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Prognostic significance of coronary artery calcium in asymptomatic subjects with usual cardiovascular risk

AMERICAN HEART JOURNAL 2003年第3期145卷 542-548页

作者： Alexopoulos, D Toulgaridis, T Davlouros, P Christodoulou, J Sitafidis, G Hahalis, G Vagenakis, AG Univ Patras Sch Med Div Cardiol Dept Med GR-26110 Patras Greece

Background Coronary calcium detected noninvasively is an attractive way to diagnose atherosclerosis before the development of symptoms. This study examines the prognostic value of coronary calcium in asymptomatic subjects with usual cardiovascular risk. Methods and Results In 425 asymptomatic subjects, 229 men,(aged 45.1 +/- 14 years) and 196 women (aged 42.7 +/- 13 years), coronary calcium presence was studied by digital cinefluoroscopy. The majority (76 %) had no or at most one risk factor. Subjects were followed up for 58.4 +/- 12.7 months for cardiac events. Coronary calcium was present in 76 of 425 (17.9%) subjects. Cardiac events were observed in 21 subjects: 2 cardiac deaths, 7 acute (myocardial infarctions, 3 coronary artery bypass grafts, 3 coronary angioplasty procedures, 3, events of unstable angina, and 10 events of stable angina pectoris. Survival curve analysis showed significant differences in all the studied end points between subjects with and those without calcium. Coronary calcium was an independent predictor of all events (3.6-fold increase, P < .008), cardiac death/myocardial infarction/revascularization (13.9-fold increase, P < .02), and stable angina (7.4-fold increase, P < .007). However, calcium did not independently predict cardiac death/myocardial infarction or acute coronary syndromes. Conclusions Coronary calcium in asymptomatic subjects with usual cardiovascular risk adds significant incremental information to risk factors information for the development of symptomatic coronary artery disease.

关键词：钙质沉着症/放射摄影术电影X线摄影术/统计学和数值数据队列研究冠状血管造影术/统计学和数值数据冠状动脉分流术/统计学和数值数据随访研究心肌梗死/流行病学心肌梗死/死亡率预后危险性评估危险因素存活率分析女(雌)性人类男(雄)性中年人

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Regional variation in the treatment and outcomes of myocardial infarction: Investigating New England's advantage

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AMERICAN HEART JOURNAL 2003年第2期146卷 242-249页

作者： Krumholz, HM Chen, J Rathore, SS Wang, Y Radford, MJ Yale Univ Sch Med Sect Cardiovasc Med Dept Med New Haven CT 06520 USA Yale Univ Sch Med Sect Hlth Policy & Adm Dept Epidemiol & Publ Hlth New Haven CT 06520 USA Yale New Haven Med Ctr Ctr Outcomes Res & Evaluat New Haven CT 06504 USA Qualidigm Middletown CT USA Yale New Haven Hlth Ctr Outcomes Res & Evaluat New Haven CT USA

Background Previous studies have reported that myocardial infarction (MI) treatment in New England differs from that of other regions of the United States. We sought to determine whether regional differences in MI treatment were independent of regional differences in patient, hospital, or physician characteristics, and whether the New England region's practice pattern was associated with better outcomes than those of patients in other regions. Methods We evaluated 167,180 patients aged : 65 years who were hospitalized with MI between 1994 to 1996 to assess regional variations in quality of care. Patients were evaluated for the use of reperfusion therapy, aspirin, and beta-blockers on admission and 30-day mortality rate. Hierarchical logistic regression models were used to determine whether practice patterns specific to New England were independent of regional variations in patient, physician, hospital, or other geographic characteristics. Results New England had the highest use of beta-blockers (72% vs 52% other regions, P <.001), and aspirin (80% vs 76% other regions, P <.001), a lower use of reperfusion therapy (61% vs 67% other regions, P <.001), and the lowest risk-standardized 30-day mortality rate (15% vs 19% other regions, P <.001). These differences persisted after adjusting for patient, physician, and hospital characteristics. Conclusions Patients with MI in New England have higher rates of medical therapy use and lower 30-day mortality rates than patients in other US regions. This pattern is independent of patient or provider characteristics, suggesting other factors likely contribute to better short-term outcomes in New England.

