Biomedical subjects

J M Gore

Publications and source records attributed to J M Gore.

At least 19 recordsLinked to original sources

PubMed2003

Creatinine clearance and adverse hospital outcomes in patients with acute coronary syndromes: findings from the global registry of acute coronary events (GRACE).

OBJECTIVE: To determine whether creatinine clearance at the time of hospital admission is an independent predictor of hospital mortality and adverse outcomes in patients with acute coronary syndromes (ACS). DESIGN: A prospective multicentre observational study, GRACE (global registry of acute coronary events), of patients with the full spectrum of ACS. SETTING: Ninety four hospitals of varying size and capability in 14 countries across four continents. PATIENTS: 11 774 patients hospitalised with ACS, including ST and non-ST segment elevation acute myocardial infarction and unstable angina. MAIN OUTCOME MEASURES: Demographic and clinical characteristics, medication use, and in-hospital outcomes were compared for patients with creatinine clearance rates of > 60 ml/min (normal and minimally impaired renal function), 30-60 ml/min (moderate renal dysfunction), and < 30 ml/min (severe renal dysfunction). RESULTS: Patients with moderate or severe renal dysfunction were older, were more likely to be women, and presented to participating hospitals with more comorbidities than those with normal or minimally impaired renal function. In comparison with patients with normal or minimally impaired renal function, patients with moderate renal dysfunction were twice as likely to die (odds ratio 2.09, 95% confidence interval 1.55 to 2.81) and those with severe renal dysfunction almost four times more likely to die (odds ratio 3.71, 95% confidence interval 2.57 to 5.37) after adjustment for other potentially confounding variables. The risk of major bleeding episodes increased as renal function worsened. CONCLUSION: In patients with ACS, creatinine clearance is an important independent predictor of hospital death and major bleeding. These data reinforce the importance of increased surveillance efforts and use of targeted intervention strategies in patients with acute coronary disease complicated by renal dysfunction.

Adult↗

PubMed2001

Age and the utilization of cardiac catheterization following uncomplicated first acute myocardial infarction treated with thrombolytic therapy (The Second National Registry of Myocardial Infarction [NRMI-2]).

Considerable data indicates that patients <50 years of age have lower morbidity and mortality after acute myocardial infarction (AMI) than older patients. It has been demonstrated that use of routine cardiac catheterization and revascularization in younger patients with AMI and successful thrombolysis does not confer benefit compared with a more conservative approach. Despite this, it has been our impression that cardiac catheterization is frequently employed in younger patients with AMI. Patients with uncomplicated initial AMI treated with thrombolytic therapy in the Second National Registry of Myocardial Infarction (NRMI-2) between June 1994 and April 1998 were identified. Patients were categorized into 4 age strata for purposes of analysis. A total of 61,232 cases met our inclusion criteria. Cardiac catheterization was performed during hospitalization in 78% of patients after an uncomplicated initial AMI. Age was inversely associated with receipt of cardiac catheterization: 85% of those < or =49 years old underwent catheterization compared with 63% of those > or =70 years old. Regression analysis revealed that use of catheterization was 2.9 times greater (95% confidence intervals 2.7 to 3.2) in patients < or =49 years old compared with those > or =70 years old. Geographic location and payor status also strongly influenced utilization of this procedure. In conclusion, routine coronary angiography after uncomplicated AMI is extensively utilized in all age groups, particularly in those <50 years of age. The efficacy and cost effectiveness of this strategy in these patients has not yet been determined in clinical trials.

Age Factors↗

PubMed2001

Temporal trends (1986-1997) in cholesterol level assessment and management practices in patients with acute myocardial infarction: a population-based perspective.

