Percutaneous radiologic, surgical endoscopic, and percutaneous endoscopic gastrostomy/gastrojejunostomy: comparative study and cost analysis

PURPOSE

To compare the results and costs of three different means of achieving direct percutaneous gastroenteric access.

METHODS

Three groups of patients received the following procedures: fluoroscopically guided percutaneous gastrostomy/gastrojejunostomy (FPG, n = 42); percutaneous endoscopic gastrostomy/gastrojejunostomy (PEG, n = 45); and surgical endoscopic gastrostomy/gastrojejunostomy (SEG, n = 34). Retrospective review of the medical records was performed to evaluate indications for the procedure, procedure technical success, and outcome. Estimated costs were compared for each of the three procedures, using a combination of charges and materials costs.

RESULTS

Technical success was greater for FPG and SEG (100% each) than for PEG (84%, p = 0.008 vs FPG and p = 0.02 vs SEG). All patients (n = 7) who failed PEG subsequently underwent successful FPG. Success in placing a gastrojejunostomy was 91% for FPG, and estimated at 43% for PEG and 0 for SEG. Complications did not differ in frequency among groups. For gastrostomy, the average cost per successful tube was lowest in the PEG group ($1862, p = 0.02); FPG averaged $1985, and SEG $3694. SEG costs significantly more than FPG or PEG (p = 0.0001). For gastrojejunostomy, FPG averaged $2201, PEG $3158, and SEG $3045.

CONCLUSION

Technical success for gastrostomy is higher for FPG and SEG than PEG. Though PEG is the least costly procedure, the difference is modest compared with FPG. For gastrojejunostomy, FPG offers the highest technical success rate and lowest cost. Due to high costs associated with the operating room, SEG should be reserved for those patients undergoing a concurrent surgical procedure.

Influence of payor on use of invasive cardiac procedures and patient outcome after myocardial infarction in the United States. Participants in the National Registry of Myocardial Infarction

OBJECTIVES

We sought to determine the influence of payor status on the use and appropriateness of cardiac procedures.

BACKGROUND

The use of invasive procedures affects the cost of cardiovascular care and may be influenced by payor status.

METHODS

We compared treatment and outcomes of myocardial infarction among four payor groups: fee for service (FFS), health maintenance organization (HMO), Medicaid and uninsured. Multivariate comparison was performed on the use of invasive cardiac procedures, length of hospital stay and in-hospital mortality in 17,600 patients <65 years old enrolled in the National Registry of Myocardial Infarction from June 1994 to October 1995. To determine the appropriateness of coronary angiography, we compared its use in patients at low and high risk for cardiac events.

RESULTS

Angiography was performed in 86% of FFS, 80% of HMO, 61% of Medicaid and 75% of uninsured patients. FFS patients were more likely to undergo angiography than HMO (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13 to 1.42), Medicaid (OR 2.43, 95% CI 2.11 to 2.81) and uninsured patients (OR 1.99, 95% CI 1.76 to 2.25). Similar patterns for the use of coronary revascularization were found. Among those at low risk, FFS patients were as likely to undergo angiography as HMO patients but more likely than Medicaid and uninsured patients. For those at high risk, FFS patients were more likely to undergo angiography than patients in other payor groups. Adjusted mean length of stay (7.3 days) was similar among all payor groups, but adjusted mortality was higher in the Medicaid group (Medicaid vs. FFS: OR 1.55, 95% CI 1.19 to 2.01).

CONCLUSIONS

Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction. The higher in-hospital mortality in the Medicaid cohort merits further study.

Observations of the treatment of women in the United States with myocardial infarction: a report from the National Registry of Myocardial Infarction-I

BACKGROUND

To determine whether there are sex differences in the demographics, treatment, and outcome of patients with acute myocardial infarction in the United States, data from the National Registry of Myocardial Infarction-I from September 1990 to September 1994 were examined.

METHODS

The National Registry of Myocardial Infarction-I is a national observational database consisting of 1234 US hospitals in which each hospital submits data from each patient with acute myocardial infarction to a central data collection center. For these analyses, the following variables were examined in 354 435 patients with acute myocardial infarction: demographics; use of medical therapy including thrombolytic agents; use of procedures including cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery; length of hospital stay; adverse events (stroke, major bleeding, or recurrent myocardial infarction); and causes of death.

RESULTS

In comparison with men, women experiencing acute myocardial infarction in the United States are older, with 55.7% older than 70 years. Women have a higher mortality rate than men even when controlled for age and die less often from arrhythmia but more often from cardiac rupture whether or not thrombolytic therapy is used. Treatment with aspirin, heparin, or beta-blockers is less frequent in women. When thrombolytic therapy is used, women are treated an average of almost 14 minutes later than men and experience a greater incidence of major bleeding. Cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass surgery are used less often in women.

CONCLUSIONS

Observations from the National Registry of Myocardial Infarction-I document important sex differences in demographics, treatment, and outcome of patients with acute myocardial infarction in the United States.

Early assessment and in-hospital management of patients with acute myocardial infarction at increased risk for adverse outcomes: a nationwide perspective of current clinical practice. The National Registry of Myocardial Infarction (NRMI-2) Participants

BACKGROUND

Therapeutic decision making in critically ill patients requires both prompt and comprehensive analysis of available information. Data derived from randomized clinical trials provide a powerful tool for risk assessment in the setting of acute myocardial infarction (MI); however, timely and appropriate use of existing therapies and resources are the key determinants of outcome among high-risk patients.

