortality, and subsequent revascularisation in the ACRE (appropriateness of coronary revascularisation) study. DESIGN: Population based, prospective study. The ACRE expert panel rated hypothetical clinical indications as inappropriate, uncertain, or appropriate before recruitment of a cohort of real patients. SETTING: Royal Hospitals Trust, London, UK. PARTICIPANTS: 3631 consecutive patients undergoing coronary angiography (no exclusion criteria). MAIN OUTCOME MEASURES: Angiographic findings, mortality (n = 226 deaths), and revascularisation (n = 1556 procedures) over 2.5 years of follow up. RESULTS: The indications for coronary angiography were rated appropriate in 2253 (62%) patients. 166 (5%) coronary angiograms were performed for indications rated inappropriate, largely for asymptomatic or atypical chest pain presentations. The remaining 1212 (33%) angiograms were rated uncertain, of which 47% were in patients with mild angina and no exercise ECG or in patients with unstable angina controlled by inpatient management. Three vessel disease was more likely among appropriate cases and normal coronaries were more likely among inappropriate cases (p < 0.001). Mortality and revascularisation rates were highest among patients with an appropriate indication, intermediate in those with an uncertain indication, and lowest in the inappropriate group (log rank p = 0.018 and p < 0.0001, respectively). CONCLUSION: The ACRE ratings of appropriateness for angiography predicted angiographic findings, mortality, and revascularisation rates. These findings support the clinical usefulness of expert panel methods in defining criteria for performing coronary angiography.

Adult↗
PubMed2001

Coronary stent deployment in situs inversus.

Situs inversus with dextrocardia occurs in approximately one in 10 000 patients. Successful stent deployment for the treatment of unstable angina and situs inversus is presented. Three technical challenges associated with the procedure are highlighted. Firstly, the successful choice of diagnostic and interventional catheters is based on an understanding of the orientation of the aortic arch. With a right sided aorta Judkins catheters should be successful. Secondly, image reversal is not necessarily required for image interpretation. Thirdly, successful coronary engagement with catheters requires rotation in a direction opposite to that normally used.

Aged↗
PubMed2001

Changing face of acute myocardial infarction in east London: a prospective cohort study of trends in management and outcome in the reperfusion era.

AIMS: To define the trends in management and outcome of acute myocardial infarction over the first decade since the widespread adoption of thrombolytic therapy. METHODS: Prospective cohort study of 1737 consecutive patients with acute myocardial infarction admitted for coronary care between January 1988 and December 1997. RESULTS: Trend analysis with comparison of early (1988-1992) and late (1993-1997) cohorts showed significant increments in median age (interquartile range) from 62 (54-70) to 64 (55-72) years (P < 0.01) but the proportion of smokers fell from 72.7% to 65.8% (P < 0.01). The proportion of patients receiving thrombolytic therapy increased from 70% to 78.1% (P < 0.01) as median door-to-needle times fell significantly from 92 (60-145) to 68 (45-123) minutes (P < 0.01). The proportion of patients discharged on aspirin increased from 88.2% to 95.9% (P < 0.01), -blockers increased from 37.4% to 45.8% (P < 0.01), and angiotensin converting enzyme inhibitors increased from 12.4% to 35.7% (P < 0.01). Median hospital stay fell from 9 (7-11) to 6 (5-9) days (P < 0.0001). Although the severity of infarction declined, judged by reductions in the frequency of Q-wave development from 78.1% to 73.9% (P = 0.01) and peak CK from 1250 (569-2085) to 1004 (511-1722) IU/l, survival (95% confidence intervals) for the early and late cohorts did not change significantly either at 30 days [0.86 (0.83-0.88) vs. 0.85 (0.83-0.88)] or at 1 year [0.79 (0.76-0.81) vs 0.78 (0.76-0.81)]. CONCLUSION: The decade from 1988-1997 saw significant changes in the demographic characteristics and risk factor profiles of patients with acute myocardial infarction admitted for coronary care. We observed trends towards increasingly aggressive antithrombotic treatment and early discharge policies, with more patients being prescribed drugs for secondary prevention. The combined effects of these complex changes on the outcome of infarction defy simple analysis and there was no palpable change in short- and longer-term.

Aged↗
PubMed2000

Waiting for coronary angiography: is there a clinically ordered queue?

Among over 3000 patients undergoing coronary angiography in the absence of a formal queue-management system, we found that a-priori urgency scores were strongly associated with waiting times, prevalence of coronary-artery disease, rate of revascularisation, and mortality. These data challenge the widely held assumption that such waiting lists are not clinically ordered; however, the wide variation in waiting times within urgency categories suggests the need for further improvements in clinical queueing.

