Aims: To assess the association of prolonged QRS duration and late mortality in unselected post- infarction patients of the revascularization era. Methods and results: A total of 1455 survivors of acute myocardial inf...
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Aims: To assess the association of prolonged QRS duration and late mortality in unselected post- infarction patients of the revascularization era. Methods and results: A total of 1455 survivors of acute myocardial infarction(MI) in sinus rhythm and under 76 years of age were enrolled. Ninety eight percent of the patients received reperfusion/ revascularization therapy(90% percutaneous coronary intervention). After revascularization, prolonged QRS duration(≥ 120 ms) was present in 87 patients(6.0% ). Additional risk factors studied were age(≥ 65 years), presence of diabetes mellitus, history of previous MI, mean heart rate(>75 b.p.m.), heart rate variability index(≤ 20 U), arrhythmia on Holter, left ventricular ejection fraction(LVEF ≤ 30% ), and heart rate turbulence(HRT). Primary endpoint was total mortality. During a follow- up period of 22± 5 months, 70 patients died. On multivariable analysis, prolonged QRS duration showed the highest association with total mortality(hazard ratio 4.0; Cl 2.3- 6.9) followed by HRT Category 2(3.8; 2.0- 7.3) and LVEF≤ 30% (3.1; 1.7- 5.6). The association of prolonged QRS duration and late mortality was particularly strong in patients with LVEF ≤ 30% (5.0; 1.8- 14.1). On multivariable analysis of secondary endpoints, prolonged QRS duration was significantly associated with cardiac mortality(3.9; 1.9- 7.8), but not with sudden death and serious arrhythmic events. Conclusion: In the revascularization era, incidence of prolonged QRS duration is reduced. However, prolonged QRS duration is still highly correlated with increased late mortality.
Context: Certificate of need regulations were enacted to control health care costs by limiting unnecessary expansion of services. While many states have repealed certificate of need regulations in recent years, few an...
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Context: Certificate of need regulations were enacted to control health care costs by limiting unnecessary expansion of services. While many states have repealed certificate of need regulations in recent years, few analyses have examined relationships between certificate of need regulations and outcomes of care. Objective: To compare rates of coronary revascularization and mortality after acute myocardial infarction in states with and without certificate of need regulations. Design, Setting, and Participants: Retrospective cohort study of 1 139 792 Medicare beneficiaries aged 68 years or older with AMI who were admitted to 4587 US hospitals during 2000-2003. Main Outcome Measures: Thirty-day risk-adjusted rates of coronary revascularization with either coronary artery bypass graft surgery or percutaneous coronary intervention and 30-day all-cause mortality. Results: The 624 421 patients in states with certificate of need regulations were less likely to be admitted to hospitals with coronary revascularization services(321 573[51.5%] vs 323 695[62.8%]; P< .001) or to undergo revascularization at the admitting hospital(163 120[26.1%] vs 163 877[31.8%]; P< .001) than patients in states without certificates of need but were more likely to undergo revascularization at a transfer hospital(73 379[11.7%] vs 45 907[8.9%]; P< .001). Adjusting for demographic and clinical risk factors, patients in states with highly and moderately stringent certificate of need regulations, respectively, were less likely to undergo revascularization within the first 2 days(adjusted hazard ratios, 0.68; 95%confidence interval[CI], 0.54-0.87; P=.002 and 0.80; 95%CI, 0.71-0.90; P< .001) relative to patients in states without certificates of need, although no differences in the likelihood of revascularization were observed during days 3 through 30. Unadjusted 30-day mortality was similar in states with and without certificates of need(109 304[17.5%] vs 90 104[17.5%]; P=.76), as was adjusted mortalit
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