Nora M. Cosgrove

Sex differences in the management and long-term outcome of acute myocardial infarction. A statewide study. MIDAS Study Group. Myocardial Infarction Data Acquisition System.

BACKGROUND We wished to evaluate whether differences in the rate of invasive cardiac procedures between men and women with acute myocardial infarction are associated with different short- and long-term mortality. METHODS AND RESULTS The database (Myocardial Infarction Data Acquisition System, MIDAS) included all discharges for the years 1986 and 1987 with the diagnosis of acute myocardial infarction in New Jersey, based on the New Jersey hospital discharge data system (MIDS/UB-82). Accuracy of the data was evaluated by auditing 726 randomly selected charts. The variables examined included age, sex, race, comorbidity (anemia, chronic liver disease, cancer, chronic obstructive pulmonary disease, diabetes, hypertension, prior myocardial infarction), complications (left ventricular dysfunction, arrhythmias, conduction defects), insurance status, performance of cardiac catheterization, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery, and survival up to 3 years. Women were older, had longer hospital stay, and were more likely than men to have anemia, diabetes, hypertension, left ventricular dysfunction, and Medicare or Medicaid insurance coverage. They were less likely than men to be admitted to a hospital equipped to perform invasive procedures or to have chronic obstructive pulmonary disease, chronic liver disease, prior myocardial infarction, or arrhythmias. After adjustment for these differences, women were less likely than men to have cardiac catheterization. Cardiac catheterization was associated with lower mortality. Women up to age 70 had higher 3-year death rates than men after adjustment for age, race, comorbidity, complications, and insurance type. This difference between men and women was somewhat diminished after the performance of cardiac catheterization and revascularization was taken into account. Unadjusted mortality was high in this study group. CONCLUSIONS Women with acute myocardial infarction are less likely to have invasive cardiac procedures and have higher 3-year adjusted death rate up to age 70 than men.

The Effectiveness of Outpatient Appointment Reminder Systems in Reducing No-Show Rates

BACKGROUND Patients who do not keep physician appointments (no-shows) represent a significant loss to healthcare providers. For patients, the cost includes their dissatisfaction and reduced quality of care. An automated telephone appointment reminder system may decrease the no-show rate. Understanding characteristics of patients who miss their appointments will aid in the formulation of interventions to reduce no-show rates. METHODS In an academic outpatient practice, we studied patient acceptance and no-show rates among patients receiving a clinic staff reminder (STAFF), an automated appointment reminder (AUTO), and no reminder (NONE). Patients scheduled for appointments in the spring of 2007 were assigned randomly to 1 of 3 groups: STAFF (n=3266), AUTO (n=3219), or NONE (n=3350). Patients in the STAFF group were called 3 days in advance by front desk personnel. Patients in the AUTO group were reminded of their appointments 3 days in advance by an automated, standardized message. To evaluate patient satisfaction with the STAFF and AUTO, we surveyed patients who arrived at the clinic (n=10,546). RESULTS The no-show rates for patients in the STAFF, AUTO, and NONE groups were 13.6%, 17.3%, and 23.1%, respectively (pairwise, P<.01 by analysis of variance for all comparisons). Cancellation rates in the AUTO and STAFF groups were significantly higher than in the NONE group (P<.004). Appointment reminder group, age, visit type, wait time, division specialty, and insurance type were significant predictors of no-show rates. Patients found appointment reminders helpful, but they could not accurately remember whether they received a clinic staff reminder or an automated appointment reminder. CONCLUSIONS A clinic staff reminder was significantly more effective in lowering the no-show rate compared with an automated appointment reminder system.

Association between chlorthalidone treatment of systolic hypertension and long-term survival.

