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Mai V, Guay CA, Perreault L, Bonnet S, Bertoletti L, Lacasse Y, Jardel S, Lega JC, Provencher S. Extended Anticoagulation for VTE. Chest 2019; 155:1199-1216. [DOI: 10.1016/j.chest.2019.02.402] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/27/2019] [Accepted: 02/19/2019] [Indexed: 12/19/2022] Open
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2
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Hakim R, Thuaire C, Saint-Etienne C, Marcollet P, Chassaing S, Dequenne P, Laure C, Gautier S, Akkoyun-Farinez J, Motreff P, Rangé G. [Non-ST elevation acute coronary syndrome: CRAC register experience]. Ann Cardiol Angeiol (Paris) 2018; 67:422-428. [PMID: 30391012 DOI: 10.1016/j.ancard.2018.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE To compare the clinical, angiographic, therapeutic and prognostic characteristics of nonagenarians presenting with non-ST elevation acute coronary syndrome with those of patients under 90 years of age. METHODS We used the CRAC register database including 6 catheterization laboratories in the Center Val-de-Loire region. Only patients with positive-troponin non-ST elevation ACS included in the registry from 2014 to 2017 were selected for epidemiological and procedural data. Regarding antiplatelet therapy, hospital and one-year follow-up data, only patients in the 2014-2015 period were analyzed. RESULTS From January 1st, 2014 to December 31st, 2017, 5.964 patients with a positive-troponin non-ST ACS, including 133 nonagenarians (2.2%) were included in the CRAC registry. Arterial hypertension and the history of coronary angioplasty were more common among nonagenarians. They present more multivessel and left main disease. The use of the bare metal stent was predominant in 2014-2015 and then became marginal in 2016-2017. Clopidogrel was the most widely used anti platelet and more than one in two nonagenarians remain on dual therapy after 12 months. One-year stroke and hospital and one-year mortality were higher in this age group. CONCLUSIONS Nonagenarians with a positive-troponin non-ST elevation ACS have more severe coronary artery disease and a poorer prognosis than those younger than 90 years of age.
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Affiliation(s)
- R Hakim
- Service de cardiologie, les hôpitaux de Chartres, Chartres, France
| | - C Thuaire
- Service de cardiologie, les hôpitaux de Chartres, Chartres, France
| | - C Saint-Etienne
- Service de cardiologie, centre hospitalo universitaire de Tours, 37170 Tours, France
| | - P Marcollet
- Service de cardiologie, centre hospitalier de Bourges, 18000 Bourges, France
| | - S Chassaing
- Service de cardiologie, clinique Saint-Gatien, 37000 Tours, France
| | - P Dequenne
- Service de cardiologie, clinique Oréliance, 45770 Saran, France
| | - C Laure
- Service de cardiologie, les hôpitaux de Chartres, Chartres, France
| | - S Gautier
- Service de cardiologie, les hôpitaux de Chartres, Chartres, France
| | | | - P Motreff
- Service de cardiologie, CHU de Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | - G Rangé
- Service de cardiologie, les hôpitaux de Chartres, Chartres, France.
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3
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Laursen J, Kornholt J, Betzer C, Petersen TS, Christensen MB. General Practitioners' Barriers Toward Medication Reviews in Polymedicated Multimorbid Patients: How can a Focus on the Pharmacotherapy in an Outpatient Clinic Support GPs? Health Serv Res Manag Epidemiol 2018; 5:2333392818792169. [PMID: 30246058 PMCID: PMC6144514 DOI: 10.1177/2333392818792169] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2018] [Revised: 07/09/2018] [Accepted: 07/09/2018] [Indexed: 11/20/2022] Open
Abstract
Purpose: The aim of this study was to explore whether general practitioners (GPs) experienced barriers toward medication reviews in polymedicated, multimorbid patients, and how a clinical pharmacologist with a focus on pharmacotherapy can support the GPs in an outpatient clinic. Design: The study was descriptive and exploratory and had a qualitative design with a phenomenological/hermeneutic orientation for the interviews. Participants: The study comprised 14 interviews with 14 different GPs from the Capital Region of Denmark. Results: Three themes emerged from the interviews: (1) The care of patients With polypharmacy is challenged by the lack of professional dialogue and collaboration between GPs and hospital-based clinical pharmacologists, (2) the relationship between the patients with polypharmacy and the GP is characterized by care and individual considerations, and (3) the culture encourages adding medication and inhibits dialogue about medication withdrawal even for patients with polypharmacy. Conclusion and implications for practice: This study found that the primary barriers toward multimorbid patients with polypharmacy were the need for communication and teamwork with specialists (cardiologists, neurologists, endocrinologists, etc). Often, GPs felt that the specialists at the hospitals were more concerned about following standards and guidelines regarding specific diseases instead of a more holistic patient approach. To improve management of polypharmacy patients, the GPs suggest that a joint force is necessary, a partner-like relationship with greater transparency regarding information transfer, feedback, and shared decision-making, but also more education in the pharmacological field is essential.
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Affiliation(s)
- Jannie Laursen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jonatan Kornholt
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Cecilie Betzer
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Tonny S Petersen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mikkel B Christensen
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
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4
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Lajoie AC, Bonnet S, Lacasse Y, Lega JC, Provencher S. Interpreting risk reduction in clinical trials for pulmonary arterial hypertension. Eur Respir Rev 2018; 27:27/148/180020. [PMID: 29769296 DOI: 10.1183/16000617.0020-2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 04/06/2018] [Indexed: 11/05/2022] Open
Abstract
Because of scepticism concerning study results when relying solely on relative effect estimates, the number needed to treat (NNT) has been used extensively to quantify the net clinical benefit of an intervention, and is reported increasingly in randomised trials and observational studies. This method is a simple measure representing the number of patients who would need to be treated to prevent one additional adverse event. However, like relative risk, the NNT is an inherently time-dependent measure. Thus, its calculation may lead to misleading interpretations, especially for studies involving varying follow-up times or recurrent outcomes. In addition to study duration and the efficacy of the therapy and the comparator, multiple other factors directly influence the NNT and should be taken into account in its interpretation as for comparative effectiveness of therapies. Its accurate estimation and interpretation, as well as its limitations, are therefore crucial to avoid erroneous clinical and public health decisions. We discuss the calculation and the interpretation of risk reduction and the NNT in the context of the changing landscape of clinical trials in pulmonary arterial hypertension.
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Affiliation(s)
- Annie C Lajoie
- Pulmonary Hypertension Research Group, Université Laval, Quebec, Canada.,Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Université Laval, Quebec, Canada
| | - Sébastien Bonnet
- Pulmonary Hypertension Research Group, Université Laval, Quebec, Canada.,Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Université Laval, Quebec, Canada.,Dept of medicine, Université Laval, Quebec, Canada
| | - Yves Lacasse
- Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Université Laval, Quebec, Canada.,Dept of medicine, Université Laval, Quebec, Canada
| | - Jean-Christophe Lega
- Dept of internal and vascular medicine, Centre Hospitalier Lyon Sud, Pierre-Bénite cedex, France.,UMR 5558, Laboratoire de Biométrie et Biologie Évolutive, CNRS, Lyon, France
| | - Steeve Provencher
- Pulmonary Hypertension Research Group, Université Laval, Quebec, Canada.,Institut universitaire de cardiologie et de pneumologie de Québec Research Center, Université Laval, Quebec, Canada.,Dept of medicine, Université Laval, Quebec, Canada
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5
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Abstract
The clinical evidence for treatment of acute coronary syndrome (ACS) in the elderly is less robust than in patients younger than 75 years. The elderly have the highest incidence of cardiovascular disease and frequently present with ACS. This number can be expected to increase over time because society is aging. Older adults often sustain unfavorable outcomes from ACS because of atypical presentation and delay in recognition. In addition, elderly patients commonly do not receive optimal guideline-directed ACS treatment. Owing to their high baseline risk of ischemic complications, the elderly also fare worse even with optimal ACS treatment as they frequently have more complex coronary disease, more comorbidities, less cardiovascular reserve, and a higher risk of treatment complications. They are also subjected to a broader range of pharmacologic treatment. Treatment complications can be mitigated to some extent by meticulous dose adjustment of antithrombotic and adjunctive therapies. While careful transitions of care and appropriate utilization of post-discharge secondary preventive measures are important in ACS patients of all ages, the elderly are more vulnerable to system errors and thus deserve special attention from the clinician.
