Lori Parsons

Sex-Based Differences in Early Mortality after Myocardial Infarction

Background There is conflicting information about whether short-term mortality after myocardial infarction is higher among women than among men after adjustment for age and other prognostic factors. We hypothesized that younger, but not older, women have higher mortality rates during hospitalization than their male peers. Methods We analyzed data on 384,878 patients (155,565 women and 229,313 men) who were 30 to 89 years of age and who had been enrolled in the National Registry of Myocardial Infarction 2 between June 1994 and January 1998. Patients who had been transferred from or to other hospitals were excluded. Results The overall mortality rate during hospitalization was 16.7 percent among the women and 11.5 percent among the men. Sex-based differences in the rates varied according to age. Among patients less than 50 years of age, the mortality rate for the women was more than twice that for the men. The difference in the rates decreased with increasing age and was no longer significant after the age ...

A Comparison of Thrombolytic Therapy with Primary Coronary Angioplasty for Acute Myocardial Infarction

BACKGROUND Several relatively small randomized trials have shown that primary angioplasty results in a better short-term outcome than thrombolytic therapy in patients with acute myocardial infarction. These results, however, have not been duplicated other than in investigational trials. METHODS We compared mortality during hospitalization and long-term mortality, as well as the use of resources, among 1050 patients in a primary-angioplasty group and 2095 patients in a thrombolytic-therapy group. Patients were selected from the Myocardial Infarction Triage and Intervention Project Registry cohort of 12,331 consecutive patients admitted with acute myocardial infarction to 19 Seattle hospitals between 1988 and 1994. Because of the potential for selection bias, several subgroup analyses were performed that included patients eligible for thrombolysis, high-risk patients, and patients in the primary-angioplasty group who were treated at hospitals with high volumes of angioplasty. RESULTS There was no significant difference in mortality during hospitalization or long-term follow-up between patients in the thrombolytic-therapy group and those in the primary-angioplasty group (mortality during hospitalization, 5.6 percent and 5.5 percent, respectively; P=0.93; adjusted hazard ratio for the risk of death within three years after primary angioplasty, 0.95; 95 percent confidence interval, 0.8 to 1.2). There was also no significant difference in mortality between high-risk subgroups of patients in the two treatment groups. The rates of procedures and costs were lower among patients in the thrombolytic-therapy group both at the time of hospital discharge and after three years of follow-up (30 percent fewer coronary angiograms, 15 percent fewer coronary angioplasties, and 13 percent lower costs after three years of follow-up). CONCLUSIONS In a community setting, we observed no benefit in terms of either mortality or the use of resources with a strategy of primary angioplasty rather than thrombolytic therapy in a large cohort of patients with acute myocardial infarction.

Hospital outcomes in patients presenting with congestive heart failure complicating acute myocardial infarction: A report from the Second National Registry of Myocardial Infarction (NRMI-2)

OBJECTIVES The purpose of this study was to examine treatment and outcomes in patients admitted to the hospital with acute myocardial infarction (AMI) complicated by congestive heart failure (CHF). BACKGROUND Although cardiogenic shock complicating AMI has been studied extensively, the hospital course of patients presenting with CHF is less well established. METHODS The Second National Registry of Myocardial Infarction (NRMI-2) was analyzed to determine hospital outcomes for patients with ST-elevation AMI admitted with CHF (Killip classes II or III). RESULTS Of 190,518 patients with AMI, 36,303 (19.1%) had CHF on admission. Patients presenting with CHF were older (72.6 +/- 12.5 vs. 63.2 +/- 13.5 years), more often female (46.8% vs. 32.1%), had longer time to hospital presentation (2.80 +/- 2.6 vs. 2.50 +/- 2.4 h), and had higher prevalence of anterior/septal AMI (38.8% vs. 33.3%), diabetes (33.1% vs. 19.5%), and hypertension (54.6% vs. 46.1%) (all p < 0.0005). Also, they had longer lengths of stay (8.1 +/- 7.1 vs. 6.8 +/- 5.3 days, p < 0.00005) and greater risk for in-hospital death (21.4% vs. 7.2%; p < 0.0005). Patients with CHF were less likely to receive aspirin (75.7% vs. 89.0%), heparin (74.6% vs. 91.1%), oral beta-blockers (27.0% vs. 41.7%), fibrinolytics (33.4% vs. 58.0%), or primary angioplasty (8.6% vs. 14.6%), and more likely to receive angiotensin-converting enzyme inhibitors (25.4% vs. 13.0%). Congestive heart failure on admission was one of the strongest predictors of in-hospital death (adjusted odds ratio 1.68; 95% confidence interval 1.62, 1.75). CONCLUSIONS Patients with AMI presenting with CHF are at higher risk for adverse in-hospital outcomes. Despite this, they are less likely to be treated with reperfusion therapy and medications with proven mortality benefit.