CONTEXT In the Systolic Hypertension in the Elderly Program (SHEP) trial, conducted between 1985 and 1990, antihypertensive therapy with chlorthalidone-based stepped-care therapy resulted in a lower rate of cardiovascular events than placebo but effects on mortality were not significant. OBJECTIVE To study the gain in life expectancy of participants randomized to active therapy at the 22-year follow-up. DESIGN, SETTING, AND PARTICIPANTS A National Death Index ascertainment of death in the long-term follow-up of a randomized, placebo-controlled, clinical trial (SHEP) of patients aged 60 years or older with isolated systolic hypertension. Recruitment was between March 1, 1985, and January 15, 1988. After the end of a 4.5-year randomized phase of the SHEP trial, all participants were advised to receive active therapy. The time interval between the beginning of recruitment and the ascertainment of death by National Death Index (December 31, 2006) was approximately 22 years (21 years 10 months). MAIN OUTCOME MEASURES Cardiovascular death and all-cause mortality. RESULTS At the 22-year follow-up, life expectancy gain, expressed as the area between active (n = 2365) and placebo (n = 2371) survival curves, was 105 days (95% CI, -39 to 242; P = .07) for all-cause mortality and 158 days (95% CI, 36-287; P = .009) for cardiovascular death. Each month of active treatment was therefore associated with approximately 1 day extension in life expectancy. The active treatment group had higher survival free from cardiovascular death vs the placebo group (hazard ratio [HR], 0.89; 95% CI, 0.80-0.99; P = .03) but similar survival for all-cause mortality (HR, 0.97; 95% CI, 0.90-1.04; P = .42). There were 1416 deaths (59.9%) in the active treatment group and 1435 deaths (60.5%) in the placebo group (log-rank P = .38, Wilcoxon P = .24). Cardiovascular death was lower in the active treatment group (669 deaths [28.3%]) vs the placebo group (735 deaths [31.0%]; log-rank P = .03, Wilcoxon P = .02). Time to 70th percentile survival was 0.56 years (95% CI, -0.14 to 1.23) longer in the active treatment group vs the placebo group (11.53 vs 10.98 years; P = .03) for all-cause mortality and 1.41 years (95% CI, 0.34-2.61; 17.81 vs 16.39 years; P = .01) for survival free from cardiovascular death. CONCLUSION In the SHEP trial, treatment of isolated systolic hypertension with chlorthalidone stepped-care therapy for 4.5 years was associated with longer life expectancy at 22 years of follow-up.

Trends in Incidence and Mortality Rates of Ventricular Septal Rupture During Acute Myocardial Infarction

Since the introduction of reperfusion in the treatment of acute myocardial infarction (AMI), rates of ventricular septal rupture (VSR) and associated mortality have decreased, but it is not known if incidence and mortality have continued to decrease. We describe trends in incidence and mortality rates of patients with postinfarction VSR during the previous 2 decades and identify risk factors that predict the development and mortality of this rare but catastrophic complication. We analyzed occurrence and mortality rates in patients with first AMI with (n = 408) and without VSR (n = 148,473) who were hospitalized from 1990 to 2007 using the New Jersey Myocardial Infarction Data Acquisition System (MIDAS) database. The annual rate of VSR in AMI was 0.25% to 0.31%. Compared to patients with AMI without VSR, patients with VSR were older, more likely to be women, had increased rate of chronic renal disease, congestive heart failure, and cardiogenic shock, and were less likely to be hypertensive or diabetic (all p values < 0.0001). During the 18-year study period, we found no change in hospital and 1-year mortalities, which were 41% and 60% in 1990 to 1992 and 44% and 56% in 2005 to 2007, respectively. The survival benefit associated with VSR surgical repair was seen only in hospital (hazard ratio 0.66, 95% confidence interval 0.45 to 0.95) but not at 30 days or 1 year. In conclusion, despite improvement in medical treatment and revascularization techniques, the rate of VSR complicating AMI has not changed during the previous 2 decades, and the mortality associated with VSR has remained high and relatively constant.

Recruitment in the Trial of Nonpharmacologic Intervention in the Elderly (TONE)

OBJECTIVE: To compare the effectiveness of different approaches to participant enrollment in a behavior modification trial.

Mass Mailing and Staff Experience in a Total Recruitment Program for a Clinical Trial: The SHEP Experience

The Systolic Hypertension in the Elderly Program (SHEP) staff contacted 447,921 screenees, of whom 11,919 (2.7%) were originally eligible and 4,736 (1.1%) maintained eligibility and were randomized. The total number of participants enrolled at the 16 clinical centers ranged from 133 to 559. The low yield of screenees to randomizations resulted from the study design, not from low levels of agreement to participate, and required the employment of a variety of recruitment strategies in a prudent overall plan. SHEP was one of the first clinical trials to use mass mailing as a primary strategy of recruitment. The study used mailing lists from seven generic sources. More than 3.4 million letters of invitation were mailed; they yielded an overall response rate of 4.3%. Motor vehicle and voter registration lists provided the greatest numbers of names. Mailings to members of health maintenance organizations (HMOs) and registrants of the Health Care Finance Administration (HCFA) provided the greatest response rates. Considerable variability in response rates existed among clinical centers using generically similar mailing lists. Generally, the number of hours spent on recruitment showed a positive, but not statistically significant, association with randomization yields. The recruitment yield was statistically significantly higher in clinics with experienced recruitment coordinators than in clinics with inexperienced ones (p = 0.0008). From these findings we conclude that mass mailing is an important strategy in an overall recruitment program, that the involvement of experienced recruitment staff is important, and that although the total time spent by staff on recruitment may also improve results, it matters less than the staffs level of recruiting experience.