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Affiliation(s)
- Niels Engberding
- Department of Medicine, Division of Cardiology, National Jewish Health, Denver, Colorado, USA
| | - Nanette K Wenger
- Emory Heart and Vascular Center, Atlanta, Georgia, USA.,Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia, USA
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Díaz J, Gándara J, Sénior JM. Características clínicas, angiográficas y desenlaces clínicos en adultos mayores de 65 años con síndrome coronario agudo sin elevación del segmento ST. REVISTA COLOMBIANA DE CARDIOLOGÍA 2017. [DOI: 10.1016/j.rccar.2017.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Alter DA, Yu B, Bajaj RR, Oh PI. Relationship Between Cardiac Rehabilitation Participation and Health Service Expenditures Within a Universal Health Care System. Mayo Clin Proc 2017; 92:S0025-6196(17)30075-7. [PMID: 28365098 DOI: 10.1016/j.mayocp.2016.12.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Revised: 12/06/2016] [Accepted: 12/28/2016] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To examine the relationship between cardiac rehabilitation participation and health service expenditures in Ontario, Canada. PATIENTS AND METHODS A total of 6284 patients referred to cardiac rehabilitation between April 1, 2003, and December 31, 2010, were linked to 6284 matched cardiac rehabilitation eligible nonreferred controls and followed over a 3-year period across multiple linked administrative databases to identify health service utilization expenditures and mortality. All patients had previous cardiac hospitalizations within the preceding year. Four cardiac rehabilitation eligible groups of patients were balanced using propensity score weights: (1) no referral; (2) no participation; (3) low participation levels (ie, attending <67% of prescheduled classes); and (4) high participation levels (ie, attending ≥67% prescheduled classes). Each group of patients was balanced in age, sex, geography, socioeconomic status, previous hospitalizations, ambulatory care conditions, cardiovascular risk factors, comorbidities, and previous health care expenditures. Generalized linear models were used to examine differences in health service expenditures (from all sources including hospitalizations, physician visits, diagnostic tests, and drugs for those older than 65 years) per "eligible day alive" over the 3-year period. RESULTS Compared with the nonreferred population, health service expenditures followed a dose-response relationship and were lowest in patients who had the highest cardiac rehabilitation programmatic participation levels (P<.001). Cost differences across groups separated early, remained divergent, and applied to all components of health care expenditures (P<.001). Sensitivity analyses confirmed that the findings were not secondary to reverse causality. CONCLUSION Participation in cardiac rehabilitation is associated with lower long-term health service utilization expenditures within a publicly funded health care system.
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Affiliation(s)
- David A Alter
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.
| | - Bing Yu
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ravi R Bajaj
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Sunnybrook Health Science Centre, Toronto, Ontario, Canada
| | - Paul I Oh
- University Health Network Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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8
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Baseline risk has greater influence over behavioral attrition on the real-world clinical effectiveness of cardiac rehabilitation. J Clin Epidemiol 2016; 79:55-61.e1. [DOI: 10.1016/j.jclinepi.2016.03.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 03/02/2016] [Accepted: 03/11/2016] [Indexed: 12/29/2022]
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9
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O'Brien EC, Zhao X, Fonarow GC, Schulte PJ, Dai D, Smith EE, Schwamm LH, Bhatt DL, Xian Y, Saver JL, Reeves MJ, Peterson ED, Hernandez AF. Quality of Care and Ischemic Stroke Risk After Hospitalization for Transient Ischemic Attack: Findings From Get With The Guidelines-Stroke. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S117-24. [PMID: 26515199 DOI: 10.1161/circoutcomes.115.002048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with transient ischemic attack (TIA) are at increased risk for ischemic stroke. We derived a prediction rule for 1-year ischemic stroke risk post-TIA, examining estimated risk, receipt of inpatient quality of care measures for TIA, and the presence or absence of stroke at 1 year post discharge. METHODS AND RESULTS We linked 67 892 TIA Get With The Guidelines-Stroke patients >65 years (2003-2008) to Medicare inpatient claims to obtain longitudinal outcomes. Using Cox proportional hazards modeling in a split sample, we identified baseline demographics and clinical characteristics associated with ischemic stroke admission during the year post-TIA, and developed a Get With The Guidelines Ischemic Stroke after TIA Risk Score; performance was examined in the validation sample. Quality of care was estimated by a global defect-free care measure, and individual performance measures within estimated risk score quintiles. The overall hospital admission rate for ischemic stroke during the year post-TIA was 5.7%. Patients with ischemic stroke were more likely to be older, black, and have higher rates of smoking, previous stroke, diabetes mellitus, previous myocardial infarction, heart failure, and atrial fibrillation. The Risk Score showed moderate discriminative performance (c-statistic=0.606); highest quintile patients were less likely to receive statins, smoking cessation counseling, and defect-free care. Although not associated with 1-year ischemic stroke, DCF was associated with a significantly lower risk of all-cause mortality. CONCLUSIONS TIA patients with high estimated ischemic stroke risk are less likely to receive defect-free care than low-risk patients. Standardized risk assessment and delivery of optimal inpatient care are needed to reduce this risk-treatment mismatch.
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Affiliation(s)
- Emily C O'Brien
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.).
| | - Xin Zhao
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C Fonarow
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Phillip J Schulte
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - David Dai
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Eric E Smith
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Lee H Schwamm
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Ying Xian
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Jeffrey L Saver
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Mathew J Reeves
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Adrian F Hernandez
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
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10
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Zaman MJ, Fleetcroft R, Bachmann M, Sarev T, Stirling S, Clark A, Myint PK. Association of increasing age with receipt of specialist care and long-term mortality in patients with non-ST elevation myocardial infarction. Age Ageing 2016; 45:96-103. [PMID: 26601697 DOI: 10.1093/ageing/afv162] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 09/30/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND observational studies suggest that older patients are less likely to receive secondary prevention medicines following acute coronary syndrome (ACS). OBJECTIVES to examine the association of increasing age with receipt of specialist care and influence of specialist care on long-term mortality in patients with non-ST elevation myocardial infarction (NSTEMI). DESIGN a cohort study. SETTING National ACS registry of England and Wales. SUBJECTS a total of 85,183 patients admitted with NSTEMI between 2006 and 2010. METHODS logistic regression analyses to assess receipt of secondary prevention medicines (ACE inhibitor, β-blocker, statin, aspirin) by age group; multivariate Cox regression models to examine longitudinal effect of cardiologist care on all-cause mortality by age group. RESULTS mean age 72.0 years (SD 13.0 years), mean follow-up was 2.13 years. Older patients received less cardiologist care (70.2% of NSTEMI patients ≥85 years compared with 94.7% of patients <65) years and had more co-morbidity. Cardiologists prescribed more secondary prevention in all age groups than generalists, but this was mostly explained away by co-morbidity (receipt of statin crude OR 1.51 (1.27,1.80), fully adjusted OR 1.11 (0.92,1.33) in patients ≥85 years). Receiving cardiologist care compared with generalist care was associated with a decreased risk of death in all even after adjustment for co-morbidity, disease severity and secondary prevention; this benefit reduced incrementally with older age group (adjusted hazard ratio (HR) 0.58 (0.49,0.68) aged <65; 0.87 (0.82,0.92) aged ≥85). CONCLUSION older patients with NSTEMI were less likely to see a cardiologist, but reduced treatment by generalists was explained away by co-morbidity. Cardiologist care was associated with lower mortality in all age groups than a generalist, but this survival benefit was less pronounced in older patients.
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Affiliation(s)
- M Justin Zaman
- Medicine, James Paget University Hospital, Great Yarmouth, Norfolk NR31 6LA, UK Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - Robert Fleetcroft
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - Toomas Sarev
- Medicine, James Paget University Hospital, Great Yarmouth, Norfolk NR31 6LA, UK Cardiology, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | - Susan Stirling
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK
| | - Allan Clark
- Norwich Medical School, University of East Anglia, Norwich, Norfolk NR4 7TJ, UK School of Medicine, Health Policy and Practice, University of East Anglia, Norwich, Norfolk, UK
| | - Phyo Kyaw Myint
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen AB25 2ZD, UK
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11
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Hogan TM, Hansoti B, Chan SB. Assessing knowledge base on geriatric competencies for emergency medicine residents. West J Emerg Med 2015; 15:409-13. [PMID: 25035745 PMCID: PMC4100845 DOI: 10.5811/westjem.2014.2.18896] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 01/17/2014] [Accepted: 02/03/2014] [Indexed: 11/29/2022] Open
Abstract
Introduction Emergency care of older adults requires specialized knowledge of their unique physiology, atypical presentations, and care transitions. Older adults often require distinctive assessment, treatment and disposition. Emergency medicine (EM) residents should develop expertise and efficiency in geriatric care. Older adults represent over 25% of most emergency department (ED) volumes. Yet many EM residencies lack curricula or assessment tools for competent geriatric care. Fully educating residents in emergency geriatric care can demand large amounts of limited conference time. The Geriatric Emergency Medicine Competencies (GEMC) are high-impact geriatric topics developed to help residencies efficiently and effectively meet this training demand. This study examines if a 2-hour didactic intervention can significantly improve resident knowledge in 7 key domains as identified by the GEMC across multiple programs. Methods A validated 29-question didactic test was administered at six EM residencies before and after a GEMC-focused lecture delivered in summer and fall of 2009. We analyzed scores as individual questions and in defined topic domains using a paired student t test. Results A total of 301 exams were administered; 86 to PGY1, 88 to PGY2, 86 to PGY3, and 41 to PGY4 residents. The testing of didactic knowledge before and after the GEMC educational intervention had high internal reliability (87.9%). The intervention significantly improved scores in all 7 GEMC domains (improvement 13.5% to 34.6%; p<0.001). For all questions, the improvement was 23% (37.8% pre, 60.8% post; P<0.001) Graded increase in geriatric knowledge occurred by PGY year with the greatest improvement post intervention seen at the PGY 3 level (PGY1 19.1% versus PGY3 27.1%). Conclusion A brief GEMC intervention had a significant impact on EM resident knowledge of critical geriatric topics. Lectures based on the GEMC can be a high-yield tool to enhance resident knowledge of geriatric emergency care. Formal GEMC curriculum should be considered in training EM residents for the demands of an aging population.
