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G S Reeder

Publications and source records attributed to G S Reeder.

At least 19 recordsLinked to original sources
PubMed2006

A new simplified immediate prognostic risk score for patients with acute myocardial infarction.

BACKGROUND: Immediate risk stratification of patients with myocardial infarction in the emergency department (ED) at the time of initial presentation is important for their optimal emergency treatment. Current risk scores for predicting mortality following acute myocardial infarction (AMI) are potentially flawed, having been derived from clinical trials with highly selective patient enrollment and requiring data not readily available in the ED. These scores may not accurately represent the spectrum of patients in clinical practice and may lead to inappropriate decision making. METHODS: This study cohort included 1212 consecutive patients with AMI who were admitted to the Mayo Clinic coronary care unit between 1988 and 2000. A risk score model was developed for predicting 30 day mortality using parameters available at initial hospital presentation in the ED. The model was developed on patients from the first era (training set--before 1997) and validated on patients in the second era (validation set-during or after 1997). RESULTS: The risk score included age, sex, systolic blood pressure, admission serum creatinine, extent of ST segment depression, QRS duration, Killip class, and infarct location. The predictive ability of the model in the validation set was strong (c = 0.78). CONCLUSION: The Mayo risk score for 30 day mortality showed excellent predictive capacity in a population based cohort of patients with a wide range of risk profiles. The present results suggest that even amidst changing patient profiles, treatment, and disease definitions, the Mayo model is useful for 30 day risk assessment following AMI.

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PubMed2002

Strong predictive value of TIMI risk score analysis for in-hospital and long-term survival of patients with right ventricular infarction.

BACKGROUND: While right ventricular myocardial infarction is associated with increased in-hospital morbidity and mortality, prognostic risk factors for in-hospital and long-term mortality are poorly defined. OBJECTIVES: To evaluate the prognostic value of TIMI (Thrombolysis in Myocardial Infarction) risk score analysis in patients with right ventricular myocardial infarction (RVI). DESIGN: Retrospective analysis of a community population. SETTING: Mayo Clinic Coronary Care Unit. PATIENTS: One hundred and two patients with RVI from 580 consecutive patients from Rochester, Minnesota admitted to the Coronary Care Unit with acute inferior or lateral wall myocardial infarction from January 1988 through March 1998. MEASUREMENT: Combined TIMI risk score analysis with in-hospital and long-term mortality. RESULTS: In-hospital morbidity (RVI: 54.9% vs non-RVI: 22.2%; P<0.001) and mortality (RVI: 21.6% vs non-RVI: 6.9%;P <0.001) were increased in patients with RVI. The TIMI risk score predicted risk (per one point increase in TIMI score) for in-hospital mortality (OR 1.23, 95% CI 1.02-1.51, P=0.037) and long-term mortality (OR 1.57, 95% CI 1.25-1.96, P<0.001). Patients with RVI whose TIMI risk score was >or=4 had significantly worse long-term survival compared to those patients with RVI and TIMI score <4 (P=0.006). CONCLUSIONS: In-hospital morbidity and mortality, and long-term mortality are increased by right ventricular infarction and can be accurately predicted by the initial TIMI risk score.

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PubMed2001

Influence of coronary thrombus on outcome of percutaneous coronary angioplasty in the current era (the Mayo Clinic experience).

Earlier studies documented an increased risk of percutaneous coronary intervention (PCI) in patients with angiographic evidence of thrombus. With newer antiplatelet agents and stents, it is not known whether thrombus is a risk factor after PCI. This study examines whether outcome of PCI in patients with thrombus has improved, and whether thrombus is associated with adverse outcome after PCI in the current era. This single-institution retrospective analysis of PCI in 7,184 patients was divided into 2 periods: group I, 1990 to 1995 (n = 3,640), and group II, 1996 to 1999 (n = 3,544). The groups were subdivided according to the presence or absence of angiographic thrombus before PCI. We compared the outcome of PCI for patients with and without thrombus in group II. A comparison was made in the 2 groups in patients with angiographic thrombus. Procedural success improved in group II compared with group I patients with thrombus (93% vs 88%, p <0.001). There was significant reduction in abrupt closure in the recent era in patients with thrombus (4% vs 7%, p = 0.01). In group II, procedural success remained lower in patients with (93% vs 96%) than without thrombus (p <0.001). After adjusting for the significant univariate characteristics of group II patients, thrombus remained an independent predictor of Q-wave infarction (odds ratio 3.78; 95% confidence interval [CI], 1.8 to 8.0; p <0.0013) and the composite end point of death, Q-wave infarction, and emergency bypass surgery (odds ratio 2.37; 95% CI 1.4 to 4.1; p = 0.002). There was a trend toward increased in-hospital death among patients with thrombus (odds ratio 2.06; 95% CI 0.9 to 4.8; p = 0.09). The 1-year outcome after successful PCI was similar for those with and without thrombus. Despite improvement in the outcome of patients with thrombus undergoing PCI in recent years, thrombus is still an independent predictor of adverse in-hospital outcomes after PCI.

