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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]

Comments on the push for regional treatment centers for patients with acute coronary syndromes. Planning for regionalized care begun by the State of Maryland; Presentation of concerns for this approach to patient care and possible unintended consequences; Arguments for the benefits of the ACS centers, which are based on studies with notable limitations; Lack of clear consensus on the specific nature of ACS regionalization; Risks to patients; Concerns about how the direct admission of ACS patients will be handled; Economic implications; Concern that regionalization may be the end of quality care at non-ACS facilities; Conclusion and belief there is not enough data to support the value of these centers at this time.

Context: Black patients hospitalized with heart failure reportedly receive poorer quality of care and have worse outcomes than white patients. Because previous studies have been based on selected patient populations treated more than a decade ago, it is unclear if racial differences in quality of care and outcomes currently exist in the United States. Objective: To evaluate differences in quality of care and patient outcomes between black and white Medicare beneficiaries hospitalized with heart failure. Design: Retrospective analysis of medical record data systematically collected for the National Heart Failure Project. Setting and Patients: Nationwide US sample of 29 732 fee-for-service Medicare beneficiaries hospitalized with heart failure in 1998 and 1999. Main Outcome Measures: Prescription of angiotensin-converting enzyme (ACE) inhibitors, measurement of left ventricular ejection fraction (LVEF), readmission within 1 year of discharge, and mortality within 30 days and 1 year of admission. Results: Black patients and white patients had similar crude rates of LVEF assessment (67.8% black vs 66.6% white; P = .29). Among patients classified as ideal for ACE inhibitor use, black patients had higher crude rates of ACE inhibitor use than white patients (81.0% vs 73.8% white; P<.001) but had similar rates of ACE inhibitor or angiotensin receptor blocker (ARB) use (85.7% black vs 82.5% white; P = .08). After multivariable adjustment, black patients had comparable rates of LVEF assessment (risk ratio [RR], 0.99; 95% confidence interval [CI], 0.95-1.03). Black patients remained more likely to be prescribed ACE inhibitors (RR, 1.22; 95% CI, 1.14-1.28) than were white patients in an adjusted analysis, but there were no significant racial differences in the prescription of ACE inhibitors or ARBs (black vs white, RR, 1.03; 95% CI, 0.97-1.07). Black patients had higher rates of readmission within 1 year of discharge (68.2% vs 63.0%; P<.001) but had lower crude 30-day (6... [ABSTRACT FROM AUTHOR]

The Digitalis Investigation Group (DIG) trial reported that digoxin provided no overall mortality benefit and only a modest reduction in hospitalizations among patients with heart failure and depressed left ventricular systolic function. The clinical outcomes associated with digoxin therapy at different serum concentrations in the DIG trial have not been assessed. Our objective was to assess variations in serum digoxin concentration (SDC) and their association with mortality and hospitalization in patients with heart failure. Post hoc analysis of the randomized, double-blinded, placebo-controlled DIG trial, conducted from August 1991 to December 1995, with the main analysis restricted to men with a left ventricular ejection fraction of 45% or less (n = 3782). Patients randomly assigned to receive digoxin were divided into 3 groups based on SDC at 1 month (0.5-0.8 ng/mL, n = 572; 0.9-1.1 ng/mL, n = 322; and ≥1.2 ng/mL, n = 277) and compared with patients randomly assigned to receive placebo (n = 2611). All-cause mortality at a mean follow-up of 37 months. Results: Higher SDCs were associated with increased crude all-cause mortality rates (0.5-0.8 ng/mL, 29.9%; 0.9-1.1 ng/mL, 38.8%; and ≥1.2 ng/mL, 48.0%; P = .006 for trend). Patients with SDCs of 0.5 to 0.8 ng/mL had a 6.3% (95% confidence interval [CI], 2.1%-10.5%) lower mortality rate compared with patients receiving placebo. Digoxin was not associated with a reduction in mortality among patients with SDCs of 0.9 to 1.1 ng/mL (2.6% increase; 95% CI, - 3.0% to 8.3%), whereas patients with SDCs of 1.2 ng/mL and higher had an 11.8% (95% CI, 5.7%-18.0%) higher absolute mortality rate than patients receiving placebo. The association between SDC and mortality persisted after multivariable adjustment (SDC 0.5-0.8 ng/mL hazard ratio [HR] 0.80, 95% CI, 0.68-0.94; SDC 0.9-1.1 ng/mL HR 0.89, 95% CI, 0.74-1.08; SDC ≥1.2 ng/mL HR 1.16, 95% CI, 0... [ABSTRACT FROM AUTHOR]

Reports on a study to investigate the relationship between patient sex, physician sex, and the use of cardiac procedures, specifically whether sex differences in cardiac catheterization after acute myocardial infarcation (AMI) were greater when patients were treated by male attending physicians compared with female physicians. Methods; Results; Conclusion suggesting that factors other than sexual bias by male physicians toward women account for sex differences in cardiac procedure use.