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Affiliation(s)
- Teresita M Hogan
- University of Chicago, Section of Emergency Medicine, Chicago, Illinois ; Presence Resurrection Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Bhakti Hansoti
- University of Chicago, Section of Emergency Medicine, Chicago, Illinois ; Johns Hopkins University, Department of Emergency Medicine, Baltimore, Maryland
| | - Shu B Chan
- Presence Resurrection Medical Center, Department of Emergency Medicine, Chicago, Illinois
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12
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Lee HW, Cha KS, Ahn J, Choi JC, Oh JH, Choi JH, Lee HC, Yun E, Jang HY, Choi JH, Hong TJ, Jeong MH, Ahn Y, Chae SC, Kim YJ. Comparison of transradial and transfemoral coronary intervention in octogenarians with acute myocardial infarction. Int J Cardiol 2015; 202:419-24. [PMID: 26433163 DOI: 10.1016/j.ijcard.2015.09.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 06/21/2015] [Accepted: 09/04/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND The transradial (TR) approach for percutaneous coronary intervention (PCI) is challenging and associated with failure in elderly patients. We compared the TR and transfemoral (TF) approaches in patients>80 years with acute myocardial infarction (MI) undergoing PCI. METHODS A total of 1945 (7.2%) octogenarians were enrolled from among 27,129 patients in the Korea Acute Myocardial Infarction Registry. The TR group (n=336, 17.3%) was compared with the TF group (n=1609, 82.7%) in the overall and propensity-matched cohorts with respect to procedural success, complications, in-hospital mortality, and one-year mortality and total major adverse cardiac event (MACE; death, MI, and revascularization) rate. RESULTS In the overall cohort, the TR group had lower incidence of Killip class III or IV compared to the TF group. The disease extent and lesion severity were similar between groups, as was the procedural success rate (97.7% vs. 98.3%); however, in-hospital complications were significantly lower in the TR group (8.1% vs. 20.3%). In-hospital mortality was significantly lower in the TR group than the TF group (3.4% vs. 11.4%), as were the one-year mortality and total MACE (9.8% vs. 18.4% and 13% vs. 21.9%, respectively). These outcomes were consistent in the propensity-matched cohort. The TR approach was found to be a significant predictor of low in-hospital mortality (OR 0.355, 95% CI 0.139-0.907), but not of one-year mortality (OR 0.644, 95% CI 0.334-1.240). CONCLUSIONS In octogenarians with acute MI undergoing PCI, the TR approach was more effective than the TF approach as it had lower complication rate and better clinical outcomes with comparable procedural success.
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Affiliation(s)
- Hye Won Lee
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Kwang Soo Cha
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea; Medical Research Institute, Pusan National University Hospital, Busan, South Korea.
| | - Jinhee Ahn
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Jung Cheon Choi
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Jun-Hyok Oh
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Jung Hyun Choi
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Han Cheol Lee
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Eunyoung Yun
- Medical Research Institute, Pusan National University Hospital, Busan, South Korea
| | - Hye Yoon Jang
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Jong Hyun Choi
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Taek Jong Hong
- Department of Cardiology, Pusan National University Hospital, Busan, South Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, South Korea
| | - Shung Chull Chae
- Department of Cardiology, Kyungpook National University Hospital, Daegu, South Korea
| | - Young Jo Kim
- Department of Cardiology, Yeungnam University Hospital, Daegu, South Korea
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Abstract
Ischemic heart disease is the leading cause of mortality worldwide. Due to advances in medicine in the past few decades, life expectancy has increased resulting in an aging population in developed and developing countries. Acute coronary syndrome causes greater morbidity and mortality in this group of older patients, which appears to be due to age-related comorbidities. This review examines the incidence and prevalence of acute coronary syndrome among older patients, examines current treatment strategies, and evaluates the predictors of adverse outcomes. In particular, the impact of frailty on outcomes and the need for frailty assessment in developing future research and management strategies among older patients are discussed.
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Centralized Pan-Middle East Survey on the Under-Treatment of Hypercholesterolemia: Results from the CEPHEUS Study in Egypt. Cardiol Ther 2014; 3:27-40. [PMID: 25403341 PMCID: PMC4265229 DOI: 10.1007/s40119-014-0031-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Cardiovascular disease is a major cause of morbidity and mortality; however, the risks associated with this disease can be reduced by targeting circulating low-density lipoprotein cholesterol (LDL-C) with lipid-lowering drugs, as recommended in many treatment guidelines. Their effectiveness for hypercholesterolemia management depends on appropriate use in at-risk patients. Observational studies have shown varying adherence to national and international guidelines on reaching LDL-C treatment goals. METHODS The Centralized Pan-Middle East Survey on the under-treatment of hypercholesterolemia (CEPHEUS) study observed the current management of hypercholesterolemia in patients on lipid-lowering drugs in seven Middle Eastern countries, and results from 1,043 patients in Egypt are presented here. RESULTS Overall, less than 50% of patients achieved their LDL-C treatment goal, with patients at higher risk of a cardiovascular event being less likely to attain their target. Nearly, three-quarters of patients in this study were considered high or very high risk, with only 10% of high-risk patients reaching their treatment goal. CONCLUSIONS Management of hypercholesterolemia in Egypt is comparatively worse than the average for similar countries in the region, and many patients with high risk of CVD are not being effectively treated. Initiatives to improve physicians' management of these patients and patient compliance to treatment are urgently needed. FUNDING AstraZeneca, Cairo, Egypt.
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Alabas OA, Allan V, McLenachan JM, Feltbower R, Gale CP. Age-dependent improvements in survival after hospitalisation with acute myocardial infarction: an analysis of the Myocardial Ischemia National Audit Project (MINAP). Age Ageing 2014; 43:779-85. [PMID: 24362555 DOI: 10.1093/ageing/aft201] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND recent studies report an age-dependent decline in mortality after acute myocardial infarction (AMI). OBJECTIVE to investigate age-dependent improvements in survival after hospitalisation with AMI. DESIGN population-based cohort study using data from the Myocardial Ischaemia National Audit Project. SUBJECTS a total of 583,466 patients with AMI admitted to 247 hospitals between 1 January 2003 and 31 December 2010. METHODS six-month relative survival (RS) was calculated from the ratio of observed to expected survival using an age-, sex- and biennial year-matched population from the Office for National Statistics. Risk-adjusted mortality rates (RMAR) were estimated using shared frailty regression. Data were stratified by age group, AMI phenotype [(ST-elevation myocardial infarction, (STEMI) and non-STEMI, (NSTEMI)] and period of admission to hospital. RESULTS for STEMI, there was an increase in RS for patients aged 65-80 years (84.8 versus 89.2%) and those over 80 years (68.0 versus 71.8%), but not for patients aged 18 to <65 years (96.4 versus 96.9%). For NSTEMI patients aged 18 to <65 years RS was higher, but stable (95.5 versus 96.8%) and improved for patients aged 65-80 years (83.2 versus 88.5%) and patients aged >80 years (68.3% versus 75.5%). Likewise, RMAR improved for patients aged ≥65 years, were stable and higher for patients <65 years. CONCLUSIONS there were significant improvements in survival after hospitalisation with AMI in the older but not younger patients. The scope for further reductions in mortality is likely to be much greater for older than younger patients with AMI.
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Affiliation(s)
- Oras A Alabas
- Division of Epidemiology and Biostatistics, University of Leeds, Leeds, UK
| | - Victoria Allan
- Division of Epidemiology and Biostatistics, University of Leeds, Leeds, UK
| | - Jim M McLenachan
- Department of Cardiology, Leeds Teaching Hospitals NHS Foundation Trust, Leeds, UK
| | - Richard Feltbower
- Division of Epidemiology and Biostatistics, University of Leeds, Leeds, UK
| | - Chris P Gale
- Division of Epidemiology and Biostatistics, University of Leeds, Leeds, UK Department of Cardiology, York Teaching Hospital NHS Foundation Trust, York, UK
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Faustino A, Mota P, Silva J. Non-ST-elevation acute coronary syndromes in octogenarians: Applicability of the GRACE and CRUSADE scores. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2014. [DOI: 10.1016/j.repce.2014.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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17
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Síndromes coronárias agudas sem supradesnivelamento‐ST nos octogenários: aplicabilidade dos scores GRACE e CRUSADE. Rev Port Cardiol 2014; 33:617-27. [DOI: 10.1016/j.repc.2014.01.025] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/21/2014] [Accepted: 01/24/2014] [Indexed: 11/23/2022] Open
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Ishii S, Kojima T, Yamaguchi K, Akishita M. Guidance statement on appropriate medical services for the elderly. Geriatr Gerontol Int 2014. [DOI: 10.1111/ggi.12310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Shinya Ishii
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Taro Kojima
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Kiyoshi Yamaguchi
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine; Graduate School of Medicine; The University of Tokyo; Tokyo Japan
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Guidance statement on appropriate medical services for the elderly by the study group of the Ministry of Health, Labour and Welfare. Nihon Ronen Igakkai Zasshi 2014; 51:89-96. [PMID: 24747506 DOI: 10.3143/geriatrics.51.89] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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20
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Tjia J, Allison J, Saczynski JS, Tisminetzky M, Givens JL, Lapane K, Lessard D, Goldberg RJ. Encouraging trends in acute myocardial infarction survival in the oldest old. Am J Med 2013; 126:798-804. [PMID: 23835196 PMCID: PMC3840395 DOI: 10.1016/j.amjmed.2013.02.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 02/02/2013] [Indexed: 12/22/2022]
Abstract
BACKGROUND There are limited data informing the optimal treatment strategy for acute myocardial infarction in the oldest old (aged ≥85 years). The study aim was to examine whether decade-long increases in guideline-based cardiac medication use mediate declines in post-discharge mortality among oldest old patients hospitalized with acute myocardial infarction. METHODS The study sample included 1137 patients aged ≥85 years hospitalized in 6 biennial periods between 1997 and 2007 for acute myocardial infarction at all 11 greater Worcester, Massachusetts, medical centers. We examined trends in 90-day survival after hospital discharge and guideline-based medication use (aspirin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, lipid-lowering agents) for acute myocardial infarction during hospitalization and at discharge. Sequential multivariable Cox regression models examined the relationship among guideline-based medication use, study year, and 90-day post-discharge survival rates. RESULTS Patients hospitalized between 2003 and 2007 experienced higher 90-day survival rates than those hospitalized between 1997 and 2001 (69.1% vs 59.8%, P < .05). Between 1997 and 2007, the average number of guideline-based medications prescribed at discharge increased significantly (1.8 to 2.9, P < .001). The unadjusted hazard ratio for 90-day post-discharge mortality in 2003-2007 compared with 1997-2001 was 0.73 (95% confidence interval, 0.60-0.89); after adjustment for patient characteristics and guideline-based cardiac medication use, this relationship was no longer significant (hazard ratio, 1.26; 95% confidence interval, 1.00-1.58). CONCLUSIONS Between 1997 and 2007, 90-day survival improved among a population-based sample of patients aged ≥85 years hospitalized for acute myocardial infarction. This encouraging trend was explained by increased use of guideline-based medications.