BACKGROUND: Elevated serum cholesterol levels are associated with increased risk for acute myocardial infarction (AMI) and adverse patient outcomes. It is unclear what proportion of patients have their serum cholesterol levels measured during hospitalization for AMI and are given hypolipidemic therapy. OBJECTIVE: To examine decade-long trends in measurement of serum cholesterol levels during hospitalization for AMI and use of hypolipidemic therapy. METHODS: Observational study of 5204 residents of the Worcester, Mass, metropolitan area hospitalized with validated AMI in all greater Worcester hospitals in seven 1-year periods from 1986 through 1997. RESULTS: Increases in the measurement of serum cholesterol levels during hospitalization for AMI were observed between 1986 and 1991, followed by a progressive decrease; only 24% of patients with AMI in 1997 underwent cholesterol level testing. Younger age, male sex, and absence of a history of cardiovascular disease were associated with an increased likelihood measurement of serum cholesterol levels. Although the relative use of hypolipidemic therapy increased significantly over time (0.4% in 1986 vs 10.7% in 1997), the absolute rate of use remained low. In patients with elevated serum cholesterol levels (>/=6.2 mmol/L [>/=240 mg/dL]), 1.9% received hypolipidemic therapy in 1986 and 36.6% in 1997. CONCLUSIONS: These findings suggest recent declines in the assessment of total cholesterol levels in patients hospitalized with AMI. Although the use of hypolipidemic therapy during hospitalization for AMI has increased over time, considerable room for improvement remains.

Age Distribution↗

PubMed2001

Outcomes and early revascularization for patients > or = 65 years of age with cardiogenic shock.

Hospital survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock has improved during recent years. It is unclear whether this mortality benefit also applies to elderly patients with cardiogenic shock. Elderly residents (age > or = 65 years) of the Worcester, Massachusetts metropolitan area (1990 census population = 437,000) hospitalized with confirmed AMI and cardiogenic shock in all metropolitan Worcester, Massachusetts hospitals between 1986 and 1997 constituted the sample of interest. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in a cohort of 166 cardiogenic patients treated early in the reperfusion era (1986 to 1991) compared with 144 patients with AMI treated approximately 1 decade later (1993 to 1997). There was a significant increase in the use of an early revascularization strategy over time (2% vs 16%, p <0.001). Marked increases in use of antiplatelet therapy, beta blockers, and angiotensin-converting enzyme inhibitors were also observed over the decade-long experience. In-hospital case fatality declined significantly over time, from 80% (1986 to 1991) to 69% (1993 to 1997) in elderly patients who developed cardiogenic shock (p = 0.03). After adjusting for differences in potentially confounding prognostic characteristics between patients hospitalized in the 2 study periods, an even more pronounced reduction in hospital mortality (42%) was observed for the most recently hospitalized cohort. The most powerful predictor of in-hospital survival was use of an early revascularization approach to treatment. Thus, hospital mortality has declined for patients > or = 65 years of age with AMI complicated by cardiogenic shock, and this decline has occurred in the setting of broader use of early revascularization and adjunctive medical therapy for this high-risk population.

Adrenergic beta-Antagonists↗

PubMed2001

Death or nonfatal stroke in patients with acute myocardial infarction treated with tissue plasminogen activator. Participants in the National Registry of Myocardial Infarction 2.

In a retrospective cohort of patients treated in community hospitals, tissue plasminogen activator (t-PA) was associated with decreased odds of in-hospital death or nonfatal stroke. However, the relative benefit was less evident in older patients and women, and some older subgroups did not benefit from treatment.

Age Factors↗

PubMed2001

Early clinical outcomes and routine management of patients with non-ST-segment elevation myocardial infarction: a nationwide perspective.

BACKGROUND: Myocardial infarction (MI) in the absence of electrocardiographic ST-segment elevation or new bundle branch block is the cause of hospitalization for a large and steadily increasing proportion of patients with acute ischemic chest pain. Despite its prevalence, the common demographic features, current hospital-based management, and short-term clinical outcome among patients with non-ST-segment elevation MI remain poorly defined. METHODS: A total of 183 113 patients with non-ST-segment elevation MI were identified in the National Registry of Myocardial Infarction database. Using a validated model, 43 928 patients (24.0%) were retrospectively placed in major, 34 917 (19.1%) in intermediate, and 104 268 (56.9%) in minor severity clinical event categories that included hospital death, recurrent myocardial ischemia, and nonfatal recurrent MI. RESULTS: The administration of widely available and universally recommended pharmacologic therapies, including aspirin and beta-adrenergic blocking agents, was suboptimal, particularly among patients with major severity clinical events. In contrast, coronary angiography and mechanical revascularization procedures were commonplace (>60% of all patients) and most frequently performed in patients within the minor (compared with the major) severity clinical event category (58.2% and 42.7%, respectively). CONCLUSIONS: Patients with non-ST-segment elevation MI are a heterogeneous population, with readily identifiable demographic characteristics and clinical features associated with important early outcomes, including death. Nationwide efforts directed toward maximizing pharmacologic therapy utilization and the performance of invasive procedures according to established guidelines must continue.