OBJECTIVE--To evaluate the relationship between A1C and glucose therapy intensification (GTI) in patients with diabetes mellitus (DM) hospitalized for acute myocardial infarction (AMI). RESEARCH DESIGN AND METHODSdA1C was measured as part of routine care (clinical A1C) or in the core laboratory (laboratory A1C, results unavailable to clinicians). GTI predictors were identified using hierarchical Poisson regression. RESULTS--Of 1,274 patients, 886 (70%) had clinical A1C and an additional 263 had laboratory A1C measured. Overall, A1C was <7% in 419 (37%), 7-9% in 415 (36%), and >9% in 315 patients (27%). GTI occurred in 31% of patients and was more frequent in those with clinical A1C both before (34 vs. 24%, P < 0.001) and after multivariable adjustment (relative risk 1.34 [95% CI 1.12-1.62] vs. no clinical A1C). CONCLUSIONS--Long-term glucose control is poor in most AMI patients with DM, but only a inority of patients undergo GTI at discharge. Inpatient A1C assessment is strongly associated with intensification of glucose-lowering therapy. [ABSTRACT FROM AUTHOR]

Evaluates the recruitment for clinical research candidates based on race or ethnic group. Concerns raised by the low participation by minorities in random trials; Efforts to standardize clinical research in the U.S., Japan and Europe; View that studies should be conducted to ascertain reasons for low participation of minorities.

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]

Background: Although increased attention has been paid to sex and racial differences in the management of myocardial infarction, it is unknown whether these differences have narrowed over time. Methods: With the use of data from the National Registry of Myocardial Infarction, we examined sex and racial differences in the treatment of patients who were deemed to be “ideal candidates” for particular treatments and in deaths among 598,911 patients hospitalized with myocardial infarction between 1994 and 2002. Results: In the unadjusted analysis, sex and racial differences were observed for rates of reperfusion therapy (for white men, white women, black men, and black women: 86.5, 83.3, 80.4, and 77.8 percent, respectively; P<0.001), use of aspirin (84.4, 78.7, 83.7, and 78.4 percent, respectively; P<0.001), use of beta-blockers (66.6, 62.9, 67.8, and 64.5 percent; P<0.001), and coronary angiography (69.1, 55.9, 64.0, and 55.0 percent; P<0.001). After multivariable adjustment, racial and sex differences persisted for rates of reperfusion therapy (risk ratio for white women, black men, and black women: 0.97, 0.91, and 0.89, respectively, as compared with white men) and coronary angiography (relative risk, 0.91, 0.82, and 0.76) but were attenuated for the use of aspirin (risk ratio, 0.97, 0.98, and 0.94) and beta-blockers (risk ratio, 0.98, 1.00, and 0.96); all risks were unchanged over time. Adjusted in-hospital mortality was similar among white women (risk ratio, 1.05; 95 percent confidence interval, 1.03 to 1.07) and black men (risk ratio, 0.95; 95 percent confidence interval, 0.89 to 1.00), as compared with white men, but was higher among black women (risk ratio, 1.11; 95 percent confidence interval, 1.06 to 1.16) and was unchanged over time. Conclusions: Rates of reperfusion therapy, coronary angiography, and in-hospital death after myocardial infarction, but not the use of aspirin and beta-blockers, vary according to race and sex, with no evidence that the differences have narrowed in recent years. N Engl J Med 2005;353:671-82. [ABSTRACT FROM AUTHOR]

