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Background: Randomized clinical trials (RCTs) suggest benefits for the transradial approach to percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). However, transradial PCI may delay reperfusion, leading to its avoidance. We sought to quantify the delay in reperfusion from transradial PCI (“transradial delay”) that would need to be introduced to offset the potential mortality benefit of transradial PCI, compared with transfemoral, observed in RCTs. Methods: We developed a decision-analytic model to compare transfemoral and transradial PCI in STEMI. Thirty-day mortality rates were estimated by pooling STEMI patients from 2 RCTs comparing transfemoral and transradial PCI. We projected the impact of transradial delay using estimates of the increase in mortality associated with door-to-balloon time delays. Sensitivity analyses were performed to understand the impact of uncertainty in assumptions. Results: In the base case, a transradial delay of 83.0 minutes was needed to offset the mortality benefit of transradial PCI. When the mortality benefit of transradial PCI was one-quarter that observed in RCTs, the delay associated with equivalent mortality was 20.9 minutes. In probabilistic sensitivity analyses, transradial PCI was preferred over transfemoral PCI in 97.5% of simulations when transradial delay was 30 minutes and in 79.0% of simulations when delay was 60 minutes. Conclusions: A substantial transradial delay is required to eliminate even a fraction of the mortality benefit observed with transradial PCI in RCTs. Results were robust to changing multiple assumptions and have implications for operators reluctant to transition to transradial PCI in STEMI because of concern for delaying reperfusion. [Copyright &y& Elsevier]

The article discusses research on the use of intra-aortic balloon pumps (IABP) in hospitals among high risk percutaneous coronary intervention (PCI) patients and its impact on mortality. High risk PCI has many features, including unprotected left main artery as the primary target. Variaion in the use of IABP did not have impact on in-hospital mortality.

Background: Anemia is common among patients hospitalized with acute myocardial infarction and is associated with poor outcomes. Less is known about the incidence, correlates, and prognostic implications of acute, hospital-acquired anemia (HAA).Methods and Results: We identified 2909 patients with acute myocardial infarction who had normal hemoglobin (Hgb) on admission in the multicenter TRIUMPH registry and defined HAA by criteria proposed by Beutler and Waalen. We used hierarchical Poisson regression to identify independent correlates of HAA and multivariable proportional hazards regression to identify the association of HAA with mortality and health status. At discharge, 1321 (45.4%) patients had HAA, of whom 348 (26.3%) developed moderate-severe HAA (Hgb <11 g/dL). The incidence of HAA varied significantly across hospitals (range, 33% to 69%; median rate ratio for HAA, 1.13; 95% confidence interval, 1.07 to 1.23, adjusting for patient characteristics). Although documented bleeding was more frequent with more severe HAA, fewer than half of the patients with moderate-severe HAA had any documented bleeding. Independent correlates of HAA included age, female sex, white race, chronic kidney disease, ST-segment elevation myocardial infarction, acute renal failure, use of glycoprotein IIb/IIIa inhibitors, in-hospital complications (cardiogenic shock, bleeding and bleeding severity), and length of stay. After adjustment for GRACE score and bleeding, patients with moderate-severe HAA had higher mortality rates (hazard ratio, 1.82; 95% confidence interval, 1.11 to 2.98 versus no HAA) and poorer health status at 1 year.Conclusions: HAA develops in nearly half of acute myocardial infarction hospitalizations among patients treated medically or with percutaneous coronary intervention, commonly in the absence of documented bleeding, and is associated with worse mortality and health status. Better understanding of how HAA can be prevented and whether its prevention can improve patient outcomes is needed. [ABSTRACT FROM AUTHOR]

The article discusses a study on the use of hierarchical regression models in assessing the rates of risk-standardized mortality and readmission of patients with heart failure in hospitals identified in the "America's Best Hospitals" ranking by the periodical "U.S. News & World Report" and in those non-ranked facilities. The study noted there was a reduced mean rate of in-hospital mortality in ranked hospitals, compared to non-ranked ones. It is said that ranked hospitals have not shown enough evidence of superiority for readmission.

