Allan M. Skene

Quality of life four years after acute myocardial infarction: short form 36 scores compared with a normal population

OBJECTIVES To assess the impact of myocardial infarction on quality of life in four year survivors compared to data from “community norms”, and to determine factors associated with a poor quality of life. DESIGN Cohort study based on the Nottingham heart attack register. SETTING Two district general hospitals serving a defined urban/rural population. SUBJECTS All patients admitted with acute myocardial infarction during 1992 and alive at a median of four years. MAIN OUTCOME MEASURES Short form 36 (SF 36) domain and overall scores. RESULTS Of 900 patients with an acute myocardial infarction in 1992, there were 476 patients alive and capable of responding to a questionnaire in 1997. The response rate was 424 (89.1%). Compared to age and sex adjusted normative data, patients aged under 65 years exhibited impairment in all eight domains, the largest differences being in physical functioning (mean difference 20 points), role physical (mean difference 23 points), and general health (mean difference 19 points). In patients over 65 years mean domain scores were similar to community norms. Multiple regression analysis revealed that impaired quality of life was closely associated with inability to return to work through ill health, a need for coronary revascularisation, the use of anxiolytics, hypnotics or inhalers, the need for two or more angina drugs, a frequency of chest pain one or more times per week, and a Rose dyspnoea score of ⩾ 2. CONCLUSIONS The SF 36 provides valuable additional information for the practising clinician. Compared to community norms the greatest impact on quality of life is seen in patients of working age. Impaired quality of life was reported by patients unfit for work, those with angina and dyspnoea, patients with coexistent lung disease, and those with anxiety and sleep disturbances. Improving quality of life after myocardial infarction remains a challenge for physicians.

Resuscitation from out-of-hospital cardiac arrest: is survival dependent on who is available at the scene?

Objective To determine whether survival from out-of-hospital cardiac arrest is influenced by the on-scene availability of different grades of ambulance personnel and other health professionals. Design Population based, retrospective, observational study. Setting County of Nottinghamshire with a population of one million. Subjects All 2094 patients who had resuscitation attempted by Nottinghamshire Ambulance Service crew from 1991 to 1994; study of 1547 patients whose arrest were of cardiac aetiology. Main outcome measures Survival to hospital admission and survival to hospital discharge. Results Overall survival from out-of-hospital cardiac arrest remains poor: 221 patients (14.3%) survived to reach hospital alive and only 94 (6.1%) survived to be discharged from hospital. Multivariate logistic regression analysis showed that the chances of those resuscitated by technician crew reaching hospital alive were poor but were greater when paramedic crew were either called to assist technicians or dealt with the arrest themselves (odds ratio 6.9 (95% confidence interval 3.92 to 26.61)). Compared to technician crew, survival to hospital discharge was only significantly improved with paramedic crew (3.55 (1.62 to 7.79)) and further improved when paramedics were assisted by either a health professional (9.91 (3.12 to 26.61)) or a medical practitioner (20.88 (6.72 to 64.94)). Conclusions Survival from out-of-hospital cardiac arrest remains poor despite attendance at the scene of the arrest by ambulance crew and other health professionals. Patients resuscitated by a paramedic from out-of-hospital cardiac arrest caused by cardiac disease were more likely to survive to hospital discharge than when resuscitation was provided by an ambulance technician. Resuscitation by a paramedic assisted by a medical practitioner offers a patient the best chances of surviving the event.

Inpatient deaths from acute myocardial infarction, 1982-92 : Analysis of data in the Nottingham heart attack register