Background: The Digitalis Investigation Group trial reported that treatment with digoxin did not decrease overall mortality among patients with heart failure and depressed left ventricular systolic function, although it did reduce hospitalizations slightly. Even though the epidemiologic features, causes, and prognosis of heart failure vary between men and women, sex-based differences in the effect of digoxin were not evaluated. Methods: We conducted a post hoc subgroup analysis to assess whether there were sex-based differences in the effect of digoxin therapy among the 6800 patients in the Digitalis Investigation Group study. The presence of an interaction between sex and digoxin therapy with respect to the primary end point of death from any cause was evaluated with the use of Mantel–Haenszel tests of heterogeneity and a multivariable Cox proportional-hazards model, adjusted for demographic and clinical variables. Results: There was an absolute difference of 5.8 percent (95 percent confidence interval, 0.5 to 11.1) between men and women in the effect of digoxin on the rate of death from any cause (P=0.034 for the interaction). Specifically, women who were randomly assigned to digoxin had a higher rate of death than women who were randomly assigned to placebo (33.1 percent vs. 28.9 percent; absolute difference, 4.2 percent, 95 percent confidence interval, –0.5 to 8.8). In contrast, the rate of death was similar among men randomly assigned to digoxin and men randomly assigned to placebo (35.2 percent vs. 36.9 percent; absolute difference, –1.6 percent; 95 percent confidence interval, –4.2 to 1.0). In the multivariable analysis, digoxin was associated with a significantly higher risk of death among women (adjusted hazard ratio for the comparison with placebo, 1.23; 95 percent confidence interval, 1.02 to 1.47), but it had no significant effect among men (adjusted hazard ratio, 0.93; 95 percent confidence interval, 0.85 to 1.02; P=0.014 for the interaction). Conclusions: The effect of digoxin therapy differs between men and women. Digoxin therapy is associated with an increased risk of death from any cause among women, but not men, with heart failure and depressed left ventricular systolic function. (N Engl J Med 2002;347:1403-11.) [ABSTRACT FROM AUTHOR]

Background: Anemia may have adverse effects in patients with coronary artery disease. However, the benefit of blood transfusion in elderly patients with acute myocardial infarction and various degrees of anemia is uncertain. Methods: We conducted a retrospective study of data on 78,974 Medicare beneficiaries 65 years old or older who were hospitalized with acute myocardial infarction. Patients were categorized according to the hematocrit on admission (5.0 to 24.0 percent, 24.1 to 27.0 percent, 27.1 to 30.0 percent, 30.1 to 33.0 percent, 33.1 to 36.0 percent, 36.1 to 39.0 percent, or 39.1 to 48.0 percent), and data were evaluated to determine whether there was an association between the use of transfusion and 30-day mortality. Results: Patients with lower hematocrit values on admission had higher 30-day mortality rates. Blood transfusion was associated with a reduction in 30-day mortality among patients whose hematocrit on admission fell into the categories ranging from 5.0 to 24.0 percent (adjusted odds ratio, 0.22; 95 percent confidence interval, 0.11 to 0.45) to 30.1 to 33.0 percent (adjusted odds ratio, 0.69; 95 percent confidence interval, 0.53 to 0.89). It was not associated with a reduction in 30-day mortality among those whose hematocrit values fell in the higher ranges. In one of seven subgroup analyses (among patients who survived at least two days), transfusion was not associated with a reduction in mortality for patients with hematocrit values of 30.1 percent or higher. Conclusions: Blood transfusion is associated with a lower short-term mortality rate among elderly patients with acute myocardial infarction if the hematocrit on admission is 30.0 percent or lower and may be effective in patients with a hematocrit as high as 33.0 percent on admission. (N Engl J Med 2001;345:1230-6.) [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Racial Difference in the Use of Cardiac Catheterization After Acute Myocardial Infarction," by J. Chen, S. S. Rathore, M. J. Radford, et al, in the May 10, 2007 issue.

The article offers information on a study which determined the link between lack of health insurance and financial concerns about accessing care among those with health insurance, and the time from symptom onset to hospital presentation during acute myocardial infarction (AMI). Data analyzed by researchers were from a registry of AMI patients enrolled between April 11, 2005 and December 31, 2008 at 24 U.S. hospitals. Medical records were utilized to determine insurance information, while information on financial concerns was taken from structured interviews. A detailed discussion on the research findings is presented.

The article presents a study which investigates the survival impact of regionalization of acute myocardial infarction (AMI) care on percutaneous coronary intervention (PCI) hospitals in the U.S. Risk-standardized mortality rates (RSMRs) between PCI hospitals and non-PCI hospitals within the same health care regions were analyzed. The study suggests that regionalizing AMI care to PCI hospitals can reduce mortality rates, however, survival outcomes varies across the regions.