Background: Patients of low socioeconomic status (SES) have higher mortality after acute myocardial infarction (AMI). Little is known about the underlying mechanisms or the relationship between SES and rehospitalization after AMI. Methods: We analyzed data from the PREMIER observational study, which included 2142 patients hospitalized with AMI from 18 US hospitals. Socioeconomic status was measured by self-reported household income and education level. Sequential multivariable modeling assessed the relationship of socioeconomic factors with 1-year all-cause mortality and all-cause rehospitalization after adjustment for demographics, clinical factors, and quality-of-care measures. Results: Both household income and education level were associated with higher risk of mortality (hazard ratio 2.80, 95% CI 1.37-5.72, lowest to highest income group) and rehospitalization after AMI (hazard ratio 1.55, 95% CI 1.17-2.05). Patients with low SES had worse clinical status at admission and received poorer quality of care. In multivariable modeling, the relationship between household income and mortality was attenuated by adjustment for demographic and clinical factors (hazard ratio 1.19, 95% CI 0.54-2.62), with a further small decrement in the hazard ratio after adjustment for quality of care. The relationship between income and rehospitalization was only partly attenuated by demographic and clinical factors (hazard ratio 1.38, 95% CI 1.01-1.89) and was not influenced by adjustment for quality of care. Conclusions: Patients'' baseline clinical status largely explained the relationship between SES and mortality, but not rehospitalization, among patients with AMI. [Copyright &y& Elsevier]

Background: Prior studies have reported conflicting findings concerning the association of socioeconomic status (SES), treatment, and outcomes in patients hospitalized with heart failure (HF).Methods: We conducted a retrospective analysis of medical record data from a national sample of Medicare beneficiaries hospitalized with HF between March 1998 and April 1999 (n = 25,086) to assess the association of patient SES, treatment, and outcomes. Patients' SES was designated as lower, lower-middle, higher-middle, and higher using residential ZIP code characteristics. Patients were evaluated for left ventricular systolic function assessment, prescription of angiotensin-converting enzyme inhibitors at discharge, readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission. Hierarchical logistic regression models were used to assess the association of SES, quality of care, and outcomes adjusting for patient, physician, and hospital characteristics.Results: Lower SES patients (relative risk [RR] 0.92, 95% CI 0.87-0.96) were modestly less likely to have had a left ventricular systolic function assessment, but had a similar adjusted likelihood of being prescribed angiotensin-converting enzyme inhibitors (RR 1.03, 95% CI 0.93-1.11) compared with higher SES patients after multivariable adjustment. Socioeconomic status was not associated with 30-day mortality after multivariable adjustment, but lower SES patients had a higher risk of 1-year mortality (RR 1.10, 95% CI 1.02-1.19) and readmission within 1 year of discharge (RR 1.08, 95% CI 1.03-1.12) compared with higher SES patients.Conclusions: Socioeconomic status in patients hospitalized with HF was not strongly associated with quality of care or 30-day mortality. However, the increased risk of 1-year mortality and readmission among patients of lower SES suggest SES may influence outcomes after hospitalization for HF. [ABSTRACT FROM AUTHOR]

Background: The TIMI ST-elevation myocardial infarction (STEMI) score was developed and validated in a randomized controlled trial population. We sought to assess its accuracy in a community-based cohort of elderly patients hospitalized with STEMI.Methods: We evaluated the TIMI STEMI score in 47,882 patients aged > or = 65 years hospitalized with STEMI in US hospitals from 1994 to 1996. We assessed TIMI STEMI score discrimination and calibration for 30-day mortality and compared observed and published TIMI mortality rates.Results: The cohort's median TIMI score was 6 (25th-75th percentile 4, 8). Thirty-day mortality rates were higher among patients with higher TIMI scores (TIMI score 2: 4.4% vs TIMI score > 8: 35.6%, P < .0001 for trend). However, the TIMI score provided only modest discrimination (c = 0.67) and calibration (goodness-of-fit P < .0001). Mortality rates for TIMI scores differed between patients who did and did not receive reperfusion therapy (P < .0001 for TIMI score x reperfusion therapy interaction). Thirty-day mortality rates in the cohort were higher than published TIMI estimates (P = .001; eg, TIMI score 2: 4.4% cohort vs 2.2% published rate).Conclusions: The TIMI score provided modest prognostic discrimination and calibration among elderly patients with STEMI. Our findings highlight the difficulties in applying risk scores developed in randomized controlled trial cohorts to elderly patients. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although B-type natriuretic peptide (BNP) levels have been proposed as a means of assessing disease severity in patients with heart failure, it is not known if BNP levels are correlated with health status (symptom burden, functional limitation, and quality of life). Methods and Results: We studied 342 outpatients with systolic heart failure from 14 centers at baseline and 6 ± 2 weeks with BNP levels and the Kansas City Cardiomyopathy Questionnaire (KCCQ), a heart-failure-specific health status instrument. We assessed the correlation between KCCQ scores and BNP at baseline and changes in KCCQ according to changes in BNP levels between baseline and follow-up. Mean baseline BNP levels were 379 ± 387 pg/mL and mean KCCQ summary scores were 62 ± 23 points. Although baseline BNP and KCCQ were both associated with New York Heart Association classification (P < .001 for both), BNP and KCCQ were not correlated (r2 =0.008, P =.15). There was no significant relationship between changes in BNP and KCCQ regardless of the threshold used to define a clinically meaningful BNP change. For example, using >50% BNP change threshold, KCCQ improved by 3.7 ± 14.2 in patients with decreasing BNP, improved by 1.7 ± 13.6 in patients with no BNP change, and improved by 1.0 ± 13.4 in patients with increasing BNP (P =.6). Conclusion: BNP and health status are not correlated in outpatients with heart failure in the short term. This suggests that these measures may assess different aspects of heart failure severity, and that physiologic measures do not reflect patients'' perceptions of the impact of heart failure on their health status. [Copyright &y& Elsevier]