METHODS

Demographic, procedural, and outcome data from patients with MI were collected at 1073 U.S. hospitals collaborating in the National Registry of MI (NRMI 2). Patients were classified on hospital arrival as either "low risk" or "high risk" according to a modified Thrombolysis in Myocardial Infarction II Risk Scale based on predetermined demographic, electrocardiographic, and clinical features.

RESULTS

Among the 170,143 patients enrolled, 115,222 (67.5%) were classified as low risk and 55,521 (32.5%) as high risk for in-hospital death, recurrent ischemia, recurrent MI, congestive heart failure, and stroke. Using a composite unsatisfactory outcome measure, in-hospital adverse events were had by a greater proportion of patients initially classified as high risk compared with those classified as low risk. By multivariate analysis, age >70 years, prior MI, Killip class >1, anterior site of infarction, and the combination of hypotension and tachycardia were independent predictions of poor outcome in patients with or without ST-segment elevation on the presenting electrocardiogram. High-risk patients with ST-segment elevation were treated with thrombolytics (47.5%) or alternative forms of reperfusion therapy (9.3%) within 62 minutes and 226 minutes of hospital arrival, respectively. High-risk patients offered reperfusion therapy were also more likely to receive aspirin, beta-blockers (intravenous, oral) and angiotensin-converting enzyme inhibitors within 24 hours of infarction (all p < 0.0001), survive their event (8.4% versus 21.4% p < 0.0001), and leave the hospital sooner than those not reperfused.

CONCLUSIONS

This large registry experience included more than 150,000 nonselected patients with MI and suggests that high-risk patients can be identified on initial hospital presentation. The current use of reperfusion and adjunctive therapies among high-risk patients is suboptimal and may directly influence outcome. Randomized trials designed to test the impact of specific management strategies on outcome according to initial risk classification are warranted.

Clinical experience with primary percutaneous transluminal coronary angioplasty compared with alteplase (recombinant tissue-type plasminogen activator) in patients with acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2)

OBJECTIVES

We sought to compare outcomes after primary percutaneous transluminal coronary angioplasty (PTCA) or thrombolytic therapy for acute myocardial infarction (MI).

BACKGROUND

Primary PTCA and thrombolytic therapy are alternative means of achieving reperfusion in patients with acute MI. The Second National Registry of Myocardial Infarction (NRMI-2) offers an opportunity to study the clinical experience with these modalities in a large patient group.

METHODS

Data from NRMI-2 were reviewed.

RESULTS

From June 1, 1994 through October 31, 1995, 4,939 nontransfer patients underwent primary PTCA within 12 h of symptom onset, and 24,705 patients received alteplase (recombinant tissue-type plasminogen activator [rt-PA]). When lytic-ineligible patients and patients presenting in cardiogenic shock were excluded, baseline characteristics were similar. The median time from presentation to initiation of rt-PA in the thrombolytic group was 42 min; the median time to first balloon inflation in the primary PTCA group was 111 min (p < 0.0001). In-hospital mortality was higher in patients in shock after rt-PA than after PTCA (52% vs. 32%, p < 0.0001). In-hospital mortality was the same in lytic-eligible patients not in shock: 5.4% after rt-PA and 5.2% after PTCA. The stroke rate was higher after lytic therapy (1.6% vs. 0.7% after PTCA, p < 0.0001), but the combined end point of death and nonfatal stroke was not significantly different between the two groups (6.2% after rt-PA and 5.6% after PTCA). There was no difference in the rate of reinfarction (2.9% after rt-PA and 2.5% after PTCA).

CONCLUSIONS

These findings suggest that in lytic-eligible patients not in shock, PTCA and rt-PA are comparable alternative methods of reperfusion when analyzed in terms of in-hospital mortality, mortality plus nonfatal stroke and reinfarction.

Use of reperfusion therapy for acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2

BACKGROUND

There is clear evidence that reperfusion therapy improves survival in selected patients with an acute myocardial infarction. However, several studies have suggested that many patients with an acute myocardial infarction do not receive this therapy. Whether this underutilization occurs in patients appropriate for such therapy remains unclear.

METHODS AND RESULTS

We examined the use of reperfusion therapy in patients with an acute myocardial infarction hospitalized at 1470 hospitals participating in the National Registry of Myocardial Infarction 2. We identified 84 663 patients who were eligible for reperfusion therapy as defined by diagnostic changes on the initial 12-lead ECG, presentation to the hospital within 6 hours from symptom onset, and no contraindications to thrombolytic therapy. Twenty-four percent of these eligible patients did not receive any form of reperfusion therapy (7.5% of all patients). When multivariate analyses were used, left bundle-branch block (odds ratio [OR]=0.22; 95% CI=0.20 to 0.24), lack of chest pain at presentation (OR=0.22; 95% CI=0.21 to 0.24), age >75 years (OR=0.40, 95% CI=0.36 to 0.43), female sex (OR=0.88, 95% CI=0.83 to 0.92), and various preexisting cardiovascular conditions were independent predictors that the patient would not receive reperfusion therapy.

CONCLUSIONS

Reperfusion therapy may be underutilized in the United States. Increased use of reperfusion therapy could potentially reduce the unnecessarily high mortality rates observed in women, the elderly, and other patient groups with the highest risk of death from an acute myocardial infarction.

Health-related quality of life in patients served by the Department of Veterans Affairs: results from the Veterans Health Study

BACKGROUND

The Department of Veterans Affairs Health Care System (VA) is the largest integrated single payer system in the United States. To date, there has been no systematic measurement of health status in the VA. The Veterans Health Study has developed methods to assess patient-based health status in ambulatory populations.