Current guidelines recommend patients with ST-elevation myocardial infarction receive primary percutaneous coronary intervention (PCI) within 90 minutes of admission, although there are conflicting data regarding the relation between time to treatment and mortality in these patients. We used logistic regression analyses employing a fractional polynomial model to evaluate the association between door-to-balloon time and 1-year mortality in patients with ST-elevation myocardial infarction > or =65 years old undergoing primary PCI from 1994 to 1996 (n = 1,932). Median door-to-balloon time was 128 minutes (interquartile range 92 to 178, 24.2% treated within 90 minutes). Overall 1-year mortality was 21.1%. Longer door-to-balloon times were associated with higher 1-year mortality in a continuous, nonlinear fashion (30 minutes 10.9%, 60 minutes 13.6%, 90 minutes 16.5%, 120 minutes 19.5%, 150 minutes 22.5%, 180 minutes 25.3%, 210 minutes 27.9%). The nature of the association between door-to-balloon time and 1-year mortality was best modeled by a second-degree fractional polynomial (p <0.001). Findings were similar after multivariable adjustment as any increase in door-to-balloon time was associated with successive increases in patients' 1-year mortality (30 minutes 8.8%, 60 minutes 12.9%, 90 minutes 16.6%, 120 minutes 19.9%, 150 minutes 22.9%, 180 minutes 25.5%, 210 minutes 27.7%). In conclusion, any delay in primary PCI is associated with increased 1-year mortality, suggesting efforts should focus on decreasing time to treatment as much as possible, even among those centers currently providing primary PCI within 90 minutes. [ABSTRACT FROM AUTHOR]

The article focuses on a study which estimated the racial differences in survival for patients with in-hospital cardiac arrests. The study also examined the link between sociodemographic and clinical factors, and admitting hospital. It included 10,011 patients diagnosed with cardiac arrests due to ventricular fibrillation or pulseless ventricular tachycardia. Such patients were from 274 hospitals within the National Registry of Cardiopulmonary Resuscitation. Study authors found that rates of survival to discharge are lower in black patients compared to white patients. They concluded that the racial difference in survival rates was associated with hospital center.

Objectives: We evaluated whether appropriateness and baseline risk of cardiac catheterization varied according to regional intensity of invasive therapy after acute myocardial infarction (AMI), and whether AMI mortality varied according to invasive intensity regions. Background: Marked regional variations exist in cardiac invasive procedure use after AMI within the U.S. Methods: We performed an analysis of 44,639 Medicare fee-for-service beneficiaries hospitalized with AMI between 1998 and 2001. Invasive procedure intensity was determined based on overall cardiac catheterization rates for Medicare enrollees. Cardiac catheterization appropriateness was determined by the American College of Cardiology/American Heart Association classification and baseline risk was estimated using the GRACE (Global Registry of Acute Coronary Events) risk score. The primary outcomes of the study were cardiac catheterization use within 60 days and 3-year mortality after hospital admission. Results: Higher invasive intensity regions were more likely to perform cardiac catheterizations on class I patients (appropriate) (RR 1.38, 95% confidence interval [CI] 1.27 to 1.48), class II patients (equivocal) (RR 1.42, 95% CI 1.31 to 1.53), and class III patients (inappropriate) (RR 1.29, 95% 0.97 to 1.67) compared with low-intensity regions after adjusting for patient and physician characteristics. The overall cardiac catheterization use was 5.2% lower for each increase in GRACE risk decile, and this relationship was observed similarly in all regions. Risk-standardized mortality rates of AMI patients at 3 years were not substantially different between regions. Conclusions: Although higher-risk patients and those with more appropriate indications may have the most to benefit from an invasive strategy after AMI, we found that higher-invasive regions do not differentiate procedure selection based on the patients’ appropriateness or their baseline risks. [Copyright &y& Elsevier]