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PubMed2001

Bundle branch block as a predictor of long-term survival after acute myocardial infarction.

Using a community-based population of patients with acute myocardial infarction (AMI), we sought to: (1) determine the prevalence of bundle branch block (BBB) on the presenting electrocardiogram (ECG), (2) compare the clinical characteristics and the treatment administered to patients with and without BBB, and (3) determine the association of BBB with mortality. We analyzed the admission ECGs of 894 consecutive patients with AMI from Olmsted County, Minnesota, seen at our institution from January 1988 to March 1998. Of these, 53 had left BBB (LBBB) (5.9%) and 60 had right BBB (RBBB) (6.7%). Patients with BBB were more likely to be older, have a history of AMI or hypertension, and to be in Killip class >I at presentation. They were less likely to receive primary reperfusion therapy, beta blockers, or heparin, but more likely to receive angiotensin-converting enzyme inhibitors. They had lower mean predischarge ejection fractions (38 +/- 16% vs 50 +/- 15%, p <0.0001). In-hospital mortality was 13.3%, 17.0%, and 9.1% for patients with RBBB, LBBB, and no BBB, respectively (p = 0.11). Respective postdischarge survival at 1, 3, and 5 years was 80%, 60%, and 50% in the RBBB group, 78%, 56%, and 51% in the LBBB group, and 92%, 85%, and 76% in the group without BBB (p <0.0001). Although BBB was not an independent predictor of mortality on multivariate analysis, the presence of transient or persistent BBB with AMI is an easily recognized clinical marker of increased mortality. Our conclusion from this study is that in a community-based population, patients who had LBBB or RBBB at the time of AMI had lower predischarge ejection fractions and higher in-hospital and long-term unadjusted mortality.

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PubMed2001

Clinical risk stratification correlates with the angiographic extent of coronary artery disease in unstable angina.

OBJECTIVES: We sought to determine whether clinical risk stratification correlates with the angiographic extent of coronary artery disease (CAD) in patient with unstable angina. BACKGROUND: The Agency for Health Care Policy and Research (AHCPR) guidelines stratify patients with unstable angina according to short-term risk of myocardial infarction or death. Whether these guidelines are useful in predicting the extent of CAD is unknown. METHODS: All residents of Olmsted County, Minnesota, undergoing emergency department evaluation from January 1, 1985 through December 31, 1992 for unstable angina without a history of prior coronary artery bypass grafting, and who underwent early angiography (within seven days of presentation) were classified into low, intermediate and high risk subgroups based on AHCPR criteria. RESULTS: Seven hundred ninety-five patients underwent early angiography: 159 high risk, 572 intermediate risk and 64 low risk patients. Logistic regression analysis demonstrated that low risk patients had a greater likelihood of normal or mild CAD relative to intermediate risk (odds ratio [OR], 4.67; 95% confidence interval [CI], 2.70-8.06; p < 0.001) and high risk (OR, 11.1; 95% CI, 5.71-22.2; p < 0.001). Significant 1-, 2-, 3-vessel coronary disease or left main coronary disease was more likely in high relative to low risk (OR, 8.09; 95% CI, 4.22-15.5; p < 0.001), intermediate relative to low risk (OR, 4.11; 95% CI, 2.34-7.22; p < 0.001), and high relative to intermediate risk (OR, 1.97; 95% CI, 1.31-2.96; p = 0.0012). CONCLUSIONS: Among patients with unstable angina undergoing early coronary angiography, risk stratification according to the AHCPR guidelines correlates with the angiographic extent of CAD.

Adult↗
PubMed2001

Characteristics of presenting electrocardiograms of acute myocardial infarction from a community-based population predict short- and long-term mortality.

