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Use of resources, quality of life, and clinical outcomes in patients with and without new Q waves after thrombolytic therapy for acute myocardial infarction (from the GUSTO-I trial)

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第1期86卷 24-29页

作者： Barbagelata, A Califf, RM Sgarbossa, EB Goodman, SG Knight, D Mark, DB Granger, CB Agranatti, DA Mautner, B Ohman, EM Suárez, LD Armstrong, PW Gates, K Wagner, GS Duke Clin Res Inst Durham NC USA Rush Presbyterian St Lukes Med Ctr Chicago IL 60612 USA Univ Toronto St Michaels Hosp Terrence Donnelly Heart Program Toronto ON M5B 1W8 Canada Univ Alberta Edmonton AB Canada

Previous reports indicate that patients who do not develop Q waves after thrombolytic therapy are a different population with a better long-term survival than those who do develop Q waves. However, the use of resources, quality of life, and health status of this population have not been fully evaluated. Using data from the Economics and Quality of Life subset of the Global Utilization of Streptokinase and tPA for Occluded Arteries study, we examined 30-day and 1-year mortality, use of resources, and quality-of-life measures among 1,830 of 3,000 patients with acute myocardial infarction and ST-segment elevation treated with thrombolytic therapy. At hospital discharge, 555 patients (30.2%) had not developed Q waves. These patients had lower mortality than patients with Q waves at 30 days (1.6% vs 4.5%, p <0.01) and at 1 year (4.7% vs 6.8%, p <0.04). Recurrent chest pain and dyspnea were similar at 30 days and 1 year. Patients without Q waves had significantly more angiography and trends coward higher readmission, revascularization, and use of calcium antagonists at 30 days. Angiography, revascularization, readmission, and quality of life were equivalent from 30 days to 1 year, with no sign of late instability. Logistic regression analysis showed an association between in-hospital revascularization and better survival and quality of life at 1 year. Conversely, there was no association between in-hospital use of calcium antagonists and outcome to explain the lower mortality in non-Q-wave patients. The absence of Q waves after thrombolytic therapy is a marker of success, implying better prognosis and equivalent quality of life, use of resources, and health status than for patients with Q-wave acute myocardial infarction and no sign of long-term unstable clinical course. (C) 2000 by Excerpta Medica, Inc.

关键词：冠状血管造影术/利用心电描记术纤维蛋白溶解药/治疗应用健康状况住院时间/统计学和数值数据心肌梗死/药物疗法心肌梗死/死亡率心肌梗死/放射摄影术病人再入院预后生活质量复发链激酶/治疗应用存活率血栓溶解疗法组织型纤溶酶原激活物/治疗应用老年人女(雌)性人类男(雄)性中年人

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Coronary angiography and outcome following acute myocardial infarction

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EUROPEAN HEART JOURNAL 2000年第9期21卷 707-709页

作者： Higano, ST Gersh, BJ Mayo Clin Rochester MN 55905 USA

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Variations in use of cardiac services in England: Perceptions of general practitioners, general physicians and cardiologists

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Journal of Health Services Research and Policy 1998年第3期3卷 153-158页

作者： Chapple, A. Gatrell, A. Natl Primary Care Res Develop Centre Williamson Building The University of Manchester Mancherster M13 9PL United Kingdom

Objective: To explain why those who live some distance from tertiary cardiac centres make less use of coronary angiography and revascularisation than those who live close by, and why people living in particular wards within certain districts make less use of services than might be expected from their level of need. Method: Semi-structured interviews with 24 general practitioners (GPs) in two English health districts (Morecambe Bay and East Lancashire), five general physicians working in district general hospitals, and four interventional cardiologists working in tertiary centres. Transcripts of audiotape recording were analysed using the constant comparative method. Results: Those living far from tertiary centres are usually referred to general physicians before they are referred for angiography. The general physicians tend to be more conservative in their approach to treatment than interventional cardiologists. GPs working near tertiary centres are able to refer directly to interventional cardiologists. There are also logistical and economic reasons for inequitable use of services. Some GPs perceived that patients of South Asian descent undergo fewer investigations than might be expected because of communication or other difficulties. Conclusion: Use of cardiac services would be more equitable if there were interventional cardiologists based in district general hospitals who could perform angiograms for their own patients in the tertiary centres. Patients might also benefit if angiogams could be conducted in selected district general hospitals. Further qualitative research, involving both doctors and patients, is needed to explore other reasons for relatively low rates of investigation and revascularisation in certain groups of patients.