Use of Lipid-Lowering Medications at Discharge in Patients With Acute Myocardial Infarction Data From the National Registry of Myocardial Infarction 3

Background—The present study aimed to assess use of lipid-lowering medication at discharge in a current national sample of patients hospitalized with acute myocardial infarction and to evaluate factors associated with prescribing patterns. Methods and Results—Demographic, procedural, and discharge medication data were collected from 138 001 patients with acute myocardial infarction discharged from 1470 US hospitals participating in the National Registry of Myocardial Infarction 3 from July 1998 to June 1999. Lipid-lowering medications were part of the discharge regimen in 31.7%. Among patients with prior history of CAD, revascularization, or diabetes, less than one half of the patients were discharged on treatment. In multivariate analysis, factors independently related to lipid-lowering use included history of hypercholesterolemia (odds ratio [OR] 4.93; 95% CI 4.79 to 5.07), cardiac catheterization during hospitalization (OR 1.29; 95% CI 1.24 to 1.34), care provided at a teaching hospital, (OR 1.26; 95% CI 1.22 to 1.32), use of &bgr;-blocker (OR 1.43; 95% CI 1.39 to 1.48), and smoking cessation counseling (OR 1.51; 95% CI 1.44 to 1.59). Lipid-lowering medications were given less often to patients who were older (65 to 74 versus <55 years of age; OR 0.82; 95% CI 0.78 to 0.86), those with a history of hypertension (OR 0.92; 95% CI 0.89 to 0.95), and those undergoing coronary artery bypass graft surgery (OR 0.58; 95% CI 0.55 to 0.60). Conclusions—Analysis of current practice patterns for the use of lipid-lowering medications in patients hospitalized with acute myocardial infarction reveals that a significant proportion of high-risk patients did not receive treatment at time of discharge.

Trends in quality of care for patients with acute myocardial infarction in the National Registry of Myocardial Infarction from 1990 to 2006

BACKGROUND Trends in the use of guideline-based treatment for acute myocardial infarction (AMI) as well as its association with patient outcomes have not been summarized in a large, longitudinal study. Furthermore, it is unknown whether gender-, race-, and age-based care disparities have narrowed over time. METHODS AND RESULTS Using the National Registry of Myocardial Infarction database, we analyzed 2,515,106 patients with AMI admitted to 2,157 US hospitals between July 1990 and December 2006 to examine trends overall and in select subgroups of guideline-based admission, procedural, and discharge therapy use. The contribution of temporal improvements in acute care therapies to declines in in-hospital mortality was examined using logistic regression analysis. From 1990 to 2006, the use of all acute guideline-recommended therapies administered rose significantly for patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction but remained below 90% for most therapies. Cardiac catheterization and percutaneous coronary intervention use increased in patients with ST-segment elevation myocardial infarction and patients with non-ST-segment myocardial infarction, whereas coronary bypass surgery use declined in both groups. Despite overall care improvements, women, blacks, and patients > or =75 years old were significantly less likely to receive revascularization or discharge lipid-lowering therapy relative to their counterparts. Temporal improvements in acute therapies may account for up to 37% of the annual decline in risk for in-hospital AMI mortality. CONCLUSION Adherence to American Heart Association/American College of Cardiology practice guidelines has improved care of patients with AMI and is associated with significant reductions in in-hospital mortality rates. However, persistent gaps in overall care as well as care disparities remain and suggest the need for ongoing quality improvement efforts.