To investigate the relevance of presenting electrocardiographic (ECG) patterns to short- and long-term mortality in nonreferral patients with acute myocardial infarction (AMI), 6 ECG patterns were analyzed. A consecutive series of 907 patients from Olmsted County, Minnesota, admitted to the Mayo Clinic Cardiac Care Unit from January 1, 1988 to March 31, 1998 for acute myocardial infarction comprised the study population. ECG patterns and distribution in the population were: (1) ST elevation alone (20.8%), (2) ST elevation with ST depression (35.2%), (3) normal or nondiagnostic electrocardiograms (18.5%), (4) ST depression alone (11.8%), (5) T-wave inversion only (10.7%), and (6) new left bundle branch block (LBBB) (3.0%). Seven- and 28-day mortalities varied significantly (p <0.01) among the 6 ECG groups. Respective mortalities were 3.0% and 6.0% for patients with normal or nondiagnostic electrocardiograms, 3.1% and 5.2% for T-wave inversion only, 7.4% and 10.6% for ST elevation alone, 9.4% and 13.1% for ST depression alone, 10.3% and 13.8% for ST elevation with ST depression, and 18.5% and 22.2% for new LBBB. Length of hospital stay (LOS) also varied among the ECG pattern groups (p <0.001) with the longest average LOS being in the new LBBB group (12.5 days). Long-term survival was similar among 5 ECG pattern groups (45% to 55% at 8 years from discharge) with the exception of LBBB (20% at 8 years). Among non-LBBB groups, ST-segment depression with or without ST elevation was associated with increased short-term mortality. Also, in this community-based population, 18.5% of patients had normal or nondiagnostic electrocardiograms.

Adult↗
PubMed2001

Does the presence of thrombus seen on a coronary angiogram affect the outcome after percutaneous coronary angioplasty? An Angiographic Trials Pool data experience.

OBJECTIVES: This study aimed to determine whether pre-existing angiographic thrombus was associated with adverse in-hospital and six-month outcomes after percutaneous coronary interventions. BACKGROUND: There are conflicting data about whether pre-existing thrombus is an independent predictor of adverse in-hospital and short-term outcome after coronary interventions. METHODS: The Angiographic Trials Pool, a data set derived from eight prospective randomized trials, was analyzed. The study population consisted of 7,917 patients who underwent coronary interventions between 1986 and 1995. Two trials were excluded because they did not collect information regarding thrombus. Patients from the other six trials were divided on the basis of the presence or absence of thrombus. RESULTS: In patients with (n = 2,752) and without (5,165) thrombus, in-hospital mortality following angioplasty was low (0.8 vs. 0.6%, p = 0.207). Several adverse outcomes were higher in patients with thrombus: death/myocardial infarction (8.4 vs. 5.5%, p < or = 0.001), in-hospital abrupt closure (5.9 vs. 3.9%, p < or = 0.001) and an in-hospital composite of death, myocardial infarction and/or repeat revascularization (15.4 vs. 11.2%, p < or = 0.001). Six-month mortality was low and comparable between the two groups (2.1 vs. 1.8%, p = 0.34), but the incidence of six-month death/myocardial infarction was higher in patients with thrombus (11.7 vs. 8.7%, p < or = 0.0001). CONCLUSIONS: Percutaneous coronary angioplasty can be performed with low mortality in patients with pre-existing thrombus, although these patients are at higher risk of in-hospital and six-month death/myocardial infarction. Continued efforts are required to optimize the outcome in these high risk patients.

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PubMed2001

Primary percutaneous coronary interventions in patients with acute myocardial infarction and prior coronary artery bypass grafting.

BACKGROUND: The outcome of patients with previous coronary artery bypass grafting (CABG) undergoing primary percutaneous coronary intervention (PCI) for the treatment of acute myocardial infarction (AMI) is unclear. We sought to assess the outcome of patients with prior CABG undergoing primary PCI for the treatment of AMI. METHODS AND RESULTS: Between 1991 and 1997, 1072 patients with AMI underwent primary PCI without antecedent thrombolytic therapy at the Mayo Clinic. There were 128 patients with previous CABG and 944 without previous CABG. Patients with previous CABG were further subdivided according to the treated vessel: native vessels (n = 65) and bypass graft (n = 63). Clinical and angiographic characteristics and 30-day and 1-year outcomes were evaluated. Patients with previous CABG were significantly older and had a higher incidence of diabetes, hypertension, and hypercholesterolemia. They had a lower left ventricular ejection fraction and were also more likely to have congestive heart failure. After 1 year of follow-up, adverse cardiac events (death, MI, CABG, or repeat PCI) were significantly greater in patients with prior CABG (49.2% vs 35.9%, P =.04). With use of multivariate logistic regression analysis to adjust for differences in baseline characteristics, the treatment of vein graft was independently associated with adverse cardiac events (relative risk 1.48 [95% confidence interval 1.07-2.03], P =.02), but a history of prior CABG itself was not (relative risk 1.22 [95% confidence interval 0.96-1.56], P =.11). CONCLUSIONS: Primary PCI for AMI in patients with previous CABG is associated with higher adverse events largely attributable to adverse baseline clinical characteristics and the treatment of a vein graft.

