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ABSTRACTBackground: Diabetes mellitus (DM) in a setting of acute myocardial infarction (AMI) is associated with significant metabolic changes and worse outcomes.Objective: To evaluate the prevalence and the prognostic significance of electrolyte/metabolite disturbances among AMI patients with vs. without DM.Methods: Patients admitted to a tertiary medical center with AMI throughout 2002–2012 were screened. Exclusion criteria were: dialysis, mechanical ventilation, and in-hospital coronary artery bypass graft (CABG) surgery. All the results of the following analyses were obtained: Glucose, Uric Acid, (UA) Calcium, Magnesium, Albumin, Potassium, and Sodium. The primary outcome was in-hospital all-cause mortality.Results: A total of 14,364 AMI patient admissions was evaluated, mean age 68.1 ± 14.4 years, 65.5% males, and 41.2% with DM. Following an adjustment to potential confounders, DM patients had increased risk for significant hyperglycemia, hyperuricemia, hypercalcemia, hypomagnesemia, hyperkalemia, and hyponatremia as well as significantly decreased risk for hypoglycemia, hypermagnesemia, and hypokalemia compared with nondiabetics. Overall, 681 (4.7%) patients died throughout the index admission. Deceased had an increased incidence of electrolyte/metabolite abnormalities versus hospital survivors. The prognostic significance of the different categories of the investigated variables is very similar among diabetics and nondiabetics, except increased and decreased uric acid levels [<4.5 (men); <4.0 (women) and ≥9.0 (men); ≥9.4 (women)] which are associated with worse outcomes among diabetics while hyperglycemia (Glucose ≥213 mg/dL) and increased Potassium levels (Potassium ≥4.4mEq/L) which comprise significantly worse prognosis among nondiabetics.Conclusions: Patients with DM admitted with AMI are at greater risk for electrolyte/metabolite abnormalities which are associated with increased risk for in-hospital mortality. The latter association is similar among patients with and without DM except for hyperglycemia and increased potassium levels (stronger among nondiabetics).

AbstractThe need for population-based studies of adults with CHD has motivated the growing use of secondary analyses of administrative health data in a variety of jurisdictions worldwide. We aimed at systematically reviewing all studies using administrative health data sources for adult CHD research from 2006 to 2016. Using PubMed and Embase (1 January, 2006 to 1 January, 2016), we identified 2217 abstracts, from which 59 studies were included in this review. These comprised 12 different data sources from six countries. Of these, 55% originated in the United States of America, 28% in Canada, and 17% in Europe and Asia. No study was published before 2007, after which the number of publications grew exponentially. In all, 41% of the studies were cross-sectional and 25% were retrospective cohort studies with a wide variation in the availability of patient-level compared with hospitalisation-level episodes of care; 58% of studies from eight different data sources linked administrative data at a patient level; and 37% of studies reported validation procedures. Assessing resource utilisation and temporal trends of relevant epidemiological and outcome end points were the most reported objectives. The median impact factor of publication journals was 4.04, with an interquartile range of 3.15, 7.44. Although not designed for research purposes, administrative health databases have become powerful data sources for studying adult CHD populations because of their large sample sizes, comprehensive records, and long observation periods, providing a useful tool to further develop quality of care improvement programmes. Data linkage with electronic records will become important in obtaining more granular life-long adult CHD data. The health services nature of the data optimises the impact on policy and public health.

Background: Prasugrel has proved its superiority over clopidogrel for reducing ischemic events among patients with ST elevation myocardial infarction (STEMI) undergoing urgent percutaneous coronary intervention (PCI). Data on switching of antiplatelet therapy in acute coronary syndrome patients in clinical practice are very limited. Importantly, the safety of in-hospital switching from clopidogrel to prasugrel following thrombolysis has not been addressed.Methods: We reviewed consecutive STEMI patients from February 2011 to April 2014 who were transferred to a tertiary center after receiving thrombolysis and a loading dose of clopidogrel in a non-PCI-capable center. If not contraindicated, these patients were reloaded and treated with prasugrel. A control group, three times larger, was selected from patients who underwent primary PCI and were initially treated with prasugrel. In-hospital outcomes were examined.Results: Cases (n=45, 13% female, mean age 56 years) and controls (n=135, 11% female, mean age 54 years) did not differ significantly with respect to MI location, left ventricular systolic function, and extent of coronary artery disease. Mean time from thrombolysis to prasugrel loading was 32±19 hours. No significant differences were found between cases and controls in TIMI major or minor bleeding (0% vs. 3%), overall mortality (0% vs. 1.5%), and hospitalization length (4.8 vs. 5.5 days).Conclusions: In-hospital reloading and subsequent maintenance therapy with prasugrel in patients who received thrombolysis and a loading dose of clopidogrel appears to be as safe as in STEMI patients managed by primary PCI; however, larger studies are needed to verify these results.