Background: 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. Methods: Using data from the National Registry of Myocardial Infarction-2 and -3, a cohort of patients hospitalized with MI in the United States between 1994 and 2000, we sought to determine whether racial differences in reperfusion therapy use varied by geographic region in patients eligible for reperfusion therapy with no clinical contraindications to treatment (n = 204230). Results: Black patients had lower crude rates of reperfusion therapy than white patients (66.5% vs 69.9%, −3.3% racial difference, 99% CI −4.4% to −2.2%) overall. However, racial differences in reperfusion therapy use varied by geographic region. Reperfusion therapy rates were similar for black patients and white patients in the Northeast (67.9% black vs 65.3% white, +2.7% racial difference, 99% CI −0.5% to 5.8%) and statistically comparable for patients in the Midwest (68.3% black vs 69.0% white, −0.7% racial difference, 99% CI −2.9% to 1.5%) and West (70.7% black vs 72.6% white, −1.9% racial difference, 99% CI −5.1% to 1.2%). Racial differences in reperfusion therapy use were greatest for patients hospitalized in the South (64.5% black vs 71.7% white, −7.1% racial difference, 99% CI −8.7% to −5.6%). Racial differences were reduced, but geographic variations in racial differences persisted after multivariable adjustment. Conclusions: Lower rates of reperfusion therapy use among black patients with MI do not reflect a national pattern of racial differences in treatment, but a practice pattern predominantly attributable to the South. [Copyright &y& Elsevier]

Background: The Centers for Medicare and Medicaid Services provides public reporting on the quality of hospital care for patients with acute myocardial infarction (AMI). The Centers for Medicare and Medicaid Services Core Measures allow discretion in excluding patients because of relative contraindications to aspirin, β-blockers, and angiotensin-converting enzyme inhibitors. We describe trends in the proportion of patients with AMI with contraindications that could lead to discretionary exclusion from public reporting. Methods: We completed cross-sectional analyses of 3 nationally representative data cohorts of AMI admissions among Medicare patients in 1994-1995 (n = 170,928), 1998-1999 (n = 27,432), and 2000-2001 (n = 27,300) from the national Medicare quality improvement projects. Patients were categorized as ineligible (eg, transfer patients), automatically excluded (specified absolute medical contraindications), discretionarily excluded (potentially excluded based on relative contraindications), or “ideal” for treatment for each measure. Results: For 4 of 5 measures, the percentage of discretionarily excluded patients increased over the 3 periods (admission aspirin 15.8% to 16.9%, admission β-blocker 14.3% to 18.3%, discharge aspirin 10.3% to 12.3%, and angiotensin-converting enzyme inhibitors 2.8% to 3.9%; P < .001). Of patients potentially included in measures (those who were not ineligible or automatically excluded), the discretionarily excluded represented 25.5% to 69.2% in 2000-2001. Treatment rates among patients with discretionary exclusions also increased for 4 of 5 measures (all except angiotensin-converting enzyme inhibitors). Conclusions: A sizeable and growing proportion of patients with AMI have relative contraindications to treatments that may result in discretionary exclusion from publicly reported quality measures. These patients represent a large population for which there is insufficient evidence as to whether measure exclusion or inclusion and treatment represents best care. [Copyright &y& Elsevier]