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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ahj.2004.08.018 Byline: Saif S. Rathore (a)(b), Paul D. Frederick (e), Nathan R. Every (e), Hal V. Barron (f), Harlan M. Krumholz (a)(c)(d) Abstract: Racial differences in reperfusion therapy use among patients hospitalized with myocardial infarction (MI) have been previously reported as national phenomenon. However, it is unclear whether racial differences in treatment vary by region. Author Affiliation: (a) Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn (b) MD/PhD Program, Yale University School of Medicine, New Haven, Conn (c) Section of Health Policy and Administration, Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Conn (d) Yale-New Haven Hospital Center for Outcomes Research and Evaluation, New Haven, Conn (e) Ovation Research Group, Chicago, Ill (f) Genentech, Incorporated, South San Francisco, Calif Article History: Received 13 January 2004; Accepted 17 August 2004 Article Note: (miscellaneous) The National Registry of Myocardial Infarction-2 and -3 is supported by Genentech, Inc, South San Francisco, Calif. Mr Rathore is supported by National Institutes of Health National Institute of General Medical Sciences Medical Scientist Training Grant GM07205.

Heart attack patients who are treated at hospitals that do many angioplasty procedures have lower mortality rates while they are in the hospital. This was the conclusion of researchers who analyzed mortality rates among heart attack patients treated at 450 hospitals that perform angioplasty and 516 hospitals that use thrombolytic drugs. Both of these treatments are used to open up blocked arteries. The in-hospital mortality rate was 28% lower in hospitals that did the most angioplasties compared to those that did the fewest. This reduction in mortality was not seen in the hospitals that only used thrombolytic drugs.

Byline: James L. Ritchie, Charles Maynard, Nathan R. Every, Michael K. Chapko Abstract: Background Randomized trials of coronary stents versus conventional balloon angioplasty have demonstrated improved short- and long-term outcomes for selected patients receiving stents. The purpose of this study was to compare outcomes in patients receiving stents with those undergoing conventional balloon angioplasty in everyday clinical practice. Methods and Results This study uses information from the Medicare Provider Analysis and Review files for fiscal years 1994 and 1996, the first year the coronary stent code was used. For patients 65 years of age and older, 165,657 cases in 1994 and 201,869 in 1996, including 74,836 cases with stent placement, were identified. Outcomes included hospital deaths, use of same- admission coronary artery bypass surgery, and either or both. Analyses were performed separately for those with and those without a principal diagnosis of acute myocardial infarction. Hospital mortality rates were similar in both years, but the use of same-admission coronary artery bypass surgery was lower in 1996. In that year, for both patients with and those without acute myocardial infarction, hospital death and the use of same-admission coronary artery bypass surgery were lower in the stent group. Additionally, results in the stent group were generally better at high-volume (>200 cases per year) institutions, as was the case for the prestent, 1994 results. Conclusions This study documents improved short-term outcomes in older patients who undergo coronary stent placement. Stenting did not eliminate the finding of improved outcomes at high-volume centers. (Am Heart J 1999;138:437-40.) Article History: Received 22 September 1998; Accepted 14 October 1998 Article Note: (footnote) [star] From the Department of Medicine and Health Services Research and Development, Department of Veterans Affairs; and the Department of Medicine and the Department of Health Services, University of Washington., [star][star] Supported by the Department of Veterans Affairs Health Services, Research, and Development Service grant No. 99-044., a Reprint requests: James L. Ritchie, MD, Division of Cardiology, Box 356422; University of Washington, Seattle, WA 98195., aa 0002-8703/99/$8.00 + 0 4/1/96334

Young women who have a heart attack have a higher mortality rate than men their age. This was the conclusion of a study of 384,878 heart attack patients between 30 and 89 years old, 155,565 of whom were women. During their hospital stay, the mortality rate in the women less than 50 years old was more than twice the rate in men the same age. Mortality rates in young women were still higher after adjusting for the serious of the heart attack and the care the patients received.

Having to make a copayment may not necessarily reduce the use of emergency medical services. Researchers analyzed the hospital records of 1,331 people in an HMO who came to the emergency room with the signs and symptoms of a heart attack. Of these, 602 were required to make a copayment and 729 were not. A copayment requirement did not cause any significant delays in seeking medical care even after adjusting for other factors that might influence emergency room visits. Some studies have shown that copayment requirements lead to reduced use of emergency medical services.