OBJECTIVES

To describe the health status of veterans and examine the relationships between their health-related quality of life, age, comorbidity, and socioeconomic and service-connected disability status.

METHODS

Participants in the Veterans Health Study, a 2-year longitudinal study, were recruited from a representative sample of patients receiving ambulatory care at 4 VA facilities in the New England region. The Veterans Health Study patients received questionnaires of health status, including the Medical Outcomes Study Short Form 36-Item Health Survey; and a health examination, clinical assessments, and medical history taking. Sixteen hundred sixty-seven patients for whom we conducted baseline assessments are described.

RESULTS

The VA outpatients had poor health status scores across all measures of the Medical Outcomes Study Short Form 36-Item Health Survey compared with scores in non-VA populations (at least 50% of 1 SD worse). Striking differences also were found with the sample stratified by age group (20-49 years, 50-64 years, and 65-90 years). For 7 of the 8 scales (role limitations due to physical problems, bodily pain, general health perceptions, vitality, social functioning, role limitations due to emotional problems, and mental health), scores were considerably lower among the younger patients; for the eighth scale (physical function), scores of the young veterans (aged 20-49 years) were almost comparable with the levels in the old veterans (>65 years). The mental health scores of young veterans were substantially worse than all other age groups (P<.001) and scores of screening measures for depression were significantly higher in the youngest age group (51%) compared with the oldest age groups (33% and 16%) (P<.001).

CONCLUSIONS

The VA outpatients have substantially worse health status than non-VA populations. Mental health differences between the young and old veterans who use the VA health care system are sharply contrasting; the young veterans are sicker, suggesting substantially higher resource needs. Mental health differences may explain much of the worse health-related quality of life in young veterans. As health care systems continue to undergo a radical transformation, the Department of Veterans Affairs should focus on the provision of mental health services for its younger veteran.

The importance of radiating leg pain in assessing health outcomes among patients with low back pain. Results from the Veterans Health Study

STUDY DESIGN

Cross-sectional data were analyzed from the Veterans Health Study, an observational study of patients receiving ambulatory care.

OBJECTIVE

To develop a method of stratifying patients with low back pain by combining patient reports of radiating leg pain with the results of straight leg raising tests.

SUMMARY AND BACKGROUND DATA

Four hundred thirty-four participants with low back pain were identified through patient reports of ever having had low back pain, of low back pain that began more than 3 months ago, and of a health-care visit for low back pain in the past year. Four hundred twenty-eight patients with low back pain were included in the current analysis.

METHODS

Participants were mailed a health-related quality of life questionnaire and had an interview that included a low back pain questionnaire and a straight leg raising test. Patients' reports of radiating leg pain and results of the straight leg raising tests were combined into four hierarchical groups. This stratification was evaluated in relation to responses to the health-related quality of life questionnaire, localized low back pain, disability, and use of medical services.

RESULTS

The intensity of localized low back pain and disability increased from Group 1 (low back pain alone) to Group 4 (pain below knee with positive straight leg raising test result), whereas health-related quality of life decreased. Group 4 patients were 5.1 times more likely than were Group 1 patients to use medications for low back pain (95% confidence interval 1.2, 22.9), 6.8 times more likely to have a spinal magnetic resonance study (95% confidence interval, 2.7, 17.2), and 3.9 times more likely to have surgery (95% confidence interval, 1.3, 11.4).

CONCLUSIONS

The method of measuring correlation performs well in identifying patients with different levels of localized low back pain intensity, health-related quality of life, and use of services. It may be useful in studies of health outcomes, in clinical trials, and in predicting demands on health care resources.

Comparing generic and disease-specific measures of physical and role functioning: results from the Veterans Health Study

OBJECTIVES

This study compared the performance of generic measures of Medical Outcome Study Short Form 36-Item Health Survey physical functioning and role limitations with disease-specific measures of physical functioning and role limitations using specific disease attributions for chronic lung disease, chronic low back pain, and osteoarthritis of the knee.

METHODS

Data were analyzed from the Veterans Health Study among patients receiving Veteran's Administration ambulatory care. Patients identified as having one of the three study conditions were included in the study (n = 932).

RESULTS

The study revealed that the generic physical functioning and role limitations scales had higher correlations with other generic SF-36 scales, whereas disease-specific attribution measures had larger R2 values in explaining variability in symptom-based disease severity and larger t statistic values in discriminating the impacts of patients taking medications and having surgery.

CONCLUSIONS

The generic measures of physical functioning and role limitations were more applicable in assessing a broad array of health-related quality-of-life issues, whereas disease-specific measures of physical functioning and role limitations were more useful in evaluating clinical management and limitations associated with specific disease conditions. The results of the study suggest that the use of disease-specific attribution assessments was more cost-efficient than the development of new disease-specific instruments. Disease-specific attribution could be used to complement generic measures in assessing patient outcomes.