Original ResearchPulmonary Arterial HypertensionCharacterization of Connective Tissue Disease-Associated Pulmonary Arterial Hypertension From REVEAL: Identifying Systemic Sclerosis as a Unique Phenotype

BACKGROUND REVEAL (the Registry to Evaluate Early and Long-term Pulmonary Arterial Hypertension Disease Management) is the largest US cohort of patients with pulmonary arterial hypertension (PAH) confirmed by right-sided heart catheterization (RHC), providing a more comprehensive subgroup characterization than previously possible. We used REVEAL to analyze the clinical features of patients with connective tissue disease-associated PAH (CTD-APAH). METHODS All newly and previously diagnosed patients with World Health Organization (WHO) group 1 PAH meeting RHC criteria at 54 US centers were consecutively enrolled. Cross-sectional and 1-year mortality and hospitalization analyses from time of enrollment compared CTD-APAH to idiopathic disease and systemic sclerosis (SSc) to systemic lupus erythematosus (SLE), mixed connective tissue disease (MCTD), and rheumatoid arthritis (RA). RESULTS Compared with patients with idiopathic disease (n = 1,251), patients with CTD-APAH (n = 641) had better hemodynamics and favorable right ventricular echocardiographic findings but a higher prevalence of pericardial effusions, lower 6-min walk distance (300.5 ± 118.0 vs 329.4 ± 134.7 m, P = .01), higher B-type natriuretic peptide (BNP) levels (432.8 ± 789.1 vs 245.6 ± 427.2 pg/mL, P < .0001), and lower diffusing capacity of carbon monoxide (Dlco) (44.9% ± 18.0% vs 63.6% ± 22.1% predicted, P < .0001). One-year survival and freedom from hospitalization were lower in the CTD-APAH group (86% vs 93%, P < .0001; 67% vs 73%, P = .03). Compared with patients with SSc-APAH (n = 399), those with other CTDs (SLE, n = 110; MCTD, n = 52; RA, n = 28) had similar hemodynamics; however, patients with SSc-APAH had the highest BNP levels (552.2 ± 977.8 pg/mL), lowest Dlco (41.2% ± 16.3% predicted), and poorest 1-year survival (82% vs 94% in SLE-APAH, 88% in MCTD-APAH, and 96% in RA-APAH). CONCLUSIONS Patients with SSc-APAH demonstrate a unique phenotype with the highest BNP levels, lowest Dlco, and poorest survival of all CTD-APAH subgroups. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00370214; URL: clinicaltrials.gov.

Sex differences in mortality after acute myocardial infarction: changes from 1994 to 2006.

BACKGROUND Previous studies have shown that women younger than 55 years have higher hospital mortality rates after acute myocardial infarction (MI) than age-matched men. We examined whether such mortality differences have decreased in recent years. METHODS We investigated temporal trends in the hospital case-fatality rates of MI by sex and age from June 1, 1994, through December 31, 2006. The study population included 916,380 patients from the National Registry of Myocardial Infarction with a confirmed diagnosis of MI. RESULTS In-hospital mortality decreased markedly between 1994 and 2006 in all patients but more so in women than men. The mortality reduction in 2006 relative to 1994 was largest in women younger than 55 years (52.9%) and lowest in men younger than 55 years (33.3%). In patients younger than 55 years, the absolute decrease in mortality was 3 times larger in women than men (2.7% vs 0.9%). As a result, the excess mortality in younger women (<55 years) compared with men was less pronounced in 2004-2006 (unadjusted odds ratio, 1.32; 95% confidence interval, 1.07-1.67) than it was in 1994-1995 (unadjusted odds ratio, 1.93; 95% confidence interval, 1.67-2.24). The sex difference in mortality decrease was lower in older patients (P = .004 for the interaction among sex, age, and year). Changes in comorbidity and clinical severity features at admission accounted for more than 90% of these mortality trends. CONCLUSIONS In recent years, women, particularly younger ones, experienced larger improvements in hospital mortality after MI than men. The narrowing of the mortality gap between younger women and men is largely attributable to temporal changes in risk profiles.