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Affiliation(s)
- Jennifer Tjia
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA 01605, USA.
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21
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Rajendran S, Visvanathan R, Tavella R, Weekes AJ, Morgan C, Beltrame JF. In patients with chronic stable angina, secondary prevention appears better in the very old compared to younger patients: the Coronary Artery Disease in gENeral practiCE (CADENCE) Substudy. Heart Lung Circ 2012; 22:116-21. [PMID: 23137911 DOI: 10.1016/j.hlc.2012.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2012] [Revised: 09/10/2012] [Accepted: 09/11/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND With our aging communities and the increased prevalence of coronary heart disease (CAD) with age, the impact of this disease in the very old warrants further investigation. OBJECTIVE To assess health outcomes and the attainment of guideline-based secondary prevention targets in the very old (>80 years, n=482) as compared to young (<65 years, n=582) and elderly (between 65 and 80 years, n=932) patients, all of whom had chronic stable angina. DESIGN The coronary artery disease in general practice (CADENCE) study was a cluster-stratified cross-sectional survey. This study reports on health outcomes quantitated using the Seattle Angina Questionnaire and guideline targets achieved for blood pressure, smoking, lipids, diabetic control and body habitus. SETTINGS AND PARTICIPANTS 2031 stable angina patients were recruited from 207 primary care practices. RESULTS Despite similar angina frequency scores, the very old were more physically impaired by their angina than both the young and elderly [76±25 (Young) vs. 70±26 (Elderly) vs. 63±28 (Very old), p<0.05 for both comparisons]. However, the very old had better quality of life scores than young stable angina patients [72±24 vs. 65±25, p<0.05] and were similar to the elderly [72±24 vs. 72±23, p>0.05]. Also blood pressure, lipid, diabetic and body habitus targets were more often achieved in the very old and elderly patients compared to young stable angina patients. CONCLUSION Despite similar symptomatic status and greater physical limitations, the very old reported a better quality of life and more often achieved treatment targets than young stable angina patients. Failure to improve secondary prevention measures in younger age groups may potentially contribute to increased morbidity in older age, and failure to achieve 'Healthy Ageing'.
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Affiliation(s)
- Sharmalar Rajendran
- Department of Cardiology, The Queen Elizabeth Hospital/Lyell McEwin Hospital, Adelaide, South Australia, Australia; Discipline of Medicine, University of Adelaide, South Australia, Australia
| | - Renuka Visvanathan
- Discipline of Medicine, University of Adelaide, South Australia, Australia; Aged & Extended Care Services, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Rosanna Tavella
- Department of Cardiology, The Queen Elizabeth Hospital/Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Andrew J Weekes
- Servier Laboratories (Australia) Pty Ltd, Hawthorn, Victoria, Australia
| | - Claire Morgan
- Servier Laboratories (Australia) Pty Ltd, Hawthorn, Victoria, Australia
| | - John F Beltrame
- Department of Cardiology, The Queen Elizabeth Hospital/Lyell McEwin Hospital, Adelaide, South Australia, Australia; Discipline of Medicine, University of Adelaide, South Australia, Australia.
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Acute coronary syndromes: an old age problem. J Geriatr Cardiol 2012; 9:192-6. [PMID: 22934104 PMCID: PMC3419819 DOI: 10.3724/sp.j.1263.2012.01312] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 03/02/2012] [Accepted: 04/01/2012] [Indexed: 12/16/2022] Open
Abstract
The increasing population in older age will lead to greater numbers of them presenting with acute coronary syndromes (ACS). This has implications on global healthcare resources and necessitates better management and selection for evidenced-based therapies. The elderly are a high risk group with more significant treatment benefits than younger ACS. Nevertheless, age related inequalities in ACS care are recognised and persist. This discrepancy in care, to some extent, is explained by the higher frequency of atypical and delayed presentations in the elderly, and less diagnostic electrocardiograms at presentation, potentiating a delay in ACS diagnosis. Under estimation of mortality risk in the elderly due to limited consideration for physiological frailty, co-morbidity, cognitive/psychological impairment and physical disability, less input by cardiology specialists and lack of randomised, controlled trials data to guide management in the elderly may further confound the inequality of care. While these inequalities exist, there remains a substantial opportunity to improve age related ACS outcomes. The selection of elderly patients for specific therapies and medication regimens are unanswered. There is a growing need for randomised, controlled trial data to be more representative of the population and enroll those of advanced age with co-morbidity. A lack of reporting of adverse events, such as renal impairment post coronary angiography, in the elderly further limit risk benefit decisions. Substantial improvements in care of elderly ACS patients are required and should be advocated. Ultimately, these improvements are likely to lead to better outcomes post ACS. However, the improvement in outcome is not infinite and will be limited by non-modifiable factors of age-related risk.
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Forman DE, Rich MW, Alexander KP, Zieman S, Maurer MS, Najjar SS, Cleveland JC, Krumholz HM, Wenger NK. Cardiac care for older adults. Time for a new paradigm. J Am Coll Cardiol 2011; 57:1801-10. [PMID: 21527153 DOI: 10.1016/j.jacc.2011.02.014] [Citation(s) in RCA: 134] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2010] [Revised: 01/27/2011] [Accepted: 02/01/2011] [Indexed: 12/14/2022]
Affiliation(s)
- Daniel E Forman
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Wenger NK. Science and the practice of cardiovascular medicine in the geriatric population. J Geriatr Cardiol 2011; 8:67-71. [PMID: 22783287 PMCID: PMC3390084 DOI: 10.3724/sp.j.1263.2011.00067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Revised: 06/06/2011] [Accepted: 06/13/2011] [Indexed: 11/25/2022] Open
Affiliation(s)
- Nanette K Wenger
- Emory University School of Medicine, Emory Heart and Vascular Center, Atlanta, GA 30303, USA
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Abstract
With remarkable advances of medical care, the aging population is growing rapidly. Cardiovascular disease remains the leading cause of morbidity and mortality in elderly people and therefore antiplatelet therapy has been a mainstay of cardiovascular medicines for reducing and preventing cardiovascular risk in these populations. The benefits of several antiplatelet drugs in the elderly are well documented. However, there are limited data regarding the optimal use of antiplatelet agents considering the risk:benefit ratio in elderly patients, who are more vulnerable to safety issues owing to different pharmacokinetics and pharmacodynamics as compared with young patients. In this article, we review currently available evidence regarding the efficacy and safety of antiplatelet therapy (i.e., aspirin, old and new P2Y12 inhibitors and glycoprotein IIb/IIIa inhibitors) in the elderly for primary and secondary prevention strategies in cardiovascular care.