Relation of coagulation parameters to patency and recurrent ischemia in the Thrombolysis in Myocardial Infarction (TIMI) Phase II Trial

Current protocols for use of tissue-type plasminogen activator in acute myocardial infarction include heparin estimated by the activated partial thromboplastin time (aPTT). Recent reports indicate a risk of recurrent ischemic events with long aPTT values. Longer aPTT values in the Thrombolysis in Myocardial Infarction-II (TIMI II) Trial, obtained within the first 48 hours, were associated with patency at 18 to 48 hours and better left ventricular function at discharge (average 9.6 days), but also with emergency catheterizations within the first 48 hours and, weakly, with recurrent ischemia during the first 18 hours. A moderate decrease in fibrinogen, compared with a "small" decrease, was also associated with patency, but a "large" decrease was associated with hemorrhagic events. Patency was associated with higher fibrinogen values and higher plasminogen values at baseline. The aPTT results support frequent monitoring during the first 24 to 48 hours to ensure optimal clinical outcome. The coagulation factor results suggest that there may be an optimum window for fibrinogenolysis in this setting.

Factors influencing the time to thrombolysis in acute myocardial infarction. Time to Thrombolysis Substudy of the National Registry of Myocardial Infarction-1

BACKGROUND

The Time to Thrombolysis Substudy of the National Registry for Myocardial Infarction provided the opportunity to identify factors that delay thrombolytic treatment of patients with ST-segment elevation acute myocardial infarction.

PARTICIPANTS

Forty-two participating registry hospitals volunteered for the Time to Thrombolysis Substudy.

METHODS

A case report form was developed to collect time points for emergency department arrival (door), recording of the electrocardiogram (ECG) (data), entry of the order to give a thrombolytic drug (decision), and initiation of the thrombolytic infusion (drug) as defined by the National Heart Attack Alert Program. The impact of mode of transportation to the hospital, sex, policy-driven cardiology consultation and/or contact of the primary care physician on door-to-drug time, and each component interval were determined in 1755 patients who were treated with recombinant tissue-type plasminogen activator (A1-teplase). The t test was used for comparison of means and the nonparametric sign test was used for medians.

RESULTS

A minority of patients arrived at the hospital by ambulance, although more women (49.6%) arrived by ambulance than men (40.9%). However, women arrived at hospitals significantly later after onset of symptoms than men. It took half as long for patients arriving by ambulance to be seen by the physician than those who transported themselves to the hospital. It took longer for women to have the initial 12-lead ECG recorded than men. The decision to order a thrombolytic agent was delayed by 22 minutes and median door-to-drug time by 21 minutes in those patients who had a cardiac consultation over those in whom the drug was ordered and infusion was initiated by the emergency physician. Although the initial 12-lead ECG showed ST-segment elevation in 86% of patients who received the thrombolytic drugs, with no difference between men and women and no difference in the rate of cardiology consultation between men and women (77%), door-to-decision time and door-to-drug time were substantially longer for women having consultation than men. There was no significant difference in door-to-decision time between men and women when no consultation was performed, but it still took longer for a drug infusion to be initiated in women. Contacting the primary care physician delayed the decision to give a thrombolytic drug by 18 minutes and the administration of the drug by 20 minutes, but there were no differences between men and women. Preparation of the drug in the pharmacy resulted in significant delay compared with mixing it in the emergency department.

CONCLUSIONS

Hospital practices and policies, including contacting the primary care physician prior to the initiation of a lytic drug, cardiology consultation, and preparation of the drug in the pharmacy rather than in the emergency department, significantly delay the goal of early treatment of patients with ST segment elevation acute myocardial infarction. Delays in hospital arrival for women are compounded by delays in the decision to treat them with a thrombolytic drug and initiation of the drug therapy in those women who receive consultation compared with men. Other delays in acquiring the first ECG and initiating the drug infusion in women are not explained.

Dissociation between changes in intramyocardial function and left ventricular volumes in the eight weeks after first anterior myocardial infarction

OBJECTIVES

We sought to examine the relation between regional changes in intramyocardial function and global left ventricular (LV) remodeling in the first 8 weeks after reperfused first anterior myocardial infarction (MI).

BACKGROUND

Because of limitations in imaging methods used to date, this relation has not been thoroughly evaluated.

METHODS

We studied 26 patients (21 men, 5 women; mean age 51 years) by magnetic resonance imaging (MRI) on day 5 +/- 2 (mean +/- SD) and week 8 +/- 1 after their first anterior MI. All patients had single-vessel left anterior descending coronary artery disease and although they had received reperfusion therapy, all had regional LV dysfunction and an initial ejection fraction (EF) < or = 50%. Short-axis magnetic resonance tagging was performed spanning the LV. Percent intramyocardial circumferential shortening (%S) on a topographic basis, LV mass index, LV end-diastolic volume index (LVEDVI), LV end-systolic volume index and LV ejection fraction (LVEF) were measured.

RESULTS

Left ventricular mass index tended to decrease, whereas the LVEDVI increased from 82 +/- 24 to 96 +/- 27 ml/m2 (p = 0.002). Left ventricular end-systolic volume index remained unchanged, whereas LVEF increased from 39 +/- 12% to 45 +/- 14% (p = 0.002). Apical %S improved from 9 +/- 6% to 13 +/- 5% (p < 0.0001), as it did in the midanterior (6 +/- 6% to 10 +/- 7%, p < 0.02) and midseptal regions (8 +/- 7% to 12 +/- 6%, p < 0.02). Early dysfunction in remote midinferior and basal lateral regions resolved by 8 weeks. By multivariate analysis, the only significant predictor of an increase in LVEDVI over the study period was peak creatine kinase (p = 0.04).

CONCLUSIONS

In the first 8 weeks after a large, reperfused anterior MI, %S improved in the apex, midanterior and midseptal regions and normalized in remote noninfarct-related regions, but LV end-diastolic volumes also increased. This increased LVEDVI correlated with infarct size by peak creatine kinase and was not related to changes in global and regional LV function.