Abstract Objective: To assess longitudinal trends in admissions, management, and inpatient mortality from acute myocardial infarction over 10 years. Design: Retrospective analysis based on the Nottingham heart attack register. Setting: Two district general hospitals serving a defined urban and rural population. Subjects: All patients admitted with a confirmed acute myocardial infarction during 1982-4 and 1989-92 (excluding 1991, when data were not collected). Main outcome measures: Numbers of patients, background characteristics, time from onset of symptoms to admission, ward of admission, treatment, and inpatient mortality. Results: Admissions with acute myocardial infarction increased from 719 cases in 1982 to 960 in 1992. The mean age increased from 62.1 years to 66.6 years (P<0.001), the duration of stay fell from 8.7 days to 7.2 days (P<0.001), and the proportion of patients aged 75 years and over admitted to a coronary care unit increased significantly from 29.1% to 61.2%. A higher proportion of patients were admitted to hospital within 6 hours of onset of their symptoms in 1989-92 than in 1982-4, but 15% were still admitted after the time window for thrombolysis. Use of ß blockers increased threefold between 1982 and 1992, aspirin was used in over 70% of patients after 1989, and thrombolytic use increased 1.3-fold between 1989 and 1992. Age and sex adjusted odds ratios for inpatient mortality remained unchanged over the study period. Conclusions: Despite an increasing uptake of the “proved” treatments, inpatient mortality from myocardial infarction did not change between 1982 and 1992. Key messages During 1982-92 major changes in management of myocardial infarction in an unselected population have been guided by the results of randomised trials Adjusted odds ratios for deaths in hospital from acute myocardial infarction did not change over this period despite an overall fall in recorded deaths from ischaemic heart disease in Nottingham The use of existing treatments needs to be optimised and new management strategies need to be introduced if inpatient mortality from myocardial infarction is to be reduced

Relevance of clinical trial results in myocardial infarction to medical practice: comparison of four year outcome in participants of a thrombolytic trial, patients receiving routine thrombolysis, and those deemed ineligible for thrombolysis

OBJECTIVE To assess the medium to long term outcome of patients ineligible for thrombolysis compared to those enrolled in a clinical trial of thrombolysis and patients receiving non-trial thrombolysis. DESIGN Cohort study based on the Nottingham heart attack register. SETTING Two district general hospitals serving a defined urban/rural population. SUBJECTS All patients admitted with a confirmed acute myocardial infarction during 1992 categorised as either participants of a thrombolytic trial (group A, n = 140), receiving non-trial thrombolysis (group B, n = 329), or deemed ineligible for lytic treatment (group C, n = 431). MAIN OUTCOME MEASURES Background characteristics, inhospital treatment, patterns of follow up, referrals to cardiologists, revascularisation rates, and short and long term survival. RESULTS Clinical trial recruits were younger by almost 10 years, were less likely to have a previous history of myocardial infarction, and more likely to be in Killip class 1 on admission than those ineligible for thrombolysis. Cardiology follow up was mandatory for all surviving trial participants but 22% of patients in group B and 31% of patients in group C received no follow up, and during four years less than 50% ever saw a cardiologist. Revascularisation was performed in 17.2% of patients in group A, 13.6% of patients in group B, and 7.5% of patients in group C. Cumulative mortality at a median of four years was 24.3% in group A, 36.8% in B, and 59.6% in group C. Adjusting for age, sex, previous myocardial infarction, type of infarction, and Killip class in a logistic regression model the odds ratios (OR) of death at four years for groups B and C were 1.60 (95% confidence intervals (CI) 0.97 to 2.63, p = 0.065) and 2.64 (95% CI 1.61 to 4.32, p < 0.001), respectively, when compared to group A (OR 1). CONCLUSIONS Patients enrolled into thrombolytic trials are at low risk. Patients deemed ineligible for thrombolysis are high risk, receive less surveillance, are less likely to be revascularised or receive trial proven treatments, have a poor long term outcome not entirely explained by increased age or severity of infarction, and deserve further evaluation.

Calculation of marginal densities for parameters of multinomial distributions

The full Bayesian analysis of multinomial data using informative and flexible prior distributions has, in the past, been restricted by the technical problems involved in performing the numerical integrations required to obtain marginal densities for parameters and other functions thereof. In this paper it is shown that Gibbs sampling is suitable for obtaining accurate approximations to marginal densities for a large and flexible family of posterior distributions—the Å family. The method is illustrated with a three-way contingency table. Two alternative Monte Carlo strategies are also discussed.