Concomitant treatment with amiodarone and perhsexiline has been considered to be relatively contraindicated because of the hypothetical risk of potentiated adverse effects mediated by additive inhibition of carnitine palmitoyl transferase 1.

While clinical reminders can promote adherence with evidence-based clinical guidelines, they may have unintended consequences such as alert fatigue, false alarms and increased workload, which cause clinicians to ignore them. We evaluated clinicians' response rates to suggestions to enroll patients in a nationwide clinical reminders intervention, aiming to promote prevention of clinical arthrosclerosis. Analysis of 203, 164 suggestions for 108, 636 patients showed that the clinicians mostly ignored suggestions from the system and followed only 21.4% of the inclusion suggestions. The data show that when physicians could choose for which patients the reminders will be generated, they mostly chose not to include patients in the clinical reminders intervention. It seems that they tried to abort the process as soon as possible, rather than complete the workflow orderly. Insights regarding the usability of clinical reminders are discussed.

Introduction:Frequent fluctuations in hemoglobin A1c (HbA1C) values are independent predictors of diabetic complications and patient outcomes.Objective:To evaluate the prognostic significance of HbA1Clevels and its changes among diabetic patients after non-fatal AMI.Methods:Patients with diabetes mellitus (DM) who were admitted to a tertiary medical center with AMI throughout 2002-2017 and survived >1year thereafter were evaluated. All the results of HbA1Cvalues during the follow-up period (up to 10-years after discharge) were obtained and analyzed. The changes (Δ) of HbA1Cwere calculated for all pairs of tests in each patient. The time interval of ΔHbA1Cvalues was classified as rapid (<1 year) and slow (≥1 year) change. The outcome was all-cause mortality.Results:A total of 4,066 patients were analyzed, mean age 66.4±11.9 years, 36% females. A U-shaped association was observed between HbA1C and mortality: adjOR=1.887 and adjOR=1.302 for HbA1C<5.5% and ≥8.0% respectively, as compared with 5.5-6.5% (p<0.001). A U-shaped independent association between ΔHbA1Cand long-term survival was found: adjOR=2.376 and adjOR=1.340 for the groups of <-2.5% and ≥2.5% HbA1Cchanges respectively (p<0.001 for each), as compared to the group of minimal ΔHbA1C(±0.5%). Rapid increase in HbA1C(but not decrease) following AMI was associated with greater risk for mortality.Conclusions:HbA1Cvalues, its changes and their rate are significant independent prognostic markers for long-term all-cause mortality with a U-shaped association following non-fatal AMI among DM patients. Thus, ΔHbA1Cand its timing, in addition to absolute HbA1Cvalues should be monitored among these patients.

Human Factors research on warning systems may have relevance beyond the specific domain of operators receiving warnings about potential problems in technological systems. We present an analysis of physicians' responses to letters generated by an automated decision support system in terms of findings in the human factors literature on warnings. The automated system mails reminders to primary medical teams about patients requiring screening or lipid-lowering drugs. The effectiveness of the system depends, among other factors, on physicians' responses to the reminders. Some properties of the reminder letter have parallels in warning systems. They should affect physicians' responses as they affect the responses of operators of technological systems. We report the results of preliminary analyses of data after a 16 months follow-up of 6,571 patients. The compliance rate to recommendations in the letters in the intervention group, in which physicians receive reminder letters, was significantly higher than in the control group. Physicians in the control group were found to be less compliant as the number of their patients requiring the medical care grows. In contrast, physicians in the intervention group, who received the reminder letters, maintained similar levels of compliance irrespective of the number of patients who required their care. Thus the letters appear to provide valuable information for physicians who have to cope with more difficult patient populations.