关键词：肾上腺素能β受体拮抗剂/治疗应用血管成形术气囊冠状动脉/统计学和数值数据阿司匹林/治疗应用冠状动脉分流术/统计学和数值数据纤维蛋白溶解药/治疗应用住院 Logistic模型心肌梗死/药物疗法心肌梗死/死亡率心肌梗死/治疗新英格兰/流行病学结果评价(卫生保健) 卫生保健质量血栓溶解疗法/统计学和数值数据美国/流行病学老年人女(雌)性人类男(雄)性

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Short-term outcomes after percutaneous coronary intervention: Effects of stenting and institutional volume shifts

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AMERICAN HEART JOURNAL 2002年第2期144卷 309-314页

作者： Watanabe, CT Maynard, C Ritchie, JL Univ Washington Dept Med Seattle WA 98195 USA Univ Washington Dept Hlth Sci Seattle WA 98195 USA Hlth Serv Res & Dev Seattle WA USA Dept Vet Affairs Dept Med Seattle WA USA

Background This study examines how the dissemination of stenting and procedural shifts to high-volume facilities have affected short-term outcomes after percutaneous coronary intervention (PCI). Methods Discharge information from the 1994 and 1997 US Nationwide Inpatient Sample was used. Data from 1994 involved 84,036 angioplasties, 27.3% of which were performed for acute myocardial infarction (AMI), at a time when stents were generally unavailable. Data from 1997 included 118,548 angioplasties, 30.2% of which were performed for AMI and 59% of which involved stenting. Outcomes included same-admission mortality and same-admission bypass grafting surgery (CABG). Results Compared with 1994, in 1997 stents were in widespread use, and there was a significant shift in PCI procedures to high-volume facilities. There was no significant difference in overall mortality rates between 1994 and 1997. However, same-admission CABG rates were lower in 1997 than in 1994 for the AMI group (2.9% vs,4.7%, P < .0001) and for the no-AMI group (1.8% vs 3.0%, P < .0001), which was attributable almost entirely to stenting. For 1997 only, patients receiving stents had a lower mortality rate than patients undergoing PCI without stenting (AMI 2.7% vs 4.7%, P < .0001, no AMI 0.7% vs 0.9%, P = .004). Conclusions Despite the dissemination of stenting and shifts to high-volume facilities, overall mortality rates after PCI have not significantly changed. However, patients undergoing stenting in 1997 had a significantly lower mortality rate than patients who did not undergo stenting, suggesting that stents may prevent inhospital deaths. Furthermore, same-admission CABG rates have decreased dramatically, an association seen with the introduction of stenting, but not with volume shifts.

关键词：血管成形术经腔经皮冠状动脉/死亡率冠状动脉分流术/统计学和数值数据医院死亡率/发展趋势住院病人/统计学和数值数据多元分析心肌梗死/流行病学心肌梗死/治疗比值比支架/统计学和数值数据存活率/发展趋势治疗结果美国/流行病学女(雌)性人类男(雄)性中年人

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Cardiogenic shock complicating acute myocardial infarction in elderly patients: Does admission to a tertiary center improve survival?

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AMERICAN HEART JOURNAL 2002年第5期143卷 768-776页

作者： Berger, AK Radford, MJ Krumholz, HM Yale Univ Sch Med Dept Med Sect Cardiovasc Med New Haven CT 06520 USA Yale Univ Sch Med Dept Epidemiol & Publ Hlth Sect Hlth Policy & Adm New Haven CT 06520 USA Yale New Haven Med Ctr Ctr Outcomes Res & Evaluat New Haven CT 06504 USA Qualidigm Middletown CT USA

Background The role of early revascularization among patients with acute myocardial infarction complicated by cardiogenic shock remains controversial. Angioplasty registries, while suggesting a benefit, are subject to selection bias, and clinical trials have been underpowered to detect early benefits. If an invasive strategy is beneficial in this population, patients admitted to hospitals with onsite coronary revascularization might be expected to have a better prognosis. We sought to determine whether access to cardiovascular resources at the admitting hospital influenced the prognosis of patients with acute myocardial infarction complicated by cardiogenic shock. Methods By use of the Cooperative Cardiovascular Project database (a retrospective medical record review of Medicare patients discharged with acute myocardial infarction), we identified patients aged greater than or equal to65 years whose myocardial infarction was complicated by cardiogenic shock. Results Of the 601 patients with cardiogenic shock, 287 (47.8%) were admitted to hospitals without revascularization services and 3 14 (52.2%) were admitted to hospitals with coronary angioplasty and coronary artery bypass surgery facilities. Clinical characteristics were similar across the subgroups. Patients admitted to hospitals with revascularization services were more likely to undergo coronary revascularization during the index hospitalization and during the first month after acute myocardial infarction. After adjustment for demographic, clinical, hospital, and treatment strategies, the presence of onsite revascularization services was not associated with a significantly lower 30-day (odds ratio 0.83, 95% CI 0.47, 1.45) or 1-year mortality (odds ratio 0.91, 95% CI 0.49, 1.72). Conclusions In a community-based cohort, patients with acute myocardial infarction complicated by cardiogenic shock did not have significantly different adjusted 30-day and 1-year mortality, irrespective of the revascularization capab