Fibrinolytic therapy is the most common reperfusion strategy for patients with ST-segment elevation myocardial infarction (STEMI), particularly in smaller centers. Previous studies evaluated the relation between time to treatment and outcomes when few patients were treated within 30 minutes of hospital arrival and many did not receive modern adjunctive medications. To quantify the impact of a delay in door-to-needle time on mortality in a recent and representative cohort of patients with STEMI, a cohort of 62,470 patients with STEMI treated using fibrinolytic therapy at 973 hospitals that participated in the National Registry of Myocardial Infarction from 1999 to 2002 was analyzed. Hierarchical models were used to evaluate the independent effect of door-to-needle time on in-hospital mortality. In-hospital mortality was lower with shorter door-to-needle times (2.9% for ≤30 minutes, 4.1% for 31 to 45 minutes, and 6.2% for >45 minutes; p <0.001 for trend). Compared with those experiencing door-to-needle times ≤30 minutes, adjusted odd ratios (ORs) of dying were 1.17 (95% confidence interval [CI] 1.04 to 1.31) and 1.37 (95% CI 1.23 to 1.52; p for trend <0.001) for patients with door-to-needle times of 31 to 45 and >45 minutes, respectively. This relation was particularly pronounced in those presenting within 1 hour of symptom onset to presentation time (OR 1.25, 95% CI 1.01 to 1.54; OR 1.54, 95% CI 1.27 to 1.87, respectively; p for trend <0.001). In conclusion, timely administration of fibrinolytic therapy continues to significantly impact on mortality in the modern era, particularly in patients presenting early after symptom onset. [Copyright &y& Elsevier]

Objectives: We tested the hypothesis that one health status measure, the Kansas City Cardiomyopathy Questionnaire (KCCQ), provides prognostic information independent of other clinical data in outpatients with heart failure (HF). Background: Health status measures are used to describe a patient’s clinical condition and have been shown to predict mortality in some populations. Their prognostic value may be particularly useful among patients with HF for identifying candidates for disease management in whom increased care may reduce hospitalizations and prevent death. Methods: We evaluated 505 HF patients from 13 outpatient clinics who had an ejection fraction <40% using the KCCQ summary score. Proportional hazards regression was used to evaluate the association between the KCCQ summary score (range, 0 to 100; higher scores indicate better health status) and the primary outcome of death or HF admission, adjusting for baseline patient characteristics, 6-min walk distance, and B-type natriuretic peptide (BNP). Results: The mean age was 61 years, 76% of patients were male, 51% had an ischemic HF etiology, and 5% were New York Heart Association functional class IV. At 12 months, among the 9% of patients with a KCCQ score <25, 37% had been admitted for HF and 20% had died, compared with 7% (HF admissions) and 5% (death) of those with a KCCQ score ≥75 (33% of patients, p < 0.0001 for both comparisons). In sequential multivariable models adjusting for clinical variables, 6-min walk, and BNP levels, the KCCQ score remained significantly associated with survival free of HF hospitalization. Conclusions: A low KCCQ score is an independent predictor of poor prognosis in outpatients with HF. [Copyright &y& Elsevier]

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 © 2014 Mosby, Inc. All rights reserved.)

