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How generalizable are coronary risk prediction models? Comparison of Framingham and two national cohorts

AMERICAN HEART JOURNAL 1999年第5期137卷 837-845页

作者： Liao, YL McGee, DL Cooper, RS Sutkowski, MBE Loyola Univ Stritch Sch Med Dept Prevent Med & Epidemiol Maywood IL 60153 USA Loyola Univ Stritch Sch Med Dept Med Div Gen Internal Med Maywood IL 60153 USA

Background Previous models used to predict individual risk of death from coronary heart disease (CHD) were developed from data of 3 decades ago from the Framingham Heart Study. CHD mortality rates have declined markedly since that period as a result of improvement in both risk factor status and medical interventions. Generalization of the results from this one study to the population at large remains a matter of concern. We compared predictive functions derived from the major risk factors For CHD from Framingham and 2 more recent national cohorts, the First and Second National Health and Nutrition Examination Survey (NHANES I and NHANES II). Methods and Results The participants included 1846 men and 2323 women 35 to 69 years of age and free of CHD at the fourth examination (1954 to 1958) from the Framingham Study;2753 men and 3858 women from the NHANES I (1971 to 1975);and 2655 men and 3050 women from NHANES II (1976 to 1980). The 3 cohorts were monitored for 24, 20, and 15 years, respectively. Significant heterogeneity existed among studies in the magnitude of the Cox coefficients For the individual factors (ie, age, systolic blood pressure, serum total cholesterol, and smoking status), especially among men. When risk factors were considered collectively, however, functions derived from and applied to different cohorts had a similar ability to rank individual risk. The areas under the receiver operating characteristic curves were 0.71 to 0.76 in men and 0.76 to 0.81 in women when different risk functions were applied to their own population or to a second population. The cumulative CHD survival observed in women in the 2 national cohorts was close to what was predicted from the Framingham equation. However, Framingham overestimated the cumulative CHD mortality rates in men in NHANES I and NHANES II. Conclusions The Framingham risk model for the prediction of CHD mortality rates provides a reasonable rank ordering of risk for individuals in the US white population F

关键词：冠心病/死亡率随访研究马萨诸塞/流行病学人群监测预后 ROC曲线可重复性结果回顾性研究危险因素存活率青少年成年人老年人儿童儿童学龄前女(雌)性人类婴儿男(雄)性中年人

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Panic disorder among cambodian refugees attending a psychiatric clinic - Prevalence and subtypes

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GENERAL HOSPITAL PSYCHIATRY 2000年第6期22卷 437-444页

作者： Hinton, D Ba, P Peou, S Um, K Massachusetts Gen Hosp Dept Psychiat Boston MA 02114 USA Harvard Univ Sch Med Boston MA 02115 USA N Suffolk Mental Hlth Ctr SE Asian Clin Revere MA USA Arbour Counseling Lowell MA USA

This study surveys Khmer refugees attending two Psychiatric clinics to determine both the prevalence of panic disorder as well as panic attack subtypes in those suffering panic disorder. A culturally valid adaptation of the SCID-panic module, the Cambodian Panic Disorder Survey (CPDS), was administered to 89 consecutive Cambodian refugees attending these psychiatric clinics. Utilizing culturally sensitive panic probes, the CPDS provides information regarding both the presence of panic disorder and panic-attack subtypes during the month prior to interview. Of 89 patients surveyed at two psychiatric clinics, 53 (60%) currently suffered panic disorder. Among the 53 patients suffering panic disorder, the most common panic attack subtypes during the previous month were the following: "sore neck" [51% of the 53 panic disorder patients (PDPs)], orthostatic dizziness (49% of PDPs), gastrointestinal distress (26% of PDPs), effort induced (21% of PDPs), olfactory induced (21% of PDPs), and "while-sitting dizziness" (16% of PDPs). (C) 2000 Elsevier Science Inc.