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PubMed2001

Sex differences in 2-year mortality after hospital discharge for myocardial infarction.

BACKGROUND: An interaction between sex and age is thought to affect hospital mortality after myocardial infarction; younger, but not older, women have been shown to have higher mortality rates than men. It is currently unknown whether findings are similar after hospital discharge. OBJECTIVE: To determine whether an interaction between sex and age affects 2-year mortality after myocardial infarction. DESIGN: Community-based prospective cohort study. SETTING: 16 community hospitals serving the Worcester, Massachusetts, metropolitan area. PATIENTS: 6826 patients who survived hospitalization for acute myocardial infarction during ten 1-year periods between 1975 and 1995. MEASUREMENTS: Mortality 2 years after hospital discharge. RESULTS: The overall 2-year mortality rate was higher in women (28.9%) than in men (19.6%). When patients were examined by age group, however, only women younger than 60 years of age had a higher mortality rate than men of similar age. The sex difference decreased with increasing age; among the oldest patients, women had a lower mortality rate than men (P = 0.009 for the interaction between sex and age). This relationship was not affected by adjustment for demographic characteristics and medical history, clinical characteristics, and hospital and discharge treatments; the hazard of 2-year death for women compared with men increased 15.4% (95% CI, 4.3% to 27.6%) for every 10-year decrease in age. In absolute terms, after adjustment for demographic characteristics and medical history, among patients younger than 60 years of age women were at greater risk than men (risk difference, 1.8 percentage points). At older ages, however, women were at lower risk than men. CONCLUSIONS: Younger, but not older, women who survive hospitalization for myocardial infarction have a higher long-term mortality rate than men. This provides additional evidence that younger women with myocardial infarction are at greater risk for death than men.

Adult↗

PubMed2001

Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective.

OBJECTIVES: The goal of this study was to examine long-term trends in the incidence, in-hospital and long-term mortality patterns in patients with an initial non-Q-wave myocardial infarction (NQWMI) as compared with those with an initial Q-wave myocardial infarction (QWMI). BACKGROUND: Limited data are available describing trends in the incidence and mortality from an initial QWMI and NQWMI from a multi-hospital community-wide perspective. METHODS: Our study was an observational study of 5,832 metropolitan Worcester, Massachusetts residents (1990 census = 437,000) hospitalized with validated initial acute MI in all greater Worcester hospitals during 11 annual periods between 1975 and 1997. RESULTS: The incidence of QWMI progressively decreased between 1975/78 (incidence rate = 171/100,000 population) and 1997 (101/100,000 population). In contrast, the incidence of NQWMI progressively increased between 1975/78 (62/100,000 population) and 1997 (131/100,000 population). Hospital death rates were 19.5% for patients with QWMI and 12.5% for those with NQWMI. After controlling for various covariates, patients with QWMI remained at significantly increased risk for hospital mortality (adjusted odds ratio = 1.63; 95% confidence interval: 1.35, 1.97). While the hospital mortality of QWMI has progressively declined over time (1975/78 = 24%; 1997 = 14%), the in-hospital mortality for NQWMI has remained the same (1975/78 = 12%; 1997 = 12%). These trends remained after adjusting for potentially confounding prognostic factors. The multivariable adjusted two-year mortality after hospital discharge declined over time for patients with QWMI and NQWMI. CONCLUSIONS: Despite impressive declines in the incidence, in-hospital and long-term mortality associated with QWMI, NQWMI is increasing in frequency and has the same in-hospital mortality now as it did 22 years ago.