Adult↗
PubMed2000

Acute myocardial infarction in women: contribution of treatment variables to adverse outcome.

BACKGROUND: Women have excessive mortality rates after acute myocardial infarction compared with men. The extent to which this increased risk can be attributed to differences in treatment is not well-understood. METHODS: This was an observational follow-up study of 1737 patients admitted with acute myocardial infarction for coronary care between January 1, 1988, and December 31, 1997. RESULTS: Compared with men, women took longer to arrive at the hospital (132.5 minutes [range 76 to 291 minutes] vs 120 minutes [range 60 to 240 minutes]; P =.006), were less likely to receive aspirin acutely (87.8% vs 91.3%; P =.03), had longer door-to-needle times (90 minutes [range 60 to 143.5 minutes] vs 78 minutes [range 50 to 131 minutes]; P =.004), and were less likely to be given beta-blockers at hospital discharge (31.6% vs 44.9%; P <.0001). Estimated survival (95% confidence interval [CI]) at 30 days was only 78.4% (range 74.4% to 81.9%) for women compared with 88.0% (range 86.1% to 89.7%) for men. Women were older and more often white, but their excess risk (hazard ratio 2.09; 95% CI, 1.59-2.75) persisted after adjustment for age, racial group, and diabetes (hazard ratio 1.52; 95% CI, 1.15-2.01). Additional adjustment for emergency thrombolytic and aspirin therapy caused a further small reduction in the excess risk for women (hazard ratio 1.46; 95% CI, 1. 09-1.98), but with adjustment for aspirin and beta-blockers prescribed at discharge, the excess risk attributable to being female disappeared as the hazard ratio fell to 0.75 (95% CI, 0.31-1. 84). Estimated 30-day survival free of reinfarction and unstable angina was also lower for women than for men (75% [range 71% to 79%] vs 86% [range 84% to 88%]); again, the excess risk for women persisted despite adjustment for age and racial group before disappearing as treatment variables were introduced into the model. The influence of treatment variables on the differential risks for women and men disappeared at 12 months. CONCLUSIONS: This study has shown that women with acute myocardial infarction arrived later at the hospital, were less likely to be given aspirin therapy acutely, had longer door-to-needle times, and, on discharge from the hospital, were less likely to be prescribed beta-blockers for secondary prevention. The data suggest that the failure to treat women as vigorously as men made a significant contribution to their worse outcome.

Adrenergic beta-Antagonists↗
PubMed1999

How should age affect management of acute myocardial infarction? A prospective cohort study.

BACKGROUND: About 75% of patients with acute myocardial infarction are older than 70 years, but patients in this age group are commonly treated less vigorously than younger patients. This differential treatment may partly reflect clinicians' misconceptions about the outlook of such patients, and the importance of age in clinical decisions. We examined how age does and should affect the management of patients and risk stratification in acute myocardial infarction. METHODS: In this prospective cohort study, we recruited 1225 consecutive patients admitted with acute myocardial infarction to a district general hospital in east London. The primary endpoint was death. We used tabulation and regression methods to analyse the association between age group and clinical variables. FINDINGS: Patients aged 70 years or older took a longer time to arrive in hospital and were less likely to receive thrombolysis or discharge beta-blockers than patients younger than 60 years: odds ratio 0.63 (95% CI 9.45-0.88) for thrombolysis and 0.25 (0.16-0.37) for beta-blockade, adjusted for sex, diabetes, previous acute myocardial infarction, Q wave infarction, and left-ventricular failure. Left-ventricular failure was the strongest independent predictor of death within 1 year of infarction with a hazard ratio of 4.76 (3.53-6.43), adjusted for age, sex, diabetes, and Q wave infarction. Patients aged 70 years or older without left-ventricular failure had significantly better survival at 1 year after acute myocardial infarction than patients under 60 years with left-ventricular failure. 70.8% (62.2-78.2) of the older patients who survived to hospital discharge were still alive 3 years later. INTERPRETATION: Elderly patients with acute myocardial infarction were treated less vigorously than younger patients. The prognosis of acute myocardial infarction, however, was substantially affected by the development of left-ventricular failure and other clinical indices, such that many older patients had a better outlook than younger patients with adverse clinical factors. In planning risk-based management, consideration of age independently of clinical status is inappropriate.

Adrenergic beta-Antagonists↗