关键词：队列研究冠状动脉分流术/统计学和数值数据冠心病重症监护病房数据库事实型住院心肌梗死/并发症心肌梗死/死亡率心肌梗死/治疗心肌血管重建术/死亡率心肌血管重建术/利用比值比预后休克心原性/并发症休克心原性/死亡率休克心原性/治疗女(雌)性人类男(雄)性

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Characteristics and outcomes among patients undergoing coronary artery bypass grafting in western Sweden and Minneapolis-St Paul, Minnesota

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AMERICAN HEART JOURNAL 2001年第6期142卷 1080-1087页

作者： Vargas, A Doliszny, K Herlitz, J Karlsson, T McGovern, P Brandrup-Wognsen, G Luepker, RV Sahlgrens Univ Hosp Div Cardiothorac Surg Gothenburg Sweden Sahlgrens Univ Hosp Div Cardiol Gothenburg Sweden Univ Minnesota Sch Publ Hlth Div Epidemiol Minneapolis MN 55454 USA

Background The purpose of this study was to compare patient selection, operative factors, and survival for coronary artery bypass, grafting (CABG) for coronary heart disease in Minneapolis-St Paul (MSP), Minnesota, and Western Sweden. (WS). Methods and Results All patients from WS between 1988 and 1991 (n = 2365) and a 17% random sample of MSP patients between 1985 and 1990 (n = 1659) who underwent CABG surgery were studied. CABG was 3 times greater in MSP. MSP patients had significantly more obesity, cigarette smoking, prior CABG, and prior coronary angioplasty. WS patients had more and longer angina pectoris, better left ventricular function, and waited longer from previous acute MI until. CABG. WS patients had more internal, mammary artery graphs and a shorter aortic cross-clamp time. At discharge, WS patients received more P-blockers and antiplatelet agents, whereas MSP patients received more calcium channel blockers and digitalis. Age-adjusted mortality rate at 28 days was significantly higher in MSP but not at 3 years. Adjustment for patient characteristics and treatment factors reduced or eliminated these differences. Conclusions Although coronary heart disease rates were higher in WS, age-adjusted CABG rates were 3-fold higher in MSP. Better survival among WS patients was associated with differences in patient selection and clinical and treatment characteristics because MSP patients were more severely ill and at increased risk. Health system characteristics and practice may account for these differences.

关键词：年龄分布吻合术外科/方法血管造影术共病现象冠状动脉分流术/死亡率冠状动脉分流术/统计学和数值数据冠心病/流行病学冠心病/外科学发病率 Logistic模型明尼苏达/流行病学肥胖症/流行病学病人遴选随机分配性别分布存活率瑞典/流行病学治疗结果心室功能障碍左/流行病学心室功能障碍左/放射摄影术成年人老年人老年人 80以上女(雌)性人类男(雄)性

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Trends in coronary artery bypass surgery results: A recent, 9-year study

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ANNALS OF THORACIC SURGERY 2000年第1期70卷 84-90页

作者： Abramov, D Tamariz, MG Fremes, SE Guru, V Borger, MA Christakis, GT Bhatnagar, G Sever, JY Goldman, BS Univ Toronto Sunnybrook Hlth Sci Ctr Sunnybrook & Womens Coll Div Cardiovasc Surg Toronto ON M4N 3M5 Canada