Angiotensin-Converting Enzyme Gene Polymorphism in Systemic Hypertension

We determined the angiotensin-converting enzyme (ACE) insertion/deletion genotype in 209 hypertensive individuals and in 100 matched normotensive controls. A significant association was detected between hypertension and the deletion/deletion (D/D) genotype of the ACE gene when the relation was adjusted for age, sex, and body mass index.

Association of calcium channel blocker use with increased rate of acute myocardial infarction in patients with left ventricular dysfunction

The Studies of Left Ventricular Dysfunction (SOLVD) assessed the effect of enalapril in patients with systolic left ventricular dysfunction (LVD). We performed retrospective analyses of the association between calcium channel blocker (CCB) use and fatal and nonfatal myocardial infarction (MI) in these patients. MI occurred in 11.5% of 845 patients receiving CCBs versus 7.5% of 2551 patients not receiving CCBs in the enalapril group and in 14.4% of 874 patients receiving CCBs versus 9.3% of 2527 patients not receiving CCBs in the placebo group. By multivariate Cox regression analysis, adjusting for comorbidity, cause and severity of LVD, heart failure, and concomitant drug use, CCB use was an independent predictor of MI (relative risk [RR] 1.37, confidence interval [CI] 1.14 to 1.63). The increase in MI risk was greater among patients with a higher heart rate (RR 1.46, CI 1.14 to 1.86) and lower blood pressure (RR 1.45, CI 1.14 to 1.86). The adjusted risk ratio for all-cause mortality associated with CCB use was 1.14 (CI 1.00 to 1.28; p = 0.0454). In this analysis of patients with LVD, CCB use was associated with significantly increased risk of fatal or nonfatal MI.

The Effect of Hurricane Sandy on Cardiovascular Events in New Jersey

Background Hurricane Sandy made landfall in New Jersey (NJ) on October 29, 2012. We studied the impact of this extreme weather event on the incidence of, and 30‐day mortality from, cardiovascular (CV) events (CVEs), including myocardial infarctions (MI) and strokes, in NJ. Methods and Results Data were obtained from the MI data acquisition system (MIDAS), a database of all inpatient hospital discharges with CV diagnoses in NJ, including death certificates. Patients were grouped by their county of residence, and each county was categorized as either high‐ (41.5% of the NJ population) or low‐impact area based on data from the Federal Emergency Management Agency and other sources. We utilized Poisson regression comparing the 2 weeks following Sandy landfall with the same weeks from the 5 previous years. In addition, we used CVE data from the 2 weeks previous in each year as to adjust for yearly changes. In the high‐impact area, MI incidence increased by 22%, compared to previous years (attributable rate ratio [ARR], 1.22; 95% confidence interval [CI], 1.16, 1.28), with a 31% increase in 30‐day mortality (ARR, 1.31; 95% CI, 1.22, 1.41). The incidence of stroke increased by 7% (ARR, 1.07; 95% CI, 1.03, 1.11), with no significant change in 30‐day stroke mortality. There were no changes in incidence or 30‐day mortality of MI or stroke in the low‐impact area. Conclusion In the 2 weeks following Hurricane Sandy, there were increases in the incidence of, and 30‐day mortality from, MI and in the incidence of stroke.

Visit‐to‐Visit Blood Pressure Variability and Cardiovascular Death in the Systolic Hypertension in the Elderly Program

Most studies of an association of visit‐to‐visit variability of blood pressure with increased risk of future adverse cardiovascular events are of short duration and rarely include a placebo group. Using data from the double‐blind, placebo‐controlled Systolic Hypertension in the Elderly Program, the authors examined mortality from cardiovascular causes up to 17 years of follow‐up using the National Death Index. Visit‐to‐visit blood pressure variability was associated with cardiovascular death after adjustment for sex, age, serum creatinine, diabetes, body mass index, smoking status, left ventricular failure, and high‐density lipoprotein cholesterol. The relationship was significantly stronger in the active treatment group compared with the placebo group. Although this could be the result of an effect of the medications used unrelated to visit‐to‐visit variability, the data are compatible with the hypothesis that inconsistent adherence leading to missing active medication doses may be an additional explanation for the relationship of visit‐to‐visit variability with cardiovascular death.