Cognitive function 5 years after randomization to coronary angioplasty or coronary artery bypass graft surgery

BACKGROUND

Coronary bypass surgery often leads to short-term cognitive dysfunction, whereas coronary angioplasty does not. Perioperative cognitive dysfunction usually resolves, although a subgroup of surgical patients may continue to exhibit long-term cognitive dysfunction. The purpose of this study was to compare cognitive function 5 years after randomization to a strategy of either initial coronary surgery or initial angioplasty.

METHODS AND RESULTS

Five centers in the Bypass Angioplasty Revascularization Investigation participated in this ancillary study. Patients with multivessel coronary disease randomized to angioplasty or surgery were eligible at the time of their 5-year clinic visit. A battery of five measures previously shown to be sensitive to perioperative changes in cognitive function was administered, including the Logical and Figural Memory Scales from the Wechsler Memory Scale, the Digit Symbol and Digit Span subtests from the Wechsler Adult Intelligence Scale, and Part B of the Reitan Trail Making Test. The 125 study patients were generally similar to the 133 patients who were eligible but did not participate, although study participants were significantly younger (P=.003). The 64 patients randomly assigned to angioplasty had baseline characteristics similar to those of 61 patients randomly assigned to surgery. Cognitive function scores were not significantly different between angioplasty or surgery patients in an intention-to-treat analysis (P=.57). There also was no difference in cognitive function scores when the data were analyzed according to whether the patient had ever undergone bypass surgery (P=.59).

CONCLUSIONS

Long-term cognitive function is similar after coronary bypass surgery and coronary angioplasty in the majority of patients.

Breath-hold dobutamine magnetic resonance myocardial tagging: normal left ventricular response

Analysis of the changes in myocardial deformation produced by adrenergic stress has been limited by the imaging techniques used. We used rapid magnetic resonance imaging (MRI) myocardial tagging to map the dose-dependent response to incremental dobutamine in the normal human left ventricle. Thirteen volunteers underwent breath-hold tagged cine MRI during dobutamine infusion. Images were acquired throughout systole to a peak dose of 20 microg/kg/min. End-systolic percent circumferential shortening (%S) was measured at 3 transmural locations and 4 circumferential locations at 3 long-axis positions. Mean circumferential shortening velocity (CSV) was also calculated at each location and dose. Mean %S reached a maximum of 26 +/- 3% at 10 microg/kg/min compared with 21 +/- 4% at baseline (p <0.003). Peak %S was reached by 10 microg/kg/min before a significant increase in heart rate or blood pressure and was unchanged at higher doses. In contrast, CSV increased linearly with dobutamine dose from 4.4 +/- 0.9 mm/s at baseline to 9.8 +/- 1.4 mm/s at 20 microg/kg/min (p <0.0001). Breath-hold tagged dobutamine MRI is safe and effective in detecting regional and transmural changes in function during incremental dobutamine. CSV increased continuously across the dobutamine dose range. At low dose (< or =10 microg/kg/min) %S increased without any change in blood pressure or heart rate. Maintenance of peak %S beyond 10 microg/kg/min in the presence of decreasing systolic intervals resulted from a continued increase in CSV. Thus, CSV may be the preferred measure of contractile function during dobutamine stimulation in human myocardium.

Myocardial infarction and cardiac mortality in the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial

BACKGROUND

Cardiac mortality and myocardial infarction (MI) rates are used to evaluate the efficacy of coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA). We compared 5-year cardiac mortality and MI rates in 1829 patients with multivessel disease randomized to CABG or PTCA.

METHODS AND RESULTS

The 5-year cardiac mortality rate was 8.0% in patients assigned to PTCA compared with 4.9% in those assigned to CABG (relative risk [RR] of 1.55 with a 95% confidence interval [CI] of 1.07 to 2.23; P=.022). In a subgroup of 1476 nondiabetic patients, there were no significant differences between treatment groups in cardiac mortality either overall (4.6% versus 4.2%; RR= 1.04, 95% CI, 0.65 to 1.66; P=.908) or in subgroups based on symptoms, left ventricular function, number of diseased vessels, or stenotic proximal left anterior descending artery. The two treatment groups had similar event rates for the combined end point of cardiac death or MI. The RR for cardiac mortality in 264 patients who sustained an MI compared with those who did not was 5.9 (P<.001). MIs were more common after CABG during index hospitalization (P=.004), but in the PTCA group, they were more common after discharge (P<.001).

CONCLUSIONS

The Bypass Angioplasty Revascularization Investigation (BARI) trial indicates 5-year cardiac mortality in patients with multivessel disease was significantly greater after initial treatment with PTCA than with CABG. The difference was manifest in diabetic patients on drug therapy. There were no significant differences overall for the composite end point of cardiac mortality or MI between treatment groups or for cardiac mortality in nondiabetic patients regardless of symptoms, left ventricular function, number of diseased vessels, or stenotic proximal left anterior descending artery.

Reduced sympathetic innervation underlies adjacent noninfarcted region dysfunction during left ventricular remodeling

OBJECTIVES

We examined the association of sympathetic denervation and reduced blood flow with mechanical dysfunction in adjacent noninfarcted regions late after myocardial infarction (MI).

BACKGROUND

Using a well characterized ovine model of left ventricular (LV) remodeling after transmural anteroapical MI, we previously showed that histologically normal adjacent noninfarcted regions demonstrate mechanical dysfunction.