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PubMed2001

Early coronary angiography improves long-term survival in unstable angina.

BACKGROUND: The role of early coronary angiography in the evaluation of patients with unstable angina has been controversial. This study was designed to determine the effect of early coronary angiography on long-term survival in patients with unstable angina. METHODS: We reviewed the Olmsted County Acute Chest Pain Database, a population-based epidemiologic registry that includes all patients residing within Olmsted County who were seen for emergency department evaluation of acute chest pain from 1985 to 1992. Patients with symptoms consistent with myocardial ischemia qualifying as unstable angina were classified as undergoing early (</=7 days of index presentation) angiography or not. RESULTS: A total of 2264 patients with symptoms consistent with unstable angina were identified with a mean duration of follow-up of 6 years; 892 underwent early angiography. Early angiography patients were younger; less likely to have heart failure; more likely to be male, hypercholesterolemic, and smokers; had prior coronary revascularization; and had a myocardial infarction at the index presentation. After baseline differences were controlled, early angiography was associated with a reduction in all-cause long-term mortality (relative risk 0.63, 95% CI 0.53-0.74). Patients at intermediate or high risk for death or myocardial infarction at presentation were most likely to benefit from early angiography. CONCLUSION: Early angiography in the evaluation of patients with unstable angina was associated with a reduction in all-cause mortality, particularly in intermediate- and high-risk patients, in this retrospective population-based study.

Angina Pectoris↗
PubMed2001

Adjunctive therapies in the treatment of acute coronary syndromes.

Survival after myocardial infarction has been improving steadily in recent decades, in part because of more effective adjunctive medical therapies. However, the issue of underutilization of effective medical therapies remains. Adjunctive therapy for acute myocardial infarction should include aspirin, beta-adrenergic blocking agents, angiotensin-converting enzyme inhibitors, and lipid-lowering agents, all of which improve survival in the treatment and secondary prevention of myocardial infarction. This review presents the current knowledge supporting the use of specific adjunctive pharmacologic agents and also discusses the current status of other agents that are emerging or controversial.

Acute Disease↗
PubMed2001

Length of stay in myocardial infarction.

OBJECTIVE: We evaluated the association between length of hospital stay (LOS) and clinical factors, treatment intensity, and use of percutaneous coronary revascularization from 1988 to 1997. BACKGROUND: Multiple factors contribute to the observed reduction in LOS for patients with myocardial infarction. METHODS: We studied a series of 849 consecutive patients admitted with acute myocardial infarction to the Mayo Clinic Coronary Care Unit within three time periods: period I (1988-1990), period II (1991-1993), and period III (1994-1997). RESULTS: Median LOS decreased significantly between 1988 and 1997 (9 days to 5 days, 36% reduction, p < 0.0001), with significant reductions (p < 0.001) associated with certain therapies: primary reperfusion (6 days vs 7 days), b-blockers (6 days vs 8 days), and aspirin (6 days vs 8 days). Hospitalizations were lengthened by coronary artery bypass grafting (12 vs 6 days) and by serious complications (10 vs 6 days). The era of the admission (period I vs II vs III) is a significant, powerful predictor of LOS, even after adjustment for other key variables. CONCLUSION: The 36% reduction in LOS for acute myocardial infarction between 1988 and 1997 is related both to therapeutic modalities and temporal trends. Further study is needed to clarify whether the trend for decreasing LOS persists and influences outcome and health care quality variables.

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PubMed2000

Management of coronary risk factors by registered nurses versus usual care in patients with unstable angina pectoris (a chest pain evaluation in the emergency room [CHEER] substudy).