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PubMed2001

Recent magnitude of and temporal trends (1994-1997) in the incidence and hospital death rates of cardiogenic shock complicating acute myocardial infarction: the second national registry of myocardial infarction.

BACKGROUND: Limited recent data are available to describe the magnitude of, and temporal trends in, the incidence and case-fatality rates associated with cardiogenic shock complicating acute myocardial infarction. The purpose of this study was to examine recent (1994-1997) trends in the incidence of, and hospital death rates from, cardiogenic shock complicating acute myocardial infarction from a large, multihospital national perspective. METHODS: An observational study was performed of 426,253 patients hospitalized with acute myocardial infarction in 1662 hospitals throughout the United States between 1994 and 1997. RESULTS: The incidence rates of cardiogenic shock averaged 6.2%. There was evidence for a slight decline in these rates between 1994 (6.6%) and 1997 (6.0%). Results of a multivariable regression analysis controlling for factors that might affect the risk of development of cardiogenic shock indicated that patients hospitalized in more recent years were at significantly lower risk for shock. Patients with shock had a markedly increased risk for dying during hospitalization compared with patients not having shock (74% vs 10%). Significant, albeit small, absolute differences were observed in the risk of dying after cardiogenic shock over time (76% dying in 1997, 72% dying in 1994). These improving trends were magnified, however, after potentially confounding prognostic factors were controlled: patients having shock in 1997 were at approximately one fifth lower risk of dying (odds ratio 0.79, 95% confidence interval 0.71-0.87) than those hospitalized in 1994. CONCLUSIONS: Our findings indicate a slight decline in the incidence rates of cardiogenic shock and improving trends in the hospital survival of patients with shock. Despite these trends, it remains of considerable importance to prevent this clinical syndrome, given its high lethality.

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PubMed2001

The use of intra-aortic balloon counterpulsation in patients with cardiogenic shock complicating acute myocardial infarction: data from the National Registry of Myocardial Infarction 2.

BACKGROUND: Cardiogenic shock complicating acute myocardial infarction (AMI) remains the leading cause of death in patients hospitalized with AMI. Although several studies have demonstrated the importance of establishing and maintaining a patent infarct-related artery, it remains unclear as to whether intra-aortic balloon counterpulsation (IABP) provides incremental benefit to reperfusion therapy. The purpose of this study was to determine whether IABP use is associated with lower in-hospital mortality rates in patients with AMI complicated by cardiogenic shock in a large AMI registry. METHODS: We evaluated patients participating in the National Registry of Myocardial Infarction 2 who had cardiogenic shock at initial examination or in whom cardiogenic shock developed during hospitalization (n = 23,180). RESULTS: The mean age of patients in the study was 72 years, 54% were men, and the majority were white. The overall mortality rate in all patients who had cardiogenic shock or in whom cardiogenic shock developed was 70%. IABP was used in 7268 (31%) patients. IABP use was associated with a significant reduction in mortality rates in patients who received thrombolytic therapy (67% vs 49%) but was not associated with any benefit in patients treated with primary angioplasty (45% vs 47%). In a multivariate model, the use of IABP in conjunction with thrombolytic therapy decreased the odds of death by 18% (odds ratio, 0.82; 95% confidence interval, 0.72 to 0.93). CONCLUSIONS: Patients with AMI complicated by cardiogenic shock may have substantial benefit from IABP when used in combination with thrombolytic therapy.

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PubMed2001

Decade-long trends (1986 to 1997) in the medical treatment of patients with acute myocardial infarction: A community-wide perspective.