METHODS

Ten sheep underwent coronary ligation. Magnetic resonance imaging was performed before and 8 weeks after infarction for measurement of LV mass, volumes, ejection fraction and regional intramyocardial circumferential shortening (%S). Iodine-123 metaiodobenzylguanidine (I-123 MIBG) and fluorescent microspheres before and after administration of adenosine were infused before death for measurement of sympathetic innervation, blood flow and blood flow reserve from matched postmortem regions.

RESULTS

From baseline to 8 weeks after infarction, LV end-diastolic volume increased from (mean +/- SD) 1.5 +/- 0.3 to 2.6 +/- 0.5 ml/kg (p < 0.001), and LV mass increased from 2.0 +/- 0.3 to 2.6 +/- 0.5 g/kg (p = 0.001). Regionally, the decline in subendocardial %S was greater in adjacent (19 +/- 5% to 8 +/- 5%) than in remote noninfarcted regions (20 +/- 6% to 19 +/- 6%, p < 0.002). No difference in regional blood flow or blood flow reserve was found between adjacent and remote regions, whereas I-123 MIBG uptake was lower in adjacent than in remote myocardium (1.09 +/- 0.30 vs. 1.31 +/- 0.40 nmol/g, p < 0.003). Topographically, from apex to base at 8 weeks after infarction, %S correlated closely with I-123 MIBG uptake (r = 0.93, p = 0.003).

CONCLUSIONS

In mechanically dysfunctional noninfarcted regions adjacent to chronic transmural myocardial infarction in the remodeled left ventricle, blood flow and blood flow reserve are preserved, yet sympathetic innervation is reduced. Chronic sympathetic denervation in adjacent noninfarcted regions, in association with regional mechanical dysfunction, may contribute to LV remodeling after infarction.

Usefulness of magnetic resonance imaging early after acute myocardial infarction

In patients, early after acute myocardial infarction (AMI), rapid magnetic resonance imaging (MRI) techniques have been used to assess left ventricular (LV) structure, global and regional function, infarct artery patency, or contrast uptake individually. We hypothesized that MRI could be used as a comprehensive evaluation of the post-AMI patient, studying all of these parameters in < 1 hour. Twenty-seven patients were studied after first AMI. Complete examinations were performed in 23 patients, 16 with anterior and 7 with inferior wall myocardial infarction, on day 5 +/- 2 after the event. For measurement of LV structure and regional function, a breath-hold segmented k-space gradient echo tagging sequence was used. A fat-suppressed segmented k-space breath-hold sequence was used for coronary artery imaging. MRI contrast-enhanced images during bolus gadoteridol transit through the myocardium were obtained to assess first-pass contrast uptake. No adverse events were noted during the MRI scanning, which was completed in 46 +/- 5 minutes. The LV mass index, end-diastolic and end-systolic volume indexes, and ejection fraction were (mean +/- SD) 107 +/- 13 g/m2, 87 +/- 23 ml/m2, 54 +/- 20 ml/m2, and 39 +/- 12%, respectively. Intramyocardial percent circumferential shortening was 11 +/- 6% at the apex, 14 +/- 4% in the midventricle, and 15 +/- 4% at the base. Flow within all infarct arteries was visualized. Seventeen of 23 patients had regions of reduced contrast uptake on first-pass imaging with mean signal intensity of 47 +/- 24% that of remote regions. In patients with recent AMI, comprehensive assessment of LV structure and function, infarct artery patency, and regional myocardial contrast uptake was safe and feasible with MRI of < 1 hour.

The electrocardiogram predicts one-year outcome of patients with unstable angina and non-Q wave myocardial infarction: results of the TIMI III Registry ECG Ancillary Study. Thrombolysis in Myocardial Ischemia

OBJECTIVES

We sought to determine the prognostic value of the admission electrocardiogram (ECG) in patients with unstable angina and non-Q wave myocardial infarction (MI).

BACKGROUND

Although the ECG is the most widely used test for evaluating patients with unstable angina and non-Q wave MI, little prospective information is available on its value in predicting outcome in the current era of aggressive medical and interventional therapy.

METHODS

ECGs with the qualifying episode of pain were analyzed in patients enrolled in the Thrombolysis in Myocardial Ischemia (TIMI) III Registry, a prospective study of patients admitted to the hospital with unstable angina or non-Q wave MI.

RESULTS

New ST segment deviation > or = 1 mm was present in 14.3% of 1,416 enrolled patients, isolated T wave inversion in 21.9% and left bundle branch block (LBBB) in 9.0%. By 1-year follow-up, death or MI occurred in 11% of patients with > or = 1 mm ST segment deviation compared with 6.8% of patients with new, isolated T wave inversion and 8.2% of those with no ECG changes (p < 0.001 when comparing ST with no ST segment deviation). Two other high risk groups were identified: those with only 0.5-mm ST segment deviation and those with LBBB, whose rates of death or MI by 1 year were 16.3% and 22.9%, respectively. On multivariate analysis, ST segment deviation of either > or = 1 mm or > or = 0.5 mm remained independent predictors of death or MI by 1 year.

CONCLUSIONS

The admission ECG is very useful in risk stratifying patients with non-Q wave MI. The new criteria of not only > or = 1-mm ST segment deviation but also > or = 0.5-mm ST segment deviation or LBBB identify high risk patients, whereas T wave inversion does not add to the clinical history in predicting outcome.