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Affiliation(s)
| | - Duk-Woo Park
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jun-Hyok Oh
- Division of Cardiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Park JE, Chiang CE, Munawar M, Pham GK, Sukonthasarn A, Aquino AR, Khoo KL, Chan HWR. Lipid-lowering treatment in hypercholesterolaemic patients: the CEPHEUS Pan-Asian survey. Eur J Prev Cardiol 2011; 19:781-94. [PMID: 21450606 DOI: 10.1177/1741826710397100] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment of hypercholesterolaemia in Asia is rarely evaluated on a large scale, and data on treatment outcome are scarce. The Pan-Asian CEPHEUS study aimed to assess low-density lipoprotein cholesterol (LDL-C) goal attainment among patients on lipid-lowering therapy. METHODS This survey was conducted in eight Asian countries. Hypercholesterolaemic patients aged ≥18 years who had been on lipid-lowering treatment for ≥3 months (stable medication for ≥6 weeks) were recruited, and lipid concentrations were measured. Demographic and other clinically relevant information were collected, and the cardiovascular risk of each patient was determined. Definitions and criteria set by the updated 2004 National Cholesterol Education Program guidelines were applied. RESULTS In this survey, 501 physicians enrolled 8064 patients, of whom 7281 were included in the final analysis. The mean age was 61.0 years, 44.4% were female, and 85.1% were on statin monotherapy. LDL-C goal attainment was reported in 49.1% of patients overall, including 51.2% of primary and 48.7% of secondary prevention patients, and 36.6% of patients with familial hypercholesterolaemia. The LDL-C goal was attained in 75.4% of moderate risk, 55.4% of high risk, and only 34.9% of very high-risk patients. Goal attainment was directly related to age and inversely related to cardiovascular risk and baseline LDL-C. CONCLUSION A large proportion of Asian hypercholesterolaemic patients on lipid-lowering drugs are not at recommended LDL-C levels and remain at risk for cardiovascular disease. Given the proven efficacy of lipid-lowering drugs in the reduction of LDL-C, there is room for further optimization of treatments to maximize benefits and improve outcomes.
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Affiliation(s)
- Jeong Euy Park
- Cardiology, Cardiac and Vascular Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam Ku, Seoul, Korea.
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Modeling radial viscoelastic behavior of left ventricle based on MRI tissue phase mapping. Ann Biomed Eng 2010; 38:3102-11. [PMID: 20505993 DOI: 10.1007/s10439-010-0079-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2010] [Accepted: 05/13/2010] [Indexed: 10/19/2022]
Abstract
The viscoelastic behavior of myocardial tissue is a measure that has recently found to be a deterministic factor in quality of contraction. Parameters imposing the viscoelastic behavior of the heart are influenced in part by sarcomere function and myocardial composition. Despite the overall agreement on significance of cardiac viscoelasticity, a practical model that can measure and characterize the viscoelastic behavior of the myocardial segments does not yet exist. Pressure-Volume (P-V) curves are currently the only measure for stiffness/compliance of the left ventricle. However, obtaining P-V curves requires invasive cardiac catheterization, and only provides qualitative information on how pressure and volume change with respect to each other. For accurate assessment of myocardial mechanical behavior, it is required to obtain quantitative measures for viscoelasticity. In this work, we have devised a model that yields myocardial elastic and viscous damping coefficient functions through the cardiac cycle. The required inputs for this model are kinematic information with respect to changes in LV short axes that were obtained by Magnetic Resonance Imaging (MRI) using a tissue phase mapping (TPM) pulse sequence. We evaluated viscoelastic coefficients of LV myocardium in two different age groups of 20-40 and greater than 60. We found that the magnitude of stiffness coefficients is noticeably greater in the older subjects. Additionally, we found that slope of viscous damping functions follow similar patterns for each individual age group. This method may shed light on dynamics of contraction through MRI in conditions where composition of myocardium is changed such as in aging, adverse remodeling, and cardiomyopathies.
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Tjia J, Briesacher B, Xie D, Fu J, Goldberg RJ. Disparities in combination drug therapy use in older adults with coronary heart disease: a cross-sectional time-series in a nationally representative US sample. Drugs Aging 2010; 27:149-58. [PMID: 20104940 DOI: 10.2165/11532150-000000000-00000] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Despite evidence of effective combination drug therapy for secondary prevention of coronary heart disease (CHD), older adults with this condition remain undertreated. OBJECTIVE To describe time trends (1992-2003) in the adoption of combination cardiac drug therapies (beta-blockers [beta-adrenoceptor antagonists], ACE inhibitors or angiotensin II type 1 receptor antagonists [angiotensin receptor blockers; ARBs], and lipid-lowering agents) among older adults in the US with CHD and to identify factors associated with not using combination therapy. METHODS The study took the form of a cross-sectional time-series. The study population consisted of a nationally representative sample of adults aged >or=65 years with CHD (unweighted n = 6331; weighted n = 20.1 million) included in the 1992-2003 Medicare Current Beneficiary Survey. The outcome measure was low-intensity cardiac pharmacotherapy (no drug or single drug therapy with beta-blockers, ACE inhibitors/ARBs or lipid-lowering agents) compared with combination therapy (>or=2 cardiac drugs) for secondary CHD prevention. RESULTS The use of combination drug therapy in older adults with CHD increased 9-fold during the study period (from 6% in 1992 to 54% in 2003). Adjusted analyses demonstrate that suboptimal drug therapy was independently associated with advanced age (relative risk [RR] 1.18; 95% CI 1.14, 1.23) for patients aged >or=85 years versus patients aged 65-74 years, and with being non-Hispanic Black (RR 1.05; 95% CI 1.01, 1.10) or Hispanic (RR 1.13; 95% CI 1.06, 1.21) versus being non-Hispanic White. CONCLUSIONS Combination drug therapy use for secondary CHD prevention increased in older US adults over the last decade, but improvements were not uniform. The oldest-old, non-Hispanic Blacks and Hispanics experienced slower adoption of optimal medical therapy to improve their long-term prognosis for CHD.
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Affiliation(s)
- Jennifer Tjia
- Department of Medicine, University of Massachusetts Medical School, Division of Geriatric Medicine, Worcester, Massachusetts 01605, USA.
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Hogan TM, Losman ED, Carpenter CR, Sauvigne K, Irmiter C, Emanuel L, Leipzig RM. Development of geriatric competencies for emergency medicine residents using an expert consensus process. Acad Emerg Med 2010; 17:316-24. [PMID: 20370765 DOI: 10.1111/j.1553-2712.2010.00684.x] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The emergency department (ED) visit rate for older patients exceeds that of all age groups other than infants. The aging population will increase elder ED patient utilization to 35% to 60% of all visits. Older patients can have complex clinical presentations and be resource-intensive. Evidence indicates that emergency physicians fail to provide consistent high-quality care for elder ED patients, resulting in poor clinical outcomes. OBJECTIVES The objective was to develop a consensus document, "Geriatric Competencies for Emergency Medicine Residents," by identified experts. This is a minimum set of behaviorally based performance standards that all residents should be able to demonstrate by completion of their residency training. METHODS This consensus-based process utilized an inductive, qualitative, multiphase method to determine the minimum geriatric competencies needed by emergency medicine (EM) residents. Assessments of face validity and reliability were used throughout the project. RESULTS In Phase I, participants (n=363) identified 12 domains and 300 potential competencies. In Phase II, an expert panel (n=24) clustered the Phase I responses, resulting in eight domains and 72 competencies. In Phase III, the expert panel reduced the competencies to 26. In Phase IV, analysis of face validity and reliability yielded a 100% consensus for eight domains and 26 competencies. The domains identified were atypical presentation of disease; trauma, including falls; cognitive and behavioral disorders; emergent intervention modifications; medication management; transitions of care; pain management and palliative care; and effect of comorbid conditions. CONCLUSIONS The Geriatric Competencies for EM Residents is a consensus document that can form the basis for EM residency curricula and assessment to meet the demands of our aging population.
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Affiliation(s)
- Teresita M Hogan
- Department of Emergency Medicine, Resurrection Medical Center, University of Illinois, Chicago, IL, USA.
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Ko DT, Ross JS, Wang Y, Krumholz HM. Determinants of cardiac catheterization use in older Medicare patients with acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2009; 3:54-62. [PMID: 20123672 DOI: 10.1161/circoutcomes.109.858456] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cardiac catheterization is substantially underused among higher-risk patients with acute myocardial infarction (AMI) with appropriate indications but overused among patients with inappropriate indications. We sought to determine the importance of anticipated benefit and anticipated harm on the use of cardiac catheterization among older patients with AMI. METHODS AND RESULTS We performed an analysis of Medicare fee-for-service beneficiaries hospitalized with an AMI between 1998 and 2001. Multivariate models were developed to determine relative importance of anticipated benefit (baseline cardiovascular risk), anticipated harm (bleeding risk, comorbidities), and demographic factors (age, sex, race, regional invasive intensity) in predicting cardiac catheterization use within 60 days of AMI admission. Analyses were stratified by American College of Cardiology/American Heart Association class I or II as appropriate, and class III as inappropriate. Determinants of reduced likelihood of cardiac catheterization among 42 241 AMI patients with appropriate indications included (in order of importance) older age (likelihood chi(2)=1309.5), higher bleeding risk score (likelihood chi(2)=471.2), more comorbidities (likelihood chi(2)=276.6), female sex (likelihood chi(2)=162.9), hospitalization in low (likelihood chi(2)=67.9) or intermediate intensity invasive regions (likelihood chi(2)=22.4) (all P<0.001), and baseline cardiovascular risk (likelihood chi(2)=6.4, P=0.01). Among 2398 AMI patients with inappropriate indications, significant determinants of greater procedure likelihood included younger age, male sex, lower bleeding risk score, and fewer comorbidities. CONCLUSIONS Regardless of the procedure indication, the decision to perform cardiac catheterization in this population appears largely driven by demographic factors and potential harm rather than potential benefit of the procedure.