关键词：门诊医疗/统计学和数值数据柬埔寨/人种学交谈心理学马萨诸塞/流行病学精神卫生服务/统计学和数值数据惊恐病/分类惊恐病/诊断惊恐病/人种学惊恐病/病因学惊恐病/心理学患病率精神病状态评定量表心理生理性障碍/并发症难民/心理学难民/统计学和数值数据应激障碍创伤后/并发症成年人女(雌)性人类男(雄)性

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Ten-year trends in the incidence, treatment, and outcome of Q-wave myocardial infarction

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第7期86卷 730-735页

作者： Dauerman, HL Lessard, D Yarzebski, J Furman, MI Gore, JM Goldberg, RJ Univ Massachusetts Mem Med Ctr Div Cardiovasc Worcester MA 01655 USA Univ Massachusetts Sch Med Worcester MA USA

The benefits of coronary reperfusion and antiplatelet therapy for patients with Q-wave acute myocardial infarction (Q-AMI) ore well established in the context of randomized, controlled trials. The use and recent impact of these and other therapies on the broader, communitywide population of patients with Q-AMI is less well established. Residents of the Worcester, Massachusetts, metropolitan area (1990 census population 437,000) hospitalized with confirmed Q-AMI in all metropolitan Worcester, Massachusetts, hospitals in 4 1-year periods between 1986 and 1997 comprised the sample of interest. We examined the rates of occurrence, use of reperfusion strategies, and hospital mortality in a cohort of 711 patients with Q-AMI treated early in the reperfusion era (1986 and 1988) in comparison to 669 patients with Q-AMI treated a decode later (1995 and 1997). The percentage of Q-AMI among all hospitalized patients with AMI decreased over the decade of reperfusion therapy: 52% in 1986 and 1988 versus 35% in 1995 and 1997 (p < 0.001). Use of reperfusion therapy for patients with Q-AMI increased from 22% to 57%, with a marked increase in the use of primary angioplasty over time (1% vs 16%). The profile of patients receiving reperfusion therapy also changed significantly over the study period. Marked increases in use of antiplatelet therapy, p blockers, angiotensin-converting enzyme inhibitors, and decreased use of calcium channel blockers, were observed over time. The crude in-hospital case fatality rate declined from 19% (1986 and 1988) to 14% (1995 and 1997) in patients with Q-AMI. Results of a multivariable regression analysis showed lack of reperfusion therapy, older age, anterior wall AMI, and cardiogenic shock to be independent predictors of in-hospital mortality in patients with Q-AMI. Thus, the percentage of all AMI's presenting as Q-AMI, and hospital mortality after Q-AMI, has decreased significantly in the past 10 years. The decrease in mortality occurs in the setting

关键词：血管成形术化学疗法辅助心电描记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/死亡率心肌梗死/治疗回归分析血栓溶解疗法治疗结果老年人女(雌)性人类男(雄)性中年人

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Congestive heart failure in subjects with normal versus reduced left ventricular ejection fraction - Prevalence and mortality in a population-based cohort

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第7期33卷 1948-1955页

作者： Vasan, RS Larson, MG Benjamin, EJ Evans, JC Reiss, CK Levy, D NHLBI Framingham Heart Study Framingham MA 01702 USA Harvard Univ Sch Med Beth Israel Hosp Div Cardiol Boston MA USA Harvard Univ Sch Med Beth Israel Hosp Div Clin Epidemiol Boston MA USA Boston Med Ctr Cardiol Sect Boston MA USA Boston Univ Sch Med Dept Epidemiol & Prevent Med Boston MA 02118 USA Barnes Hosp St Louis MO 63110 USA NHLBI Bethesda MD 20892 USA

