Juan Carlos Zevallos

Prognosis of acute myocardial infarction complicated by complete heart block (the Worcester heart attack study)

As part of a community-based study of patients hospitalized with acute myocardial infarction (AMI) in the Worcester, Massachusetts, metropolitan area, changes over time in the incidence rates of complete heart block (CHB) complicating AMI, and the prognostic impact of CHB on the in-hospital and long-term survival of these patients were examined. In all, 4,762 patients with validated AMI hospitalized at 16 hospitals in the Worcester metropolitan area during 1975, 1978, 1981, 1984, 1986 and 1988 constituted the study sample. The incidence rates of CHB complicating AMI remained relatively stable at 5.8% over the 13-year (1975 to 1988) period studied. The incidence rates of CHB were approximately twice as high in patients with inferior/posterior wall AMI (7.7%) as in those with anterior wall AMI (3.9%). Use of a multivariate regression analysis to control for factors affecting the incidence rates of CHB revealed that patients were at highest risk for developing CHB during the latter 2 study years (1986 and 1988). Patients with AMI developing CHB had higher in-hospital case fatality rates than did those without CHB overall, as well as during each of the 6 periods studied. The in-hospital survival associated with CHB did not improve over time. After use of a multivariate regression analysis to control for additional prognostic factors, the independent effect of CHB on in-hospital prognosis remained (adjusted risk of dying = 2.10; 95% confidence intervals = 1.37, 3.21). Patients with inferior wall AMI complicated by CHB were at significantly increased risk of dying during hospitalization compared with those without CHB (adjusted risk of dying = 2.71; 95% confidence intervals = 1.60, 4.59).(ABSTRACT TRUNCATED AT 250 WORDS)

Thirty-Year Trends (1975-2005) in the Magnitude, Patient Characteristics, and Hospital Outcomes of Patients With Acute Myocardial Infarction Complicated by Ventricular Fibrillation

Limited contemporary data are available describing the incidence rates, hospital prognosis, and factors associated with the occurrence of ventricular fibrillation (VF) in patients hospitalized with acute myocardial infarction (AMI). The objectives of our study were to examine 3-decade-long trends (1975 to 2005) in the magnitude, predictors, and hospital case-fatality rates associated with VF in residents of a large New England metropolitan area hospitalized at all area medical centers with an uncomplicated AMI. The study population consisted of 7,472 residents of the Worcester (Massachusetts) metropolitan area hospitalized with an uncomplicated AMI in 15 annual periods from 1975 to 2005. The overall proportion of patients who developed VF was 4.2%. The incidence rates of VF remained stable from 1975 to 1995 but decreased thereafter, reaching their lowest frequency in 2005 (1.9%). Hospital case-fatality rates were significantly higher in patients with (40.9%) compared with those without (2.5%) VF. Decreases in hospital death rates over time were observed in patients with and without VF, with the decreases in death rates being greater for patients with VF. Patients who developed a Q-wave MI or a left or right bundle branch block were at particularly increased risk for developing VF. In conclusion, our results indicate that the incidence and hospital death rates associated with VF have decreased during recent years.

Thirty-year trends (1975-2005) in the magnitude and hospital death rates associated with complete heart block in patients with acute myocardial infarction: a population-based perspective

BACKGROUND The contemporary magnitude and prognostic implications of complete heart block (CHB) in patients with acute myocardial infarction (AMI) are unknown. As part of a community-based study of patients hospitalized with AMI in the Worcester, MA, metropolitan area, changes over time in the incidence rates of CHB complicating AMI and the prognostic impact of CHB on short-term survival were examined. METHODS The study population consisted of 13,663 residents of the Worcester metropolitan area who were hospitalized with AMI at all greater Worcester medical centers during 15 annual periods between 1975 and 2005. RESULTS The average age of the hospitalized study sample was 69 years, and 58% were men. The overall proportion of patients with AMI who developed CHB was 4.1%. The incidence rates of CHB complicating AMI declined appreciably over time, with the greatest decline in these incidence rates occurring during the most recent years under study. In 2005, 2.0% of patients hospitalized with AMI developed CHB compared to 5.1% in the initial study year of 1975. Patients with AMI who developed CHB had higher inhospital death rates (43.2%) than did those who did not develop CHB (13.0%) (P < .001). The hospital death rates associated with CHB declined appreciably over time, particularly during the most recent years under study. Several patient characteristics were associated with an increased risk for developing CHB during hospitalization for myocardial infarcation. CONCLUSIONS Our findings indicate recent encouraging declines in the incidence rates of CHB complicating AMI and improving trends in the hospital prognosis of these patients.

Predictors of Thrombolysis Administration in Mild Stroke: Florida-Puerto Rico Collaboration to Reduce Stroke Disparities

Background and Purpose— Mild stroke is the most common cause for thrombolysis exclusion in patients acutely presenting to the hospital. Thrombolysis administration in this subgroup is highly variable among different clinicians and institutions. We aim to study the predictors of thrombolysis in patients with mild ischemic stroke in the FL-PR CReSD registry (Florida-Puerto Rico Collaboration to Reduce Stroke Disparities). Methods— Among 73 712 prospectively enrolled patients with a final diagnosis of ischemic stroke or TIA from January 2010 to April 2015, we identified 7746 cases with persistent neurological symptoms and National Institutes of Health Stroke Scale ⩽5 who arrived within 4 hours of symptom onset. Multilevel logistic regression analysis with generalized estimating equations was used to identify independent predictors of thrombolytic administration in the subgroup of patients without contraindications to thrombolysis. Results— We included 6826 cases (final diagnosis mild stroke, 74.6% and TIA, 25.4%). Median age was 72 (interquartile range, 21); 52.7% men, 70.3% white, 12.9% black, 16.8% Hispanic; and median National Institutes of Health Stroke Scale, 2 (interquartile range, 3). Patients who received thrombolysis (n=1281, 18.7%) were younger (68 versus 72 years), had less vascular risk factors (hypertension, diabetes mellitus, and dyslipidemia), had lower risk of prior vascular disease (myocardial infarction, peripheral vascular disease, and previous stroke), and had a higher presenting median National Institutes of Health Stroke Scale (4 versus 2). In the multilevel multivariable model, early hospital arrival (arrive by 0–2 hours versus ≥3.5 hours; odds ratio [OR], 8.16; 95% confidence interval [CI], 4.76–13.98), higher National Institutes of Health Stroke Scale (OR, 1.87; 95% CI, 1.77–1.98), aphasia at presentation (OR, 1.35; 95% CI, 1.12–1.62), faster door-to-computed tomography time (OR, 1.81; 95% CI, 1.53–2.15), and presenting to an academic hospital (OR, 2.02; 95% CI, 1.39–2.95) were independent predictors of thrombolysis administration. Conclusions— Mild acutely presenting stroke patients are more likely to receive thrombolysis if they are young, white, or Hispanic and arrive early to the hospital with more severe neurological presentation. Identification of predictors of thrombolysis is important in design of future studies to assess the use of thrombolysis for mild stroke.