关键词：医务工作者的态度心脏病学科医院/利用卫生服务范围冠状血管造影术/利用英格兰家庭医学/统计学和数值数据地理学卫生服务易得程度心肌血管重建术/利用医师诊疗模式/统计学和数值数据转诊和会诊/统计学和数值数据地区卫生计划公费医疗运输人类

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Early use of coronary angiography and intervention

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Cardiology Clinics 1999年第2期17卷 373-386页

作者： McCullough, P.A. Cardiovascular Division Henry Ford Heart and Vascular Inst. Detroit MI 48202 6525 Second Avenue United States

In this article we have outlined the current rationale and role of invasive management in ACS. For the majority of patients with ACS, who are either at high risk or unstable, invasive management is a critical element in breaking the sequence of recurrent ischemia leading to early cardiac events (Fig. 11). Secular trends in the care of cardiovascular patients predict even more sophisticated, invasive methods of treating coronary occlusion in the future. A futurist's view on this subject may envision the following type of scenario. A patient with prior CAD experiences persistent chest pain and notifies the emergency medical system. The paramedics arrive, and perform a rapid fingerstick cardiac biomarker panel and ECG. The results are interpreted by an emergency physician via a telecommunication system, and the patient is determined to be at high risk. He or she is triaged to a center capable of angioplasty and bypass surgery. On the way to the hospital, the patient is treated with aspirin, IV heparin, and an IV glycoprotein IIb/IIIa inhibitor. The patient undergoes triage angiography within 1 hour of hospital arrival, culprit lesion(s) are identified, and a revascularization plan is made - setting a critical pathway that is definitive. This vision is not far off on the horizon. We anticipate additional clinical trial results will help form the decision points in this optimal treatment scenario, which for a large proportion of patients will involve invasive management.

关键词：心绞痛不稳定型/血液心绞痛不稳定型/放射摄影术心绞痛不稳定型/治疗血管成形术经腔经皮冠状动脉置信区间冠状血管造影术/利用冠状动脉分流术医师诊疗模式血栓溶解疗法治疗结果肌钙蛋白I/血液美国人类

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The relationship between the supply of cardiac catheterization laboratories, cardiologists and the use of invasive cardiac procedures in Northern New England

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Journal of Health Services Research and Policy 1997年第2期2卷 75-80页

作者： Wennberg, D. Dickens J., Jr. Soule, D. Kellett M., Jr. Malenka, D. Robb, J. Ryan T., Jr. Bradley, W. Vaitkus, P. Hearn, M. Hillman, R. Division of Health Services Research Department of Medicine Maine Medical Center 22 Bramhall Street Portland ME 04102 United States

Objectives: Utilization rates of coronary angiography and cardiac revascularization have been found to vary between areas. This study addresses the relationship between resource supply and procedure rates. Methods: We compared the association of per capita catheterization laboratories, per capita cardiologists and multi-provider markets (where more than one hospital offers coronary angiography services) with the utilization rates for angiography and cardiac revascularization in northern New England, USA. Administrative data were used to capture invasive cardiac procedures. Small area analyses were used to create coronary angiography service areas. Linear regression methods were used to measure associations between the resource supply and utilization rates. Results: Variation in the use of invasive cardiac procedures was strongly associated with the population-based availability of catheterization facilities and multi-provider markets and unrelated to cardiologist supply or need (as reflected in the hospitalization rates for myocardial infarction). In the multivariate model, an increase of 1 catheterization laboratory per 100,000 population was associated with an increase in the angiography rate of 1.62 per 1000 population;those service areas with multi-provider markets were associated with an additional increase in the angiography rate of 1.27 per 1000 population (R² = 0.84, P = 0.0006). There was a moderately strong relationship between the catheterization laboratories per capita and the revascularization rates (R² = 0.43, P = 0.029). Angiography rates were highly associated with cardiac revascularization rates: an increase in the angiography rate of 1 per 1000 population was associated with a 0.46 per 1000 increase in the cardiac revascularization rate (R² = 0.85, P= 0.0001). Conclusions: Our work suggests that current efforts to address variation in cardiac procedures through activities such as appropriateness criteria, guidelines

关键词：心脏病学/人力冠状血管造影术/利用卫生保健公平提供卫生服务需求心脏导管插入术/利用实验室医院/供应和分配缅因/流行病学心肌梗死/外科学新罕布什尔医师诊疗模式/统计学和数值数据小地区分析利用情况审核人类

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