Early Use of Glycoprotein IIb/IIIa Inhibitors in Non-ST-Elevation Acute Myocardial Infarction Observations From the National Registry of Myocardial Infarction 4

OBJECTIVES We sought to identify patient and hospital features associated with early glycoprotein (GP) IIb/IIIa inhibitor therapy for non-ST-elevation (NSTE) myocardial infarction (MI) and to relate this treatment to in-hospital outcomes. BACKGROUND Glycoprotein IIb/IIIa inhibitors have improved outcomes in randomized trials of NSTE MI, leading national treatment guidelines to recommend their use. Their actual use, safety, and effectiveness have not been well characterized beyond trial populations. METHODS We studied 60,770 patients with NSTE MI treated between July 2000 and July 2001 at 1,189 hospitals in a U.S. registry. Using logistic regression, we identified patient and hospital features associated with GP IIb/IIIa inhibition within 24 h after presentation. We also compared outcomes by early treatment versus no treatment after adjusting for patient and hospital characteristics and treatment propensity. RESULTS Only 25% of eligible patients received early GP IIb/IIIa therapy. Elderly patients, women, minority patients, and those without private insurance received such therapy less often than their counterparts. Treated patients had lower unadjusted in-hospital mortality (3.3% vs. 9.6%, p < 0.0001) remaining significantly lower after adjustment for patient risk, treatment propensity, and hospital characteristics (adjusted odds ratio, 0.88; 95% confidence interval, 0.79 to 0.97). Hospitals that adopted early GP IIb/IIIa inhibition more rapidly also had lower adjusted mortality rates than those slower to adopt such therapy. CONCLUSIONS Glycoprotein IIb/IIIa inhibitor therapy appears to be underused in early management of NSTE MI patients. Because this therapy is associated with better outcomes, it represents a target for quality improvement.

Relation Between Hospital Intra-Aortic Balloon Counterpulsation Volume and Mortality in Acute Myocardial Infarction Complicated by Cardiogenic Shock

Background—Increasing evidence suggests an inverse relationship between outcome and the total number of invasive cardiac procedures performed at a given hospital. The purpose of the present study was to determine if a similar relationship exists between the number of intra-aortic balloon counterpulsation (IABP) procedures performed at a given hospital per year and the in-hospital mortality rate of patients with acute myocardial infarction complicated by cardiogenic shock. Methods and Results—We analyzed data of 12 730 patients at 750 hospitals enrolled in the National Registry of Myocardial Infarction 2 from 1994 to 1998. The hospitals were divided into tertiles (low–, intermediate–, and high–IABP volume hospitals) according to the number of IABPs performed at the given hospital per year. The median number of IABPs performed per hospital per year was 3.4, 12.7, and 37.4 IABPs at low-, intermediate-, and high-volume hospitals, respectively. Of those patients who underwent IABP, there were only minor differences in baseline patient characteristics between the 3 groups. Crude mortality rate decreased with increasing IABP volume: 65.4%, lowest volume tertile; 54.1%, intermediate volume tertile; and 50.6%, highest volume tertile (P for trend <0.001). This mortality difference represented 150 fewer deaths per 1000 patients treated at the high IABP hospitals. In the multivariate analysis, high hospital IABP volume for patients with acute myocardial infarction was associated with lower mortality (OR=0.71, 95% CI=0.56 to 0.90), independent of baseline patient characteristics, hospital factors, treatment, and procedures such as PTCA. Conclusions—Among the myocardial infarction patients with cardiogenic shock who underwent IABP placement, mortality rate was significantly lower at high–IABP volume hospitals compared with low–IABP volume hospitals.

Long-Term Prognostic Value of Exercise Testing in Men and Women From the Coronary Artery Surgery Study (CASS) Registry

Many prior studies involving a predominantly male population have demonstrated the importance of exercise test results in determining the outcome of patients with coronary artery disease. The prognostic significance of exercise testing in women is unknown. In our study, a total of 3,086 men and 747 women underwent maximal treadmill exercise testing, coronary angiography, and were prospectively followed for up to 16 years. They were divided into 3 groups (high, intermediate, and low risk) on the basis of exercise testing. Sixteen-year survival based on exercise test groups ranged from 38% to 61% in men and from 44% to 79% in women (p < 0.001). Among men, 12-year survival was enhanced by coronary artery bypass surgery versus medical therapy in the high-risk subgroup (69% vs 55%, respectively, p = 0.0025), but the 2 therapies were similar in the intermediate- and low-risk subgroups. Among women, neither medical nor surgical therapy resulted in improved 12-year survival rates in any of the 3 subgroups. These results suggest that exercise testing is helpful in assessing long-term survival in men and women. However, only exercise testing in men could identify a high-risk subset whose survival was enhanced by coronary artery bypass graft surgery.