BACKGROUND: Although there are an increasing number and variety of medications available for the treatment of patients with acute myocardial infarction (AMI), few data are available describing recent, and changes over time in, use of different cardiac medications in patients with AMI from a more generalizable, community-wide perspective. Moreover, it is unclear whether the demographic and clinical profile of patients receiving these agents is similar or varies according to the type of agent prescribed. METHODS AND RESULTS: The purpose of this study was to examine recent patterns and changes over a decade-long period (1986 to 1997) in the use of cardiac medications during the acute hospitalization and at the time of hospital discharge in metropolitan Worcester, Mass, residents (1990 census estimate, 437,000) hospitalized with confirmed AMI. There was a marked increase in the use of angiotensin-converting enzyme inhibitors, aspirin, beta-blockers, lipid-lowering agents, and thrombolytic therapy between 1986 and 1997. The use of calcium antagonists, lidocaine, and other antiarrhythmic agents declined over this period. Similar trends were observed in the use of these agents in hospital survivors at the time of hospital discharge. Patient age, presence of comorbidities, and AMI-associated characteristics influenced the use of these therapies; sex differences in the use of several of these medications were also noted. CONCLUSIONS: The results of this population-based observational study provide insights into changing prescribing patterns in the hospital treatment of patients with AMI. Despite encouraging increases in the use of several of these agents, considerable opportunities for increased utilization remain.

Acute Disease↗

PubMed2000

Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: the Worcester Heart Attack study.

BACKGROUND: Duration of prehospital delay in patients with acute myocardial infarction (AMI) is receiving increasing attention given the time-dependent benefits associated with prompt use of coronary reperfusion strategies. OBJECTIVE: To examine trends (1986-1997) in time to hospital presentation and factors associated with prolonged delay in a community-wide study of patients with AMI. METHODS: Longitudinal study of 3837 residents of the Worcester, Mass, metropolitan area hospitalized with AMI in 7 one-year periods between 1986 and 1997 in whom information about prehospital delay was available. RESULTS: The mean, median, and distribution of delay times exhibited either inconsistent or no changes over time. In 1986, the mean and median prehospital delay times were 4.1 and 2.2 hours, respectively; these times were 4.3 and 2.0 hours, respectively, in patients hospitalized in 1997. Overall, with no significant differences noted over time, approximately 44% of patients with AMI presented to area-wide hospitals in less than 2 hours after the onset of acute coronary symptoms. Increasing age, history of angina or diabetes, onset of symptoms in the afternoon or evening, and hospitalization in the most recent study year (1997) were significantly associated with delays of more than 2 hours in seeking hospital care after controlling for a variety of factors that might affect delay. CONCLUSIONS: The results of this population-based study suggest that a large proportion of patients with AMI continue to exhibit prolonged delay. The characteristics of many of these individuals can be identified in advance for targeted educational efforts. Arch Intern Med. 2000;160:3217-3223.

Aged↗

PubMed2000

Ten-year trends in the incidence, treatment, and outcome of Q-wave myocardial infarction.

The benefits of coronary reperfusion and antiplatelet therapy for patients with Q-wave acute myocardial infarction (Q-AMI) are well established in the context of randomized, controlled trials. The use and recent impact of these and other therapies on the broader, community-wide population of patients with Q-AMI is less well established. Residents of the Worcester, Massachusetts, metropolitan area (1990 census population 437,000) hospitalized with confirmed Q-AMI in all metropolitan Worcester, Massachusetts, hospitals in 4 1-year periods between 1986 and 1997 comprised the sample of interest. We examined the rates of occurrence, use of reperfusion strategies, and hospital mortality in a cohort of 711 patients with Q-AMI treated early in the reperfusion era (1986 and 1988) in comparison to 669 patients with Q-AMI treated a decade later (1995 and 1997). The percentage of Q-AMI among all hospitalized patients with AMI decreased over the decade of reperfusion therapy: 52% in 1986 and 1988 versus 35% in 1995 and 1997 (p < 0.001). Use of reperfusion therapy for patients with Q-AMI increased from 22% to 57%, with a marked increase in the use of primary angioplasty over time (1% vs 16%). The profile of patients receiving reperfusion therapy also changed significantly over the study period. Marked increases in use of antiplatelet therapy, beta blockers, angiotensin-converting enzyme inhibitors, and decreased use of calcium channel blockers, were observed over time. The crude in-hospital case fatality rate declined from 19% (1986 and 1988) to 14% (1995 and 1997) in patients with Q-AMI. Results of a multivariable regression analysis showed lack of reperfusion therapy, older age, anterior wall AMI, and cardiogenic shock to be independent predictors of in-hospital mortality in patients with Q-AMI. Thus, the percentage of all AMI's presenting as Q-AMI, and hospital mortality after Q-AMI, has decreased significantly in the past 10 years. The decrease in mortality occurs in the setting of broader use of reperfusion and adjunctive therapy (including primary angioplasty).