Byline: Charles Maynard, Nathan R. Every, Jenny S. Martin, W.Douglas Weaver Abstract: The purpose of this study was to determine if less intensive use of revascularization procedures in black patients influenced the long-term survival of patients hospitalized for acute myocardial infarction (AMI) in metropolitan Seattle. From January 1988 through June 1994, AMI developed in 420 (4%) black and 10,834 white patients before hospital discharge or death. Black patients were 6 years younger, more socioeconomically disadvantaged, and had more hypertension, diabetes, and less prior coronary surgery. Similar proportions of black and white patients received thrombolytic therapy or cardiac catheterization. However, during hospitalization, 18% of black patients underwent coronary angioplasty compared with 26% of white patients (p = 0.0004); coronary artery bypass surgery was also used less frequently in black patients (7% vs 12%, p = 0.002). Unadjusted 2-year survival was 79% for black patients and 77% for white patients (p = 0.12). After adjusting for age, clinical variables, and the use of cardiac catheterization, thrombolytic therapy, and revascularization, race was not associated with long-term survival (hazard ratio = 0.92, 95% confidence interval = 0.73 to 1.17). Despite the less intensive use of revascularization procedures in black patients in Seattle, long-term survival after AMI was similar in the two groups of patients. (Am Heart J 1997;134:656-62.) Author Affiliation: Seattle, Wash., and Detroit, Mich Article History: Received 16 September 1996; Accepted 26 March 1997 Article Note: (footnote) [star] From the University of Washington, Department of Medicine, and the Henry Ford Health System., [star][star] Supported in part by grant R01HL3854 from the National Heart, Lung, and Blood Institute, Bethesda, Md., and an unrestricted grant from Genetech Inc., South San Francisco, Calif., a Charles Maynard, PhD, MITI Coordinating Center, 1910 Fairview Ave. E., Suite 205, Seattle, WA 98102., aa 4/1/82109

Treatment of acute heart attack with clot-dissolving drugs or angioplasty appears to be equally effective. Angioplasty and drugs called thrombolytics are both used to open blocked arteries. Researchers studied short-term and long-term mortality in 1,050 heart attack patients treated with angioplasty and 2,095 heart attack patients treated with thrombolytics. There was no difference in mortality between the groups in the short- or long-term. Those who received angioplasty used more resources and incurred higher costs. Thrombolytics are easy to administer and do not require technical skill.

Patients treated in hospitals with cardiac catheterization facilities were three times more likely to have coronary angiography performed after a heart attack than patients admitted to a hospital without those facilities. Coronary angiography is a diagnostic technique that uses X-rays to visualize the heart and blood vessels after the injection of a contrast medium into the veins. A review of the records of 5,867 patients admitted to 19 Seattle, WA, hospitals for treatment of heart attacks evaluated the likelihood that patients would have angiography performed. A further analysis of 614 patients treated by doctors who worked at both hospitals with the catheterization facilities and those without indicated that the doctors performed the procedure on 73% of their patients at hospitals with on-site facilities. The procedure was only performed on 47% of those admitted to hospitals without cardiac catheterization facilities. There was no association between on-site facilities and in-hospital mortality rates.

Patients with chest pain who have a normal electrocardiogram have a lower risk of dying from a heart attack than patients with an abnormal electrocardiogram. However, the mortality rate in the patients with a normal electrocardiogram was still about 6% compared to a 12% mortality rate in those with an abnormal electrocardiogram.

Heart attack patients treated with angioplasty are more likely to survive than those treated with thrombolytic drugs, but only if they are treated at hospitals with doctors who are experienced in angioplasty. This was the conclusion of a study of 62,299 patients who received either one of the treatments, both of which are used to open blocked coronary arteries.

Byline: Nathan R. Every, James L. Ritchie Author Affiliation: Seattle, Wash From the Divisions of Cardiology,.sup.aVeterans Affairs Puget Sound Health Care System, and the.sup.bUniversity of Washington School of Medicine Article Note: (footnote) [star] Reprint requests: Nathan R. Every, MD, MPH, Division of Cardiology, VA Puget Sound Health Care System, Seattle VA Medical Center, 1660 S Columbian Way, Seattle, WA 98108., [star][star] Am Heart J 1999;187;588-9. , a 0002-8703/99/$8.00 + 0 4/1/93205

Byline: Charles Maynard, Nathan R. Every Abstract: Am Heart J 1998;136:943-4. Author Affiliation: Seattle, Wash Article Note: (footnote) [star] From the Department of Medicine, Health Services Research and Development, and the Department of Veterans Affairs, Department of Medicine, University of Washington., [star][star] Reprint requests: Dr Charles Maynard, University of Washington, ADAI, Box 351415, 3937 15th Ave, NE, Seattle, WA 98105., a 4/1/91398