Background. The demographics of patients undergoing coronary artery bypass grafting (CABG) have changed over time and may contribute to differing operative mortality and the combination of mortality and morbidity (M + M). In this study, the trends in results are analyzed and causes are suggested. Methods. Prospectively collected data concerning 4,839 CABG operations was divided into three time cohorts (1990 to 1992, 1993 to 1995, 1996 to 1998) and analyzed by univariate and multivariate techniques. Results. Mean age and female gender frequency increased in the later time cohorts (60.7 +/- 9.0 to 63.4 +/- 9.9 years and 16.5% to 21.4%, respectively). The following comorbidities were more prevalent in the later time cohorts: diabetes (26.7% versus 18.6%), renal failure (8.5% versus 2.2%), peripheral vascular disease (20.7% versus 11.0%), previous cerebrovascular accident (6.7% versus 5.0%), urgent procedures (41.5% versus 26.9%), unstable angina (47.8% versus 31.7%), urgent CABG following myocardial infarction (17.1% versus 7.3%), previous percutaneous transluminal coronary angioplasty (8.0% versus 4.5%), ejection fraction less than 35% (20.5% versus 10.4%), tall p < 0.05). Procedurally, increased utilization of the left internal mammary artery, multiple arterial conduits, and warm blood cardioplegia occurred in the later cohorts (91.2%, 22.2%, and 80.4% versus 78.7%, 3.4%, and 38.0%, respectively). The mortality rate was 2.0% and the M + M rate was 15.6% in all 4,839 patients. The mortality and M + M for the three cohorts were 1.6%, 2.0%, and 2.3% and 18.4%, 17.2% and 12.5%, respectively. The risk-adjusted mortality and M + M decreased from 2.4% and 15.9%, respectively, in 1990 to 1992 to 1.8% and 8.4% in 1996 to 1998 (p < 0.001). The difference in adjusted event rates was minimized when the surgical factors were entered into the model. Conclusions. Over time, there has been a trend toward operating on older patients with more comorbidities. Though hospital mortality

关键词：冠状动脉分流术/方法冠状动脉分流术/统计学和数值数据冠状动脉分流术/发展趋势多元分析手术后并发症/流行病学预后前瞻性研究时间因素治疗结果老年人女(雌)性人类男(雄)性中年人

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Safety and efficacy of percutaneous coronary interventions performed immediately after diagnostic catheterization in northern New England and comparison with similar procedures performed later

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第1期86卷 41-45页

作者： Shubrooks, SJ Malenka, DJ Piper, WD Bradley, WA Watkins, MW Ryan, TJ Hettleman, BD VerLee, PN O'Meara, JR Robb, JF Kellett, MA Hearne, MA McGrath, PD Wennberg, DE O'Rourke, DJ Silver, TM Beth Israel Deaconess Med Ctr Div Cardiovasc Boston MA 02215 USA Dartmouth Hitchcock Med Ctr Cardiol Sect Lebanon NH 03766 USA Dartmouth Coll Hitchcock Med Ctr Dartmouth Med Sch Ctr Evaluat & Clin Sci Hanover NH 03756 USA Optima Hlth Care Manchester VT USA Fletcher Allen Hlth Care Div Cardiol Burlington VT USA Maine Med Ctr Dept Med Div Cardiol Portland ME 04102 USA Eastern Maine Med Ctr Div Cardiol Bangor ME USA Maine Med Ctr Div Hlth Serv Res Portland ME 04102 USA

"Ad hoc" percutaneous coronary interventions (PCIs)-those performed immediately after diagnostic catheterization-have been reported in earlier studies to be safe with a suggestion of higher risk in certain subgroups. Despite increasing use of this strategy, no data are available in recent years with new device technology. We studied use of on ad hoc strategy in a large regional population to determine its use and outcomes campared with staged procedures. A database from the 6 centers performing PCIs in northern New England and 1 center in Massachusetts was analyzed. During 1997, excluding only patients requiring emergency procedures or those with a prior PCI, 4,136 PCIs were performed, 1,748 (42.3%) of these being ad hoc procedures. Patients having ad hoc procedures were less likely to have peripheral vascular disease, renal failure, prior myocardial infarction, or coronary artery by-pass surgery, congestive heart failure, or poor left ventricular function, and more likely to have received preprocedural intravenous heparin or nitroglycerin or to have required an urgent procedure. Narrowings treated during ad hoc procedures were less frequently types B and C or in saphenous vein grafts. Adjusted rates of clinical success were not different between ad hoc and non-ad hoc procedures (93.7% vs 93.6%);there was no difference in the incidence of death (0.6% vs 0.5%), emergency (0.9% vs 0.8%) or any (1.4% vs 0.8%) coronary artery bypass surgery, or myocardial infraction (2.6% vs 2.0%). As currently practiced in our region, ad hoc intervention is used selectively with outcomes similar for ad hoc and non-ad hoc procedures. (C) 2000 by Excerpta Medica, Inc.