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Affiliation(s)
- Dennis T Ko
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, and Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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Föll D, Jung B, Schilli E, Staehle F, Geibel A, Hennig J, Bode C, Markl M. Magnetic resonance tissue phase mapping of myocardial motion: new insight in age and gender. Circ Cardiovasc Imaging 2009; 3:54-64. [PMID: 19996380 DOI: 10.1161/circimaging.108.813857] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND An exact understanding of normal age- and gender-matched regional myocardial performance is an essential prerequisite for the diagnosis of heart disease. Magnetic resonance phase-contrast imaging (tissue phase mapping) enabling the analysis of segmental, 3-directional myocardial velocities with high temporal resolution (13.8 ms) was used to assess left ventricular motion. METHODS AND RESULTS Radial, long-axis, and rotational myocardial velocities were acquired in 58 healthy volunteers (3 age groups, 29 women) in left ventricular basal, midventricular, and apical short-axis locations. For increased age, reduced (P<0.003) and prolonged long-axis and radial velocities (P<0.05) during diastole and reduced long-axis velocities (P<0.001) and apical rotation (P<0.005) during systole were found for both genders. Women demonstrated a reduced systolic twist (P=0.009), apical rotation (P=0.01), and systolic radial velocities (P<0.02) compared with men. Segmental analysis of long-axis motion with aging revealed differences in regional reduction of systolic (lateral 52% versus 30%) and diastolic (lateral 57% versus 41%) velocities in women compared with men. In basal segments, young women demonstrated higher long-axis velocities (+11% during diastole) than men, whereas this difference was reversed in older subjects (same segments, -20%). In addition, increased age resulted in a prolonged time to peak diastolic apical rotation (P<0.04) in women compared with men. CONCLUSIONS Age and gender strongly influence regional myocardial motion. Tissue phase mapping provides a comprehensive quantitative analysis of all myocardial velocities with high temporal and spatial resolution. The knowledge of the detected age- and gender-related differences in myocardial motion is fundamental for further investigations of cardiac disease. Clinical Trial Registration- http://www.zks.uni-freiburg.de/uklreg/php/suchergebnis_all.php. Identifier: UKF001739.
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Affiliation(s)
- Daniela Föll
- Department of Cardiology and Angiology, University Hospital Freiburg, Hugstetterstrasse 55, Freiburg, Germany.
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Perren A, Cerutti B, Lazzaro M, Donghi D, Previsdomini M, Marone C. Comparison of in-hospital secondary prevention for different vascular diseases. Eur J Intern Med 2009; 20:631-5. [PMID: 19782927 DOI: 10.1016/j.ejim.2009.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 05/27/2009] [Accepted: 07/07/2009] [Indexed: 11/20/2022]
Abstract
BACKGROUND Secondary prevention of coronary artery disease is highly effective and implemented on a large scale. However, studies testing adherence to recommended secondary prevention of other vascular diseases are rare. Our goal was to evaluate whether the kind of vascular disease influences prescription practice of secondary drug prophylaxis at hospital discharge and to which extent secondary prevention is actually complete. METHODS A 3-month prospective observational review of the hospital discharge information of all patients hospitalized because of a vascular disease diagnosis: coronary artery disease (i.e. acute myocardial infarction [AMI] and chronic stable angina [CSA]); peripheral artery disease [PAD] and cerebrovascular disease [CVD]. The analysis was done by board registered internists with a structured form that founded on internationally accepted recommendations. RESULTS From 271 patients 191 had coronary artery disease (105 AMI and 86 CSA), 88 PAD and 72 CVD. Global prescription rate (mean; 95% CI) of indicated secondary prophylaxis drugs was 74.1% (69.9-78.2) for AMI, 72.4% (67.2-77.5) for CSA, 74.7% (68.8-80.7) for PAD and 72.1% (66.9-77.3) for CVD. The proportion of patients who were prescribed a complete bundle of recommended medications was globally 29.5% (24.1-35.0). CONCLUSIONS We found similar global prescription rates of secondary prevention for the different vascular diseases. However, only one third of the studied collective gets a complete set of required prophylactic drugs.
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Affiliation(s)
- Andreas Perren
- Intensive Care Unit, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland.
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The Thrombin Receptor Antagonist for Clinical Event Reduction in Acute Coronary Syndrome (TRA*CER) trial: study design and rationale. Am Heart J 2009; 158:327-334.e4. [PMID: 19699853 DOI: 10.1016/j.ahj.2009.07.001] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2009] [Accepted: 07/06/2009] [Indexed: 11/16/2022]
Abstract
BACKGROUND The protease-activated receptor 1 (PAR-1), the main platelet receptor for thrombin, represents a novel target for treatment of arterial thrombosis, and SCH 530348 is an orally active, selective, competitive PAR-1 antagonist. We designed TRA*CER to evaluate the efficacy and safety of SCH 530348 compared with placebo in addition to standard of care in patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS) and high-risk features. TRIAL DESIGN TRA*CER is a prospective, randomized, double-blind, multicenter, phase III trial with an original estimated sample size of 10,000 subjects. Our primary objective is to demonstrate that SCH 530348 in addition to standard of care will reduce the incidence of the composite of cardiovascular death, myocardial infarction (MI), stroke, recurrent ischemia with rehospitalization, and urgent coronary revascularization compared with standard of care alone. Our key secondary objective is to determine whether SCH 530348 will reduce the composite of cardiovascular death, MI, or stroke compared with standard of care alone. Secondary objectives related to safety are the composite of moderate and severe GUSTO bleeding and clinically significant TIMI bleeding. The trial will continue until a predetermined minimum number of centrally adjudicated primary and key secondary end point events have occurred and all subjects have participated in the study for at least 1 year. The TRA*CER trial is part of the large phase III SCH 530348 development program that includes a concomitant evaluation in secondary prevention. CONCLUSION TRA*CER will define efficacy and safety of the novel platelet PAR-1 inhibitor SCH 530348 in the treatment of high-risk patients with NSTE ACS in the setting of current treatment strategies.
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Capturing outcomes of clinical activities performed by a rounding pharmacist practicing in a team environment: the COLLABORATE study [NCT00351676]. Med Care 2009; 47:642-50. [PMID: 19433997 DOI: 10.1097/mlr.0b013e3181926032] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Medical inpatients are at risk for suboptimal health outcomes from adverse drug events and under-use of evidence-based therapies. We sought to determine whether collaborative care including a team-based clinical pharmacist improves the quality of prescribed drug therapy and reduces hospital readmission. METHODS Multicenter, quasi-randomized, controlled clinical trial. Consecutive patients admitted to 2 internal and 2 family medicine teams in 3 teaching hospitals between January 30, 2006 and February 2, 2007 were included. Team care patients received proactive clinical pharmacist services (medication history, patient-care round participation, resolution of drug-related issues, and discharge counseling). Usual care patients received traditional reactive clinical pharmacist services. The primary outcome was the overall quality score measured retrospectively by a blinded chart reviewer using 20 indicators targeting 5 conditions. Secondary outcomes included 3- and 6-month readmission. RESULTS A total of 452 patients (220 team care, 231 usual care, mean age: 74 years, 46% male) met eligibility criteria. Team care patients were more likely than usual care patients to receive care specified by the indicators overall (56.4% vs. 45.3%; adjusted mean difference: 10.4%; 95% confidence interval [CI]: 4.9%, 15.7%) and for each targeted disease state except for heart failure. Team care patients experienced fewer readmissions at 3 months (36.2% vs. 45.5%; adjusted OR: 0.63; 95% CI: 0.42, 0.94) but not at 6 months (50.7% vs. 56.3%; adjusted OR; 0.78; 95% CI: 0.53, 1.15). CONCLUSIONS In patients admitted to internal and family medicine teams, team-based care including a clinical pharmacist, improved the overall quality of medication use and reduced rates of readmission.
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Relationship between cardiac rehabilitation and survival after acute cardiac hospitalization within a universal health care system. ACTA ACUST UNITED AC 2009; 16:102-13. [PMID: 19165089 DOI: 10.1097/hjr.0b013e328325d662] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The magnitude and mechanisms of survival benefit associated with cardiac rehabilitation services among real-world populations within a universal health care system remain unclear. METHODS This retrospective matched cohort study compared the long-term survival of 2042 cardiac rehabilitation participants with 2042 matched controls after an index acute cardiac hospitalization between 1999 and 2003, in Ontario, Canada. Each patient survived at least 1 year without recurrent admissions after discharge from the index hospitalization, and was followed for a mean of 5.25 years. Additional matching criteria included the type of sentinel cardiac events, age, sex, socioeconomic status, geography, previous cardiac and noncardiac hospitalizations. A Cox proportional hazards model further adjusted for baseline cardiovascular risk factors and process factors, cardiovascular risk-factor progression, downstream coronary procedure and evidence-based pharmacotherapy utilization. RESULTS Cardiac rehabilitation participation was associated with a 50% lower mortality rate (2.6 vs. 5.1%, P<0.001) as compared with population-matched controls. Statistically significant mortality benefits were observed among high-risk patients, and there was no significant interaction among age, cardiac rehabilitation participation, and survival (P=0.22). Associated survival advantages were not meaningfully altered after adjustment for cardiovascular risk-factor progression or the downstream utilization rates of cardiac procedures and evidence-based cardiovascular therapies; survival benefits predominantly applied to those patients that were most compliant with the program. CONCLUSION Cardiac rehabilitation is associated with significant long-term survival advantages after index cardiovascular hospitalizations. Despite universal access to medical care, such survival advantages seem to be mediated by compliant behaviors more so than by ancillary health service or evidence-based pharmacotherapy utilization.