Aged↗

PubMed2000

Relationship of symptom-onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction.

CONTEXT: Rapid time to treatment with thrombolytic therapy is associated with lower mortality in patients with acute myocardial infarction (MI). However, data on time to primary angioplasty and its relationship to mortality are inconclusive. OBJECTIVE: To test the hypothesis that more rapid time to reperfusion results in lower mortality in the strategy of primary angioplasty. DESIGN: Prospective observational study of data collected from the Second National Registry of Myocardial Infarction between June 1994 and March 1998. SETTING: A total of 661 community and tertiary care hospitals in the United States. SUBJECTS: A cohort of 27,080 consecutive patients with acute MI associated with ST-segment elevation or left bundle-branch block who were treated with primary angioplasty. MAIN OUTCOME MEASURE: In-hospital mortality, compared by time from acute MI symptom onset to first balloon inflation and by time from hospital arrival to first balloon inflation (door-to-balloon time). RESULTS: Using a multivariate logistic regression model, the adjusted odds of in-hospital mortality did not increase significantly with increasing delay from MI symptom onset to first balloon inflation. However, for door-to-balloon time (median time 1 hour 56 minutes), the adjusted odds of mortality were significantly increased by 41% to 62% for patients with door-to-balloon times longer than 2 hours (for 121-150 minutes: odds ratio [OR], 1.41; 95% confidence interval [CI], 1.08-1.84; P=.01; for 151-180 minutes: OR, 1.62; 95% CI, 1.23-2.14; P<.001; and for >180 minutes: OR, 1.61; 95% CI, 1.25-2.08; P<.001). CONCLUSIONS: The relationship in our study between increased mortality and delay in door-to-balloon time longer than 2 hours (present in nearly 50% of this cohort) suggests that physicians and health care systems should work to minimize door-to-balloon times and that door-to-balloon time should be considered when choosing a reperfusion strategy. Door-to-balloon time also appears to be a valid quality-of-care indicator. JAMA. 2000.

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PubMed2000

Payer status and the utilization of hospital resources in acute myocardial infarction: a report from the National Registry of Myocardial Infarction 2.

BACKGROUND: Prior studies have suggested that payer status may be an important determinant of medical resource utilization and outcome in acute myocardial infarction (AMI). METHODS: A national cohort of 332,221 patients with AMI enrolled from June 1994 to July 1996 were compared within 5 payer groups to ascertain the influence of payer status on hospital resource allocation for AMI in the United States. RESULTS: Medicare comprised the largest proportion (56%), followed by commercial insurance (25%), health maintenance organization (HMO) (10%), uninsured (6%), and Medicaid (3%). Compared with commercially insured patients, Medicare and Medicaid patients received fewer reperfusion therapies, underwent fewer invasive cardiac procedures, and had longer hospitalizations. After adjusting for differences in clinical characteristics, Medicare recipients were as likely as commercially insured patients to receive acute reperfusion therapies or any invasive cardiac procedure. Uninsured and HMO patients tended to utilize hospital resources with intermediate frequency. Medicare recipients aged 65 years or older and the HMO group had similar hospital mortality rates compared with the commercial group (odds ratio [OR], 1.07; 95% confidence interval [CI], 0.96-1.20 and OR, 0.93; 95% CI, 0.83-1.04, respectively), but Medicaid and uninsured groups had higher hospital mortality rates compared with the commercial group (OR, 1.30; 95% CI, 1.14-1.48 and OR, 1.29; 95% CI, 1.12-1.48, respectively). CONCLUSION: This report suggests significant variation by payer status in the management of AMI throughout the United States, but no important differences in mortality among the 3 largest payer groups.

Aged↗

PubMed2000

Intracranial hemorrhage rates and effect of immediate beta-blocker use in patients with acute myocardial infarction treated with tissue plasminogen activator. Participants in the National Registry of Myocardial Infarction-2.