关键词：斑块切除术冠状动脉/标准斑块切除术冠状动脉/统计学和数值数据冠状动脉分流术/统计学和数值数据心脏导管插入术医院死亡率发病率马萨诸塞/流行病学心肌梗死/流行病学心肌梗死/外科学新英格兰/流行病学危险因素安全支架存活率治疗结果女(雌)性人类男(雄)性中年人

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Third-time coronary artery bypass grafting

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ANNALS OF THORACIC SURGERY 2000年第2期70卷 483-486页

作者： Noyez, L Touma, IM Skotnicki, SH Brouwer, RMHJ Catholic Univ Nijmegen Dept Thorac & Cardiac Surg 414 NL-6500 HB Nijmegen Netherlands

Background. In this study we analyze the short- and long-term results, and the clinical, functional, and subjective status of patients after a second coronary reoperation(RE-RE-CABG). Methods. The perioperative data of 33 consecutive patients undergoing RE-RE-CABG (1987 to 1998) were studied. Follow-up information was obtained from our follow-up databank. A cross-sectional follow-up was conducted, with additional functional evaluation by the Duke Activity Status Index (DASI), and patients' evaluations of their life situation were registered. Results. Perioperative mortality was 2 of 33 patients (6%). During the follow-up (mean 51.6 months) 5 patients died. The 26 survivors showed a significant decrease in New York Heart Association class from 3.6 +/- 0.4 preoperatively versus 2.2 +/- 0.6 postoperatively. The mean Duke Activity Status Index score was 29.30 +/- 16.34 (range 7.22 to 48.9). In all, 18 of 26 patients (70%) were declared to have benefitted from the RE-RECABG. Conclusions. The significant improve in New York Heart Association class and good postoperative functional capacity, justified the RE-RE-CABG. However, patients must be informed about the limitations of this procedure. (C) 2000 by The Society of Thoracic Surgeons.

关键词：心肺转流术冠状血管造影术冠状动脉分流术/方法冠状动脉分流术/统计学和数值数据冠心病/外科学复发再手术老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Outcome 14 to 18 years after percutaneous transluminal coronary angioplasty

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第10期85卷 1242-+页

作者： Jimenez, J Kelsey, SF Yeh, WL Williams, DO Brown Univ Sch Med Rhode Isl Hosp Providence RI 02912 USA Univ Pittsburgh Grad Sch Publ Hlth Pittsburgh PA USA

Long-term clinical outcome was evaluated in 129 patients who underwent percutaneous transluminal coronary angioplasty mostly for single-vessel coronary disease. Long-term (14 to 18 years) clinical follow-up revealed f... 详细信息

关键词：冠状动脉分流术/统计学和数值数据无病生存随访研究心肌梗死/死亡率心肌梗死/治疗预后登记时间因素女(雌)性人类男(雄)性中年人

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Diagnosis of suspected coronary artery disease in women: A cost-effectiveness analysis

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AMERICAN HEART JOURNAL 1999年第6期137卷 1019-1027页

作者： Kim, C Kwok, YS Saha, S Redberg, RF Univ Calif San Francisco Div Cardiol San Francisco CA 94131 USA Univ Calif San Francisco Dept Med San Francisco CA 94131 USA

Background The optimal strategy for the diagnosis of coronary artery disease (CAD) in women is not well defined. We compared the cost-effectiveness of several strategies for diagnosing CAD in women with chest pain. Methods we performed decision and cost-effectiveness analyses with simulations of 55-year-old ambulatory women with chest pain. With a Markov model, simulations of patients underwent exercise electrocardiography, exercise testing with thallium scintigraphy, exercise echocardiography, angiography, or no workup. Results Diagnosis with angiography cost less than $17,000 per quality-adjusted life-year compared with exercise echocardiography if the patient had definite angina and less than $76,000 per life-year if she had probable angina. If she had nonspecific chest pain, diagnosis with exercise echocardiography increased life-years compared with no testing. Conclusions Cost-effectiveness of first-line diagnostic strategy for diagnosis of CAD in women varies mostly according to pretest probability of CAD. Diagnosis of coronary artery disease with angiography is cost-effective in 55-year-old women with definite angina. In 55-year-old women with probable angina, diagnosis with angiography would increase quality-adjusted life-years but significantly increase costs. Use of exercise echocardiography as a first-line diagnosis for CAD is cost effective in 55-year-old women with probable angina and nonspecific chest pain.

关键词：加利福尼亚胸痛/诊断胸痛/经济学胸痛/治疗冠状动脉分流术/经济学冠状动脉分流术/统计学和数值数据冠心病/诊断冠心病/经济学冠心病/治疗费用效益分析决策支持技术卫生保健费用 Markov链心肌梗死/诊断心肌梗死/经济学心肌梗死/治疗质量校正寿命敏感性与特异性女(雌)性人类中年人

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