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Visualization of multidirectional regional left ventricular dynamics by high-temporal-resolution tissue phase mapping. J Magn Reson Imaging 2009; 29:1043-52. [DOI: 10.1002/jmri.21634] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Raine R, Wong W, Ambler G, Hardoon S, Petersen I, Morris R, Bartley M, Blane D. Sociodemographic variations in the contribution of secondary drug prevention to stroke survival at middle and older ages: cohort study. BMJ 2009; 338:b1279. [PMID: 19372118 PMCID: PMC2669853 DOI: 10.1136/bmj.b1279] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2009] [Indexed: 12/03/2022]
Abstract
OBJECTIVES To determine the extent to which secondary drug prevention for patients with stroke in routine primary care varies by sex, age, and socioeconomic circumstances, and to quantify the effect of secondary drug prevention on one year mortality by sociodemographic group. DESIGN Cohort study using individual patient data from the health improvement network primary care database. SETTING England. PARTICIPANTS 12 830 patients aged 50 or more years from 113 general practices who had a stroke between 1995 and 2005 and who survived the first 30 days after the stroke. MAIN OUTCOME MEASURES Multivariable associations between odds of receiving secondary prevention after a stroke, and sex, age group, and socioeconomic circumstances; hazard ratios for all cause mortality from 31 days after the stroke and within the first year among patients receiving treatment and by social group; and probabilities of one year mortality for social factors of interest and treatment. RESULTS Only 25.6% of men and 20.8% of women received secondary prevention. Receipt of secondary prevention did not vary by socioeconomic circumstances or by sex. Older patients were, however, substantially less likely to receive treatment. The adjusted odds ratio for 80-89 year olds compared with 50-59 year olds was 0.53 (95% confidence interval 0.41 to 0.69). This was because older people were less likely to receive lipid lowering drugs-for example, the adjusted odds ratio for 80-89 year olds compared with 50-59 year olds was 0.44 (95% confidence interval 0.33 to 0.59). Secondary prevention was associated with a 50% reduction in mortality risk (adjusted hazard ratio 0.50, 95% confidence interval 0.42 to 59). On average, mortality within the first year was 5.7% for patients receiving treatment compared with 11.1% for patients not receiving treatment. There was little evidence that the effect of treatment differed between the social groups examined. CONCLUSION Under-treatment among older people with stroke in routine primary care cannot be justified given the lack of evidence on variations in effectiveness of treatment by age.
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Affiliation(s)
- Rosalind Raine
- Department of Epidemiology and Public Health, University College London, London WC1E 6BT.
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General practitioners’ coronary risk assessments and lipid-lowering treatment decisions in primary prevention: comparison between two European areas with different cardiovascular risk levels. Prim Health Care Res Dev 2008. [DOI: 10.1017/s146342360800090x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Hoeks SE, Scholte op Reimer WJ, Schouten O, Lenzen MJ, van Urk H, Poldermans D. Statin use in the elderly: Results from a peripheral vascular survey in The Netherlands. J Vasc Surg 2008; 48:891-5; discussion 895-6. [DOI: 10.1016/j.jvs.2008.04.073] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 04/30/2008] [Accepted: 04/30/2008] [Indexed: 11/30/2022]
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McAlister FA. The "number needed to treat" turns 20--and continues to be used and misused. CMAJ 2008; 179:549-53. [PMID: 18779528 DOI: 10.1503/cmaj.080484] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Affiliation(s)
- Finlay A McAlister
- Dr. McAlister is from The Division of General Internal Medicine, University of Alberta, Edmonton, AB.
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Safety and effectiveness of drug-eluting stents among diabetic patients: a propensity analysis. Am Heart J 2008; 156:125-34. [PMID: 18585507 DOI: 10.1016/j.ahj.2008.01.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 01/30/2008] [Indexed: 11/23/2022]
Abstract
BACKGROUND Diabetic patients frequently receive drug-eluting stents (DES) during percutaneous coronary interventions (PCI), but recent data have raised concerns as to whether DES are associated with increased risk of myocardial infarction or death. Accordingly, we sought to evaluate the long-term safety and effectiveness of DES in diabetic patients. METHODS We used a propensity score matching method to create and analyze a well-balanced cohort that included 2,374 diabetic patients who received PCI in Ontario, Canada, from December 1, 2003, to March 31, 2005. Primary outcomes of interest were repeat target-vessel revascularization, myocardial infarction, and death after the index PCI. RESULTS The mean age of our diabetic cohort was 64 years, and 68% of the patents were male. At 2 years, rates of repeat target-vessel revascularization were significantly lower among diabetic patients treated with DES compared with those treated with bare metal stents (BMS) (7.1% vs 14.4%, P < .001). Myocardial infarction rates were not significantly different between the 2 groups after 2 years (6.6% in DES group vs 4.5% in BMS group, P = .45). In addition, mortality was not statistically different among diabetic patients treated with DES (7.6%) and BMS (9.5%) (P = .086). CONCLUSIONS Drug-eluting stents are effective among diabetic patients in substantially reducing the need for repeat target-vessel revascularization. The overall rates of myocardial infarction were not significantly different between DES and BMS. In addition, the mortality of diabetic patients who received DES was not significantly increased compared with BMS.
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Sanchez LD, Goudie JS, De la Pena J, Ban K, Fisher J. Mortality after emergency department intubation. Int J Emerg Med 2008; 1:131-3. [PMID: 19384665 PMCID: PMC2657245 DOI: 10.1007/s12245-008-0028-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 03/26/2008] [Indexed: 11/27/2022] Open
Abstract
Introduction The purpose of this study is to identify the rate of emergency department (ED) intubation and the mortality associated with ED intubation. Methods We conducted a retrospective chart review of all patients intubated in the ED between 1 January 2004 and 31 December 2004 at an urban level one trauma centre with approximately 50,000 ED visits annually. All ED intubations were identified and reviewed. Two investigators reviewed all charts and collected the following data: age, sex, and final disposition from hospital as well as reason for intubation. The main outcome measure was survival to hospital discharge. Results One hundred sixty-three intubations were reviewed. Of the total 163 patients, 44 (27.0%) died prior to discharge from the hospital, 42 (25.8.%) patients were discharged to a skilled nursing facility (e.g. nursing home, rehabilitation and extended care facility) and 71 (43.6%) patients were discharged home. Dividing our cohort into trauma and non-trauma subgroups, 38/126 (30.2%) of the non-trauma patients and 6/37 (16.2.%) of the trauma patients died. The mean age for all patients in our study group was 61.5 years, with trauma patients being younger than the non-trauma subgroup. The mean age for trauma patients was 50.1 while non-trauma patients had a mean age of 64.8. Conclusions The mortality after an ED intubation in our study population was relatively high. Further studies need to confirm these findings and help identify predictors of mortality.
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Affiliation(s)
- Leon D Sanchez
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Ko DT, Wang Y, Alter DA, Curtis JP, Rathore SS, Stukel TA, Masoudi FA, Ross JS, Foody JM, Krumholz HM. Regional Variation in Cardiac Catheterization Appropriateness and Baseline Risk After Acute Myocardial Infarction. J Am Coll Cardiol 2008; 51:716-23. [DOI: 10.1016/j.jacc.2007.10.039] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Revised: 09/19/2007] [Accepted: 10/01/2007] [Indexed: 12/22/2022]
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Schoenenberger AW, Radovanovic D, Stauffer JC, Windecker S, Urban P, Eberli FR, Stuck AE, Gutzwiller F, Erne P. Age-related differences in the use of guideline-recommended medical and interventional therapies for acute coronary syndromes: a cohort study. J Am Geriatr Soc 2008; 56:510-6. [PMID: 18179499 DOI: 10.1111/j.1532-5415.2007.01589.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To compare the use of guideline-recommended medical and interventional therapies in older and younger patients with acute coronary syndromes (ACSs). DESIGN Prospective cohort study. SETTING Fifty-five hospitals in Switzerland. PARTICIPANTS Eleven thousand nine hundred thirty-two patients with ACS enrolled between March 1, 2001, and June 30, 2006. ACS definition included ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), and unstable angina pectoris (UA). MEASUREMENTS Use of medical and interventional therapies was determined after exclusion of patients with contraindications and after adjustment for comorbidities. Multivariate logistic regression models were used to calculate odds ratios (ORs) per year increase in age. RESULTS Elderly patients were less likely to receive acetylsalicylic acid (OR=0.976, 95% confidence interval (CI)=0.969-0.980) or beta-blockers (OR=0.985, 95% CI=0.981-0.989). No age-dependent difference was found for heparin use. Elderly patients with STEMI were less likely to receive percutaneous coronary intervention (PCI) or thrombolysis (OR=0.955, 95% CI=0.949-0.961). Elderly patients with NSTEMI or UA less often underwent PCI (OR=0.943, 95% CI=0.937-0.949). CONCLUSION Elderly patients across the whole spectrum of ACS were less likely to receive guideline-recommended therapies, even after adequate adjustment for comorbidities. Prognosis of elderly patients with ACS may be improved by increasing adherence to guideline-recommended medical and interventional therapies.