In acute myocardial infarction (AMI), immediate beta-blocker therapy reduces the incidence of reinfarction and recurrent chest pain in patients receiving tissue plasminogen activator (t-PA). Data from the Thrombolysis in Myocardial Infarction (TIMI)-2 trial also raises the possibility that such therapy may reduce the rate of intracranial hemorrhage (ICH). We reviewed data obtained from 60,329 patients treated with t-PA who were enrolled in the National Registry of Myocardial Infarction 2. Of the 60,329 in the study cohort, 23,749 patients (39.4%) were treated with immediate beta-blocker therapy and 542 patients (0.9%) developed an ICH. In a multivariate model that included all covariates known to be associated with the development of ICH, immediate beta-blocker therapy was associated with a 31% reduction in the ICH rate (odds ratio 0.69, 95% confidence intervals 0.57 to 0.84). Thus, in the present study, the use of immediate beta-blocker therapy in patients with AMI treated with t-PA was associated with a significant reduction in ICH. This finding supports the observations made in the TIMI 2 trial and serves to reinforce the recommendations made by the American College of Cardiology/American Heart Association task force that immediate beta-blocker therapy should be administered to all patients with AMI who do not have contraindications to this therapy.

Adrenergic beta-Antagonists↗

PubMed2000

The impact of the stent era on the management strategy for acute myocardial infarction: A population-based perspective.

We determined trends in the use of invasive diagnostic and revascularization strategies from a multihospital community-wide perspective for patients suffering acute myocardial infarction (AMI). Comparing 3,824 patients treated in the prestent era (1986-1993) to 1,915 patients hospitalized during the stent era (1995-1997), there was a significant increase in the use of invasive procedures and revascularization techniques across a broad spectrum of AMI patients during their index hospitalization. This resulted in a higher-risk profile of patients referred for invasive management of AMI in the stent era. Cathet. Cardiovasc. Intervent. 51:255-258, 2000.

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PubMed2000

Early and pre-discharge aspirin administration among patients with acute myocardial infarction: current clinical practice and trends in the United States.

OBJECTIVES: The purpose of our study was to determine the frequency of aspirin administration among patients with acute myocardial infarction (MI) as dictated by physicians practicing in the United States. BACKGROUND: Aspirin (ASA), a widely available, inexpensive and generally well-tolerated platelet inhibitor, is recommended for patients with acute coronary syndromes, including acute MI. However, there is concern that aspirin is underutilized in daily clinical practice. METHODS: Early (<24 hours) and predischarge ASA administration were determined among 220,171 patients with suspected acute MI enrolled in the Second National Registry of Myocardial Infarction (NRMI 2) between June, 1994 and April 30, 1996. RESULTS: Overall, 165,122 (74.9%) of patients received ASA within 24 hours of hospital admission, whereas 55,049 patients did not. Early ASA recipients were younger, more often male, arrived at the hospital earlier, and were more likely to be classified as Killip Class II or less compared to those who did not receive ASA. Patients who received aspirin were also more likely to have chest pain, electrocardiographic ST segment elevation, and tended to arrive at the hospital earlier than those who did not receive ASA. However, over 20% of patients with ST segment elevation did not receive early ASA therapy. From the total cohort of early ASA recipients, only 69% received ASA at the time of hospital discharge. Trends in early and pre-discharge aspirin administration over a 2 year time period in all patients (72.6 to 75.1% and 71.5 to 74.6%, respectively; p < 0. 001) and in specific patient subsets were encouraging with a gradual but steady increase; however, utilization remained comparatively low in women and the elderly. By multivariable analysis, in-hospital recurrent MI (OR 0.90, 95% CI;.78-1.0, p = 0.04), stroke (OR 0.65, 95% CI,.52-.80, p < 0.001) and death (OR 0.24, 95% CI,.22-.26, p < 0. 001) occurred less frequently when ASA was administered within 24 hours of hospitalization. CONCLUSION: Aspirin is currently underutilized in routine clinical practice as both primary and adjunctive forms of therapy in MI, especially among patients known to be at risk for recurrent cardiothrombotic events. The targeted and timely use of aspirin reduces early cardiovascular events and should remain a priority in national health care efforts.

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