Background: Previous studies have described an "obesity paradox" with heart failure, whereby higher body mass index (BMI) is associated with lower mortality. However, little is known about the impact of obesity on survival after acute myocardial infarction., Methods: Data from 2 registries of patients hospitalized in the US with acute myocardial infarction between 2003-2004 (PREMIER) and 2005-2008 (TRIUMPH) were used to examine the association of BMI with mortality. Patients (n=6359) were categorized into BMI groups (kg/m(2)) using baseline measurements. Two sets of analyses were performed using Cox proportional hazards regression with fractional polynomials to model BMI as categorical and continuous variables. To assess the independent association of BMI with mortality, analyses were repeated, adjusting for 7 domains of patient and clinical characteristics., Results: Median BMI was 28.6. BMI was inversely associated with crude 1-year mortality (normal, 9.2%; overweight, 6.1%; obese, 4.7%; morbidly obese; 4.6%; P <.001), which persisted after multivariable adjustment. When BMI was examined as a continuous variable, the hazards curve declined with increasing BMI and then increased above a BMI of 40. Compared with patients with a BMI of 18.5, patients with higher BMIs had a 20% to 68% lower mortality at 1 year. No interactions between age (P=.37), sex (P=.87), or diabetes mellitus (P=.55) were observed., Conclusions: There appears to be an "obesity paradox" among patients after acute myocardial infarction such that higher BMI is associated with lower mortality, an effect that was not modified by patient characteristics and was comparable across age, sex, and diabetes subgroups., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 United States centers from 2003 through 2004, to assess the association of living alone with outcomes after AMI. Outcome measurements included 4-year mortality, 1-year readmission, and 1-year health status using the Seattle Angina Questionnaire (SAQ) and the Short Form-12 Physical Health Component scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs 14.5%, p <0.001) but comparable rates of 1-year readmission (41.6% vs 38.3%, p = 0.79). Living alone was associated with lower unadjusted quality of life (mean SAQ -2.40, 95% confidence interval [CI] -4.44 to -0.35, p = 0.02) but had no impact on Short Form-12 Physical Health Component (-0.45, 95% CI -1.65 to 0.76, p = 0.47) compared to patients who did not live alone. After multivariable adjustment, patients who lived alone had a comparable risk of mortality (hazard ratio 1.35, 95% CI 0.94 to 1.93) and readmission (hazard ratio 0.99, 95% CI 0.76 to 1.28) as patients who lived with others. Mean quality-of-life scores remained lower in patients who lived alone (SAQ -2.91, 95% CI -5.56 to -0.26, p = 0.03). In conclusion, living alone may be associated with poorer angina-related quality of life 1 year after MI but is not associated with mortality, readmission, or other health status measurements after adjusting for other patient and treatment characteristics., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Prior research reports black patients have lower medication use for hypercholesterolemia, hypertension, and diabetes., Objective: To assess whether patient race influences physicians' prescribing., Design: Web-based survey including three clinical vignettes (hypercholesterolemia, hypertension, diabetes), with patient race (black, white) randomized across vignettes., Subjects: A total of 716 respondents from 5,141 eligible sampled primary care physicians (14% response rate)., Interventions: None, Measurements: Medication recommendation (any medication vs none, on-patent branded vs generic, and therapeutic class) and physicians' treatment adherence forecast (10-point Likert scale, 1-definitely not adhere, 10-definitely adhere)., Results: Respondents randomized to view black patients (n = 371) and white patients (n = 345) recommend any medications at comparable rates for hypercholesterolemia (100.0% white vs 99.5% black, P = 0.50), hypertension (99.7% white vs 99.5% black, P = 1.00), and diabetes (99.7% white vs 99.7% black, P = 1.00). Patient race influenced medication class chosen in the hypertension vignette; respondents randomized to view black patients recommended calcium channel blockers more often (20.8% black vs 3.2% white) and angiotensin-converting enzyme inhibitors less often (47.4% black vs 62.6% white) (P < 0.001). Patient race did not influence medication class for hypercholesterolemia or diabetes. Respondents randomized to view black patients reported lower forecasted patient adherence for hypertension (P < 0.001, mean: 7.3 black vs 7.7 white) and diabetes (P = 0.05 mean: 7.4 black vs 7.6 white), but race had no meaningful influence on forecasted adherence for hypercholesterolemia (P = 0.15, mean: 7.2 black vs 7.3 white)., Conclusion: Racial differences in outpatient prescribing patterns for hypertension, hypercholesterolemia, and diabetes are likely attributable to factors other than prescribing decisions based on patient race.

Objective: To evaluate the association between door-to-balloon time and mortality in hospital in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction to assess the incremental mortality benefit of reductions in door-to-balloon times of less than 90 minutes., Design: Prospective cohort study of patients enrolled in the American College of Cardiology National Cardiovascular Data Registry, 2005-6., Setting: Acute care hospitals., Participants: 43 801 patients with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention., Main Outcome Measure: Mortality in hospital., Results: Median door-to-balloon time was 83 minutes (interquartile range 6-109, 57.9% treated within 90 minutes). Overall mortality in hospital was 4.6%. Multivariable logistic regression models with fractional polynomial models indicated that longer door-to-balloon times were associated with a higher adjusted risk of mortality in hospital in a continuous non-linear fashion (30 minutes=3.0%, 60 minutes=3.5%, 90 minutes=4.3%, 120 minutes=5.6%, 150 minutes=7.0%, 180 minutes=8.4%, P<0.001). A reduction in door-to-balloon time from 90 minutes to 60 minutes was associated with 0.8% lower mortality, and a reduction from 60 minutes to 30 minutes with a 0.5% lower mortality., Conclusion: Any delay in primary percutaneous coronary intervention after a patient arrives at hospital is associated with higher mortality in hospital in those admitted with ST elevation myocardial infarction. Time to treatment should be as short as possible, even in centres currently providing primary percutaneous coronary intervention within 90 minutes.