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Statins for Secondary Prevention in Elderly Patients. J Am Coll Cardiol 2008; 51:37-45. [DOI: 10.1016/j.jacc.2007.06.063] [Citation(s) in RCA: 255] [Impact Index Per Article: 15.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2007] [Revised: 05/31/2007] [Accepted: 06/25/2007] [Indexed: 11/21/2022]
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Vermeulen MJ, Tu JV, Schull MJ. ICD-10 adaptations of the Ontario acute myocardial infarction mortality prediction rules performed as well as the original versions. J Clin Epidemiol 2007; 60:971-4. [PMID: 17689814 DOI: 10.1016/j.jclinepi.2006.12.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 12/07/2006] [Accepted: 12/11/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To derive and validate an International Classification of Diseases-10 (ICD-10) version of the Ontario Acute Myocardial Infarction (AMI) mortality prediction rules, used to adjust for case-mix differences in studies of AMI patients using administrative data. STUDY DESIGN AND SETTING We linked the records of all Ontario patients admitted with AMI (2002-2004) with mortality data. The original ICD-9 codes were mapped to ICD-10-CA (Canada) codes using both a translation produced by coding experts and a manual search of codes; the final codes were determined by consensus. Comorbidity prevalence and mortality rates were calculated. Multivariable logistic regression models were used to predict 30-day and 1-year mortality and the C-statistic was used to evaluate the discrimination of the models. RESULTS We identified 37,271 AMI patients. The most common comorbidities were heart failure and dysrhythmias; 30-day and 1-year mortality rates were 12.3% and 21.8%, respectively; and mortality rates were highest among patients with shock, cancer, and acute renal failure. The C-statistics were 0.77 and 0.80, compared with 0.78 and 0.79 in the ICD-9 version, for 30-day and 1-year mortality, respectively. CONCLUSION An ICD-10 version of the AMI mortality prediction rules predicted 30-day and 1-year mortality as well as the original ICD-9 version.
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Affiliation(s)
- Marian J Vermeulen
- Institute for Clinical Evaluative Sciences, Department of Health Policy, Management and Evaluation, University of Toronto, Ontario, Canada
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47
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Alexander KP, Newby LK, Cannon CP, Armstrong PW, Gibler WB, Rich MW, Van de Werf F, White HD, Weaver WD, Naylor MD, Gore JM, Krumholz HM, Ohman EM. Acute coronary care in the elderly, part I: Non-ST-segment-elevation acute coronary syndromes: a scientific statement for healthcare professionals from the American Heart Association Council on Clinical Cardiology: in collaboration with the Society of Geriatric Cardiology. Circulation 2007; 115:2549-69. [PMID: 17502590 DOI: 10.1161/circulationaha.107.182615] [Citation(s) in RCA: 476] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Age is an important determinant of outcomes for patients with acute coronary syndromes (ACS); however, community practice reveals a disproportionately lower use of cardiovascular medications and invasive treatment even among elderly patients with ACS who would stand to benefit. Reasons include limited trial data to guide the care of older adults and uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age or complex health status. METHODS AND RESULTS This 2-part American Heart Association scientific statement summarizes evidence on patient heterogeneity, clinical presentation, and treatment of non-ST-elevation ACS in relation to age (< 65, 65 to 74, 75 to 84, and > or = 85 years). In addition, we review methodological issues that influence the acquisition and application of evidence to the elderly patients treated in community practice. A writing group combining international cardiovascular and geriatric perspectives convened to summarize available data from trials (5 combined Virtual Coordinating Center for Global Collaborative Cardiovascular Research [VIGOUR] trials) and 3 registries (Global Registry of Acute Coronary Events, National Registry of Myocardial Infarction, and the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the American College of Cardiology/American Heart Association guidelines national quality improvement initiative [CRUSADE]) to provide a conceptual framework for future work in the care of the elderly with acute cardiac disease. Treatment for non-ST-segment-elevation ACS (Part I) and ST-segment-elevation myocardial infarction (Part II) are reviewed. In addition, ethical considerations pertaining to acute care and secondary prevention are considered (Part II). The primary goal is to identify the areas in which sufficient evidence is available to guide practice, as well as to determine areas that warrant further study. Although treatment-related benefits should rise in an elderly population with high disease risk, data to assess these benefits are limited, outcomes of importance vary, and heterogeneity among the elderly increases treatment-related risks. Although a uniform approach to care in the oldest of the old is unlikely, understanding the major contributors to benefits and risks from treatment will advance the ability to apply guideline-based care in this subset of patients. CONCLUSIONS Although a few recent trials have described treatment effects in older patients, others continue to exclude patients on the basis of age. Going forward, prospective trials should enroll elderly subjects proportionate to their prevalence among the treated population to define risk and benefit. Findings from age subgroup analyses should be reported in a consistent manner across trials, including absolute and relative risks for efficacy and safety. Outcomes of particular relevance to the elderly, such as quality of life, physical function, and independence, should also be considered. Creatinine clearance should be calculated for every elderly patient to enable appropriate dosing. In addition, physicians need an understanding of conditions unique to older patients (eg, frailty, cognitive impairment) that influence treatment goals and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed in the health context of the elderly patient with ACS.
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48
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Shah R, Wang Y, Masoudi FA, Foody JM. Sex and racial differences in outcomes and guideline-based management of troponin-only-positive acute myocardial infarction in older persons. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2007; 16:97-105. [PMID: 17380619 DOI: 10.1111/j.1076-7460.2007.05744.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Multiple studies have shown sex and racial differences in the management and outcomes of ischemic heart disease, but whether these sex and racial disparities persist in patients with troponin-only-positive acute myocardial infarction (AMI) is unknown. The authors evaluated a nationwide sample of eligible Medicare beneficiaries, 65 years or older, who were hospitalized (N=71,120) with a primary discharge diagnosis of AMI. Analysis was restricted to patients with troponin-only-positive AMI (n=5897) and was substratified into 4 groups: white men, white women, nonwhite men, and nonwhite women. The authors found that the traditional sex and racial disparities in the evidence-based medication prescriptions for ischemic heart diseases resolved in this cohort of older patients. Similarly, in settings of equal care, sex and race seem to have no impact on the outcomes for older patients with troponin-only-positive AM.
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Affiliation(s)
- Rahman Shah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT 06520-8025, USA
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49
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Ko DT, Krumholz HM, Wang Y, Foody JM, Masoudi FA, Havranek EP, You JJ, Alter DA, Stukel TA, Newman AM, Tu JV. Regional Differences in Process of Care and Outcomes for Older Acute Myocardial Infarction Patients in the United States and Ontario, Canada. Circulation 2007; 115:196-203. [PMID: 17190861 DOI: 10.1161/circulationaha.106.657601] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background—
Previous comparisons of acute myocardial infarction (AMI) treatment between the United States and Canada are limited because they compared selected patients from randomized trials, used administrative data that lacked clinical detail, or did not consider regional differences in AMI treatment.
Methods and Results—
We compared medication use, invasive cardiac procedure use, and 30-day risk-standardized mortality rates of 38 886 fee-for-service Medicare beneficiaries hospitalized with AMI in the United States and 5634 similarly aged patients in Ontario, Canada, from 1998 and 2001. Baseline characteristics and illness severity across the US regions and Ontario were not substantially different. Cardiac catheterization use in AMI patients was significantly higher in the United States compared with Ontario (38.7% versus 16.8%,
P
<0.001), but significant regional variations existed, in which the northeastern United States had significantly lower utilization rates (25.6%) compared with other US regions. β-Blocker use among ideal candidates was highest in the northeastern United States (77.6% versus 69.7% in the United States as a whole,
P
<0.001) and angiotensin-converting enzyme inhibitor use was highest in Ontario (69.1% versus 58.2% in the United States,
P
<0.001). Risk-standardized mortality rates at 30 days were not substantially different across the regions.
Conclusions—
Previous studies have suggested a clear divergence in invasive cardiac therapy for AMI patients between the United States and Canada on the basis of health care financing and structural differences. Our findings of similar treatment patterns in the northeastern United States and Ontario suggest that regional practices may have a greater impact on treatment patterns than the respective health care delivery systems.
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Affiliation(s)
- Dennis T Ko
- Division of Cardiology, Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Tricoci P, Peterson ED, Roe MT. Patterns of guideline adherence and care delivery for patients with unstable angina and non-ST-segment elevation myocardial infarction (from the CRUSADE Quality Improvement Initiative). Am J Cardiol 2006; 98:30Q-35Q. [PMID: 17169628 DOI: 10.1016/j.amjcard.2006.09.022] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative is a prospective, rapid-cycle quality-improvement initiative that focuses on improving both the diagnostic evaluation of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS; defined as ischemic ST-segment changes and/or positive cardiac markers) and the use of treatments recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for management of NSTE ACS. The ultimate goal of the CRUSADE initiative is to improve the quality of care among high-risk patients with NSTE ACS. At the same time, the CRUSADE initiative provides the unique opportunity to evaluate the pattern of NSTE ACS management in a large-scale, routine practice setting in the United States. Cumulatively, the CRUSADE initiative has collected data from >165,000 patients with NSTE ACS admitted at >400 US hospitals since 2001. This article reviews the major results from the CRUSADE initiative on risk stratification, gaps in guidelines adherence, paradoxical care, and the association of guideline adherence with outcomes.
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Affiliation(s)
- Pierluigi Tricoci
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina 27705, USA.
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