A symptom-based measure of the severity of chronic lung disease: results from the Veterans Health Study

STUDY OBJECTIVES

We developed a symptom-based measure of severity for chronic lung disease (CLD) that can be readily administered in ambulatory care settings and be used to supplement general health-related quality of life (HRQoL) assessments and pathophysiologic indicators in research and clinical care.

DESIGN

Cross-sectional data from the Veterans Health Study, an observational study of health outcomes in patients receiving Veterans Affairs (VA) ambulatory care.

SETTING

Four VA outpatient clinics.

STUDY SUBJECTS

Two hundred ninety-two participants with CLD were identified on the basis of patient report of having a physician's diagnosis of chronic bronchitis, emphysema, or asthma and either using inhaled medications or having a productive cough on most days for 3 months.

MEASUREMENTS AND RESULTS

Participants were scheduled for an in-person interview in which they completed a CLD questionnaire and measurements of peak expiratory flow rate (PEFR). They were also mailed an HRQoL questionnaire, the Short Form Health Survey (SF-36). The CLD questionnaire included six symptom items chosen by an expert panel (two items each for dyspnea, wheezing, and productive cough). The combination of these items yielded a CLD severity index that correlated significantly with all eight scales of the SF-36 (range of r, -0.19 to -0.37; p<0.01). In contrast, PEFR had statistically significant correlations only with two SF-36 scales: physical functioning and bodily pain.

CONCLUSIONS

The CLD severity index is a reliable and valid patient-administered instrument that may be used to evaluate the effects of CLD on general HRQoL and predict future health services utilization.

Relation between clinical, angiographic and ischemic findings at baseline and ischemia-related adverse outcomes at 1 year in the Asymptomatic Cardiac Ischemia Pilot study. ACIP Study Group

OBJECTIVES

We attempted to investigate the relation between patient characteristics and adverse outcome in patients with ischemia and clinically stable coronary artery disease (CAD).

BACKGROUND

Evidence suggests that cardiac ischemia, detected by exercise stress testing (ETT) and ambulatory electrocardiographic (AECG) monitoring during daily living, identifies a subgroup of patients at increased risk for adverse outcome, but the relation between these ischemia findings and clinical and angiographic characteristics is largely unknown.

METHODS

We examined the relation between clinical, angiographic and ischemia characteristics at entry with adverse outcome observed at 1 year in the 558 patients enrolled in the Asymptomatic Cardiac Ischemia Pilot (ACIP) study.

RESULTS

By the 12-month visit 13.1% of patients had an ischemia-related adverse clinical outcome that included death, nonfatal myocardial infarction or an ischemia-related hospital admission. Multivariate analysis identified only the number of AECG ischemic episodes at entry (odds ratio [OR] 1.06, 99% confidence interval [CI] 1.01 to 1.12, p = 0.002) as an independent predictor of outcome. Assignment to revascularization (as opposed to an initial medical treatment strategy) showed a trend (OR 0.56, 99% CI 0.26 to 1.2, p = 0.05). None of the other baseline clinical, exercise or angiographic variables examined provided additional information relative to adverse outcome.

CONCLUSIONS

Determinants of adverse outcome, among clinically stable patients with CAD and ischemia induced by stress and daily life were magnitude of AECG ischemia before treatment and, possibly, initial treatment assignment. Among the many other characteristics examined, including age, symptom status and angiographic and exercise variables, none contributed additional independent prognostic information. These two simple variables, which may be modifiable, need further study in a larger trial.

Ischemic cerebral infarction after rt-PA and heparin therapy for acute myocardial infarction. The TIMI-II pilot and randomized clinical trial combined experience

BACKGROUND AND PURPOSE

Ischemic cerebral infarction (CI) is a serious complication of acute myocardial infarction (MI). Little information exists on CI after thrombolytic therapy for MI.

METHODS

Of 3924 MI patients treated with recombinant tissue plasminogen activator (rt-PA) and heparin, 29 (0.7%) developed CI after treatment. All CI patients had detailed neurological evaluations, and 27 (93%) had CT scans centrally reviewed.

RESULTS

Age range was 40 to 74 years (mean, 60 years); 25 patients (86%) were men, and 22 (76%) were white. The electrocardiographic location of MI was anterior in 22 (76%) and nonanterior in 7 (24%). Five CIs occurred within 6 hours, 4 between 6 to 24 hours, 8 during the remainder of the first week, 10 during the second week, and 2 others distributed over the 4 weeks after study entry. Six of 29 CIs did not involve the cerebral cortex; 9 patients (31%) had multiple CIs. Of 28 CIs thought to be embolic in origin, 17 showed strong evidence for at least one cardiac abnormality (mural clot, wall-motion abnormality, aneurysm, or atrial fibrillation) known to be associated more specifically with embolism than MI. Eight of 27 CIs (30%) with CT scans had hemorrhagic transformation of varying degrees; 5 were symptomatic.

CONCLUSIONS

The time of occurrence and sites of CI after rt-PA and heparin therapy for acute MI are similar to those reported during the prethrombolytic era.

The prehospital electrocardiogram in acute myocardial infarction: is its full potential being realized? National Registry of Myocardial Infarction 2 Investigators

OBJECTIVES

This study sought to examine the management and subsequent outcomes of patients with a prehospital electrocardiogram (ECG) in a large, voluntary registry of myocardial infarction.

BACKGROUND

The prehospital ECG has been proposed as a means of rapidly identifying patients with acute myocardial infarction who might be eligible for reperfusion therapy.