This study examined whether nurses could manage coronary risk factors in patients with unstable angina more effectively than physicians practicing usual care. Three hundred twenty-six patients were randomized in the emergency room to a 6-month program of risk factor management by a registered nurse versus participation in usual care. The nurse intervention consisted of a 30-minute counseling visit at 6 to 10 days after the chest pain episode and a second 30-minute session 1 month later. Multiple risk factors were assessed and addressed: smoking, blood lipids, blood pressure, blood glucose, physical inactivity, weight, psychological stress, and social isolation. Compared with usual care, nurse intervention patients significantly reduced both triglycerides (-29 +/- 8 vs 5 +/- 6 mg/dl; p <0.0004) and weight (-0.9 +/- 3.3 vs +0.1 +/- 2.1 kg; p = 0.0071), and had corresponding improvements in self-reported diet compliance and exercise (+34 +/- 106 vs +9 +/- 98 minutes, p = 0.0491). No significant differences between groups were observed in terms of 6-month changes in total, high-density lipoprotein, or low-density lipoprotein cholesterol, blood pressure, fasting blood glucose, percent body fat or waist-hip ratio, or psychological distress scores. The 6-month rate of recurrent events (cardiac death, out-of-hospital cardiac arrest, myocardial infarction) and/or revascularizations (coronary artery bypass surgery or coronary angioplasty) was lower in the nurse intervention group (1% vs 9%; p = 0.002). We conclude that a nurse-delivered risk factor intervention program for patients with chest pain is feasible and more effective than usual care in terms of fostering lifestyle changes that may lower coronary risk.

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PubMed2000

Quality of life after coronary revascularization in the United States and Canada.

Cardiac procedures are performed less frequently in Canada than in the United States (US), yet rates of cardiac death and myocardial infarction are similar. We therefore sought to compare long-term symptoms and quality of life in Canadian and American patients undergoing initial coronary revascularization. The 161 patients enrolled in the Bypass Angioplasty Revascularization Investigation at the Montreal Heart Institute were compared with 934 patients enrolled at 7 US sites. Patients' outcomes were documented for 5 years after random assignment to percutaneous transluminal coronary angioplasty or coronary artery bypass graft surgery. Functional status was assessed using the Duke Activity Status Index. Canadian patients were significantly younger and had more angina at study entry. Death and nonfatal myocardial infarction were not significantly different between Canadian and US patients after adjustment for baseline risk. Canadian patients had significantly greater improvements in functional status at 1-year follow-up (Duke Activity Status Index score + 13.5 vs. + 6.0, p = 0.002), but this difference progressively narrowed over 5 years. Angina was equally prevalent in Canadian and US patients at 1 year (16% vs. 19%), but significantly more prevalent in Canadian patients at 5 years (36% vs. 16%, p = 0.001). Repeat revascularization procedures were performed less often over 5 years among Canadian patients (26% vs. 34%, p = 0.08), especially coronary artery bypass graft surgery after initial percutaneous transluminal coronary angioplasty (18% vs. 32%, p = 0.03). These results suggest more anginal symptoms are required in Canada before coronary revascularization, but as a result Canadians receive greater improvements in quality of life after the procedure.

Angina Pectoris↗
PubMed2000

Sex differences in evaluation and outcome of unstable angina.

CONTEXT: The existence of sex bias in the delivery of cardiac care is controversial, and little is known about the association between sex and delivery of care and outcomes at an early point in the diagnostic sequence, such as when patients present for the evaluation of chest pain. OBJECTIVE: To test the hypothesis that female sex is negatively associated with care delivered to and outcomes of persons diagnosed as having unstable angina. DESIGN: Inception population-based cohort study with an average of 6 years of follow-up. SETTING: Emergency departments (EDs) in Olmsted County, Minnesota. PATIENTS: A total of 2271 Olmsted County residents (1306 men and 965 women) who presented to the ED for the first time with symptoms meeting criteria for unstable angina between 1985 and 1992. MAIN OUTCOME MEASURES: Use of cardiac procedures within 90 days of ED visit, overall mortality, and cardiac events (cardiac death, nonfatal myocardial infarction, nonfatal cardiac arrest, and congestive heart failure), compared by sex and Agency for Health Care Policy and Research cardiovascular risk category (low, intermediate, or high). RESULTS: Women were older (P<.001), more likely to have a history of hypertension (P = .001), and less likely to present with typical angina (P = .004) than men. Men were more likely than women to undergo noninvasive cardiac tests (relative risk [RR], 1.27; 95% confidence interval [CI], 1.14-1.40) as well as invasive cardiac procedures (RR, 1.72; 95% CI, 1.51-1.97). After adjustment, male sex was associated with a 24% increase in the use of cardiac procedures. Survival of both men and women in the high and intermediate risk categories was significantly lower than expected per the general population (P<.001). Women had a worse outcome than men, but after multivariate adjustment, male sex was associated with a trend toward an increase in the risk of death (RR, 1.23; 95% CI, 0.99-1.54) and significantly associated with increased risk of cardiac events (RR, 1.21; 95% CI, 1.03-1.42). CONCLUSIONS: Our population-based data indicate that after an ED visit for symptoms of unstable angina, the use of cardiac procedures was lower in women, but after taking into account baseline characteristics, men experienced worse outcomes.

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