METHODS

The characteristics and outcomes of patients with a prehospital ECG were compared with those without a prehospital ECG in the National Registry of Myocardial Infarction 2 data base. Included in the analysis were those patients who presented to the hospital within 12 h of an acute myocardial infarction. Excluded were patients with an in-hospital infarction, transferred-in referrals and self-transported patients.

RESULTS

Prehospital ECGs were obtained in 3,768 (5%) of 66,995 National Registry of Myocardial Infarction 2 patients meeting study criteria. Median time from myocardial infarction symptom onset until hospital arrival was longer among those having a prehospital ECG (152 vs. 91 min, p < 0.001). However, once in the hospital, the prehospital ECG group experienced a shorter median time to the initiation of either thrombolysis (30 vs. 40 min, p < 0.001) or primary angioplasty (92 vs. 115 min, p < 0.001). The prehospital ECG group was more likely to receive thrombolytic therapy (43% vs. 37%, p < 0.001) and to undergo primary angioplasty (11% vs. 7%, p < 0.001). Also, the prehospital ECG group was more likely to undergo coronary arteriography (55% vs. 40%, p < 0.001), angioplasty (24% vs. 16%, p < 0.001) or bypass surgery (10% vs. 6%, p < 0.001). The in-hospital mortality rate was 8% in patients with a prehospital ECG and 12% in those without a prehospital ECG (p < 0.001). After adjusting for baseline covariates utilizing multiple logistic regression analysis, this mortality difference remained statistically significant (odds ratio 0.83, 95% confidence interval 0.71 to 0.96, p = 0.01).

CONCLUSIONS

The prehospital ECG is infrequently utilized for diagnosing myocardial infarction, and among patients with a prehospital ECG, is associated with a longer time from symptom onset to hospital arrival. Despite these shortcomings, the prehospital ECG is a test that may potentially influence the management of patients with acute myocardial infarction through wider, faster in-hospital utilization of reperfusion strategies and greater usage of invasive procedures, factors that may possibly reduce shortterm mortality. Efforts to implement the prehospital ECG more widely and more rapidly may be indicated.

Long-term survival of African Americans in the Coronary Artery Surgery Study (CASS)

OBJECTIVES

This study sought to determine the long-term (> 15 years) outcome of a clinically well characterized cohort of African Americans with known or suspected coronary artery disease (CAD).

BACKGROUND

The mortality rate from CAD is higher in African Americans than in whites. An earlier analysis of data from the Coronary Artery Surgery Study (CASS) registry suggested that African American and white patients treated surgically had equal 5-year survival rates.

METHODS

Survival data from the CASS registry were analyzed to determine whether 1) African American race is an independent predictor of mortality; and 2) initial therapy is predictive of mortality among African American patients.

RESULTS

Overall, 60% of white and 52% of African American patients survived 16 years (p < 0.00001). Multivariate Cox models confirmed that African American race was independently associated with higher mortality in both the medical group (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.11 to 1.63) and the surgical group (HR 1.63, 95% CI 1.19 to 2.23). Initial therapy was not predictive of survival among African American patients (p = 0.81). However, smoking status significantly influenced survival: African Americans who did not smoke experienced significantly improved survival (60% vs. 48% for smokers), which equaled survival for white nonsmokers (61%, p = NS).

CONCLUSIONS

In contrast to results from shorter term studies, African Americans experienced higher overall mortality rates than whites over the long term, regardless of the type of initial treatment. Survival among nonsmoking African Americans at 16 years equaled survival among nonsmoking whites.

Medical care costs and quality of life after randomization to coronary angioplasty or coronary bypass surgery. Bypass Angioplasty Revascularization Investigation (BARI) Investigators

BACKGROUND

Randomized trials comparing coronary angioplasty with bypass surgery in patients with multivessel coronary disease have shown no significant differences in overall rates of death and myocardial infarction. We compared quality of life, employment, and medical care costs during five years of follow-up among patients treated with angioplasty or bypass surgery.

METHODS

A total of 934 of the 1829 patients enrolled in the randomized Bypass Angioplasty Revascularization Investigation participated in this study. Detailed data on quality of life were collected annually, and economic data were collected quarterly.

RESULTS

During the first three years of follow-up, functional-status scores on the Duke Activity Status Index, which measures the ability to perform common activities of daily living, improved more in patients assigned to surgery than in those assigned to angioplasty (P<0.05). Other measures of quality of life improved equally in both groups throughout the follow-up period. Patients in the angioplasty group returned to work five weeks sooner than did patients in the surgery group (P<0.001). The initial mean cost of angioplasty was 65 percent that of surgery ($21,113 vs. $32,347, P<0.001), but after five years the total medical cost of angioplasty was 95 percent that of surgery ($56,225 vs. $58,889), a difference of $2,664 (P = 0.047). The five-year cost of angioplasty was significantly lower than that of surgery among patients with two-vessel disease ($52,930 vs. $58,498, P<0.05), but not among patients with three-vessel disease ($60,918 vs. $59,430). After five years of follow-up, surgery had an overall cost-effectiveness ratio of $26,117 per year of life added, but unacceptable ratios of $100,000 or more per year of life added could not be excluded (P=0.13). Surgery appeared particularly cost effective in treating diabetic patients because of their significantly improved survival.

CONCLUSIONS

In patients with multivessel coronary disease, coronary-artery bypass surgery is associated with a better quality of life for three years than coronary angioplasty, after the initial morbidity caused by the procedure. Coronary angioplasty has a lower five-year cost than bypass surgery only in patients with two-vessel coronary disease.