OBJECTIVES The purpose of this study was to assess the relative proportions of normal versus impaired left ventricular (LV) systolic function among persons with congestive heart failure (CHF) in the community and to compare their long-term mortality during follow-up. BACKGROUND Several hospital-based investigations have reported that a high proportion of subjects with CHF have normal LV systolic function. The prevalence and prognosis of CHF with normal LV systolic function in the community are not known. METHODS We evaluated the echocardiograms of 73 Framingham Heart Study subjects with CHF (33 women, 40 men, mean age 73 years) and 146 age- and gender-matched control subjects (nested case-control study). Impaired LV systolic function was defined as an LV ejection fraction (LVEF) <0.50. RESULTS Thirty-seven CHF cases (51%) had a normal LVEF;36 (49%) had a reduced LVEF. Women predominated in the former group (65%), whereas men constituted 75% or the latter group. During a median follow-up of 6.2 years, CHF cases with normal LVEF experienced an annual mortality of 8.7% versus 3.0% for matched control subjects (adjusted hazards ratio = 4.06, 95% confidence interval 1.61 to 10.26). Congestive heart failure cases with reduced LVEF had an annual mortality of 18.9% versus 4.1% for matched control subjects (adjusted hazards ratio = 4.31, 95% confidence interval 1.98 to 9.36). CONCLUSIONS Normal LV systolic function is often found in persons with CHF in the community and is in more common in women than in men. Although CHF cases with normal LVEF have a lower mortality risk than cases with reduced LVEF, they have a fourfold mortality risk compared with control subjects who are free of CHF. 1999 by the American College of Cardiology.

关键词：病例对照研究超声心动描记术随访研究心力衰竭/诊断显像心力衰竭/死亡率心力衰竭/病理生理学马萨诸塞/流行病学患病率预后前瞻性研究结果可重复性每搏输出量/生理学存活率心室功能障碍左/诊断显像心室功能障碍左/死亡率心室功能障碍左/病理生理学心室功能左/生理学成年人女(雌)性人类男(雄)性中年人

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Twenty year trends (1975-1995) in the incidence, in-hospital and long-term death rates associated with heart failure complicating acute myocardial infarction - A community-wide perspective

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第5期34卷 1378-1387页

作者： Spencer, FA Meyer, TE Goldberg, RJ Yarzebski, J Hatton, M Lessard, D Gore, JM Univ Massachusetts Sch Med Dept Med Div Cardiovasc Med Worcester MA 01655 USA

OBJECTIVES: To describe from a population-based perspective, recent and temporal (1975-1995) trends in the incidence, in-hospital and postdischarge case-fatality rates of heart failure (HF) complicating acute myocardial infarction (AMI). BACKGROUND: Extremely limited data are available describing the incidence and case-fatality rates associated with HF complicating AMI from a community-wide perspective. METHODS: The medical records of 6,798 residents of the Worcester, Massachusetts metropolitan area with validated MI and without previous HF hospitalized in 10 annual periods between 1975 and 1995 were reviewed. RESULTS: The proportion of AMI patients developing HF during hospitalization declined between 1975-1978 (38%) and 1993-1995 (33%) (p < 0.001). After controlling for potentially confounding factors, the risk of developing HF declined progressively, albeit modestly, over time. in-hospital case-fatality rates of patients with AMI complicated by HF declined by approximately 46% between 1975-1978 (33%) and 1993-1995 (18%) (p < 0.001). Improving trends in hospital survival were observed after adjusting for potentially confounding prognostic factors. The one-par post-discharge mortality rate for hospital survivors of HF did not change over the 20-year period under study, even after controlling for additional prognostic characteristics. CONCLUSIONS: The results of this community-wide study suggest encouraging declines in the incidence and hospital death rates associated with HF complicating AMI. Continued efforts need to be directed towards the prevention of HF given the magnitude of this clinical syndrome. Efforts of secondary prevention are needed to identify and improve the treatment of patients with symptomatic left ventricular dysfunction following AMI given the lack of improvement in the long term prognosis of these patients. (C) 1999 by the American College of Cardiology.

关键词：共病现象心脏病/并发症心脏病/流行病学心脏病/死亡率医院死亡率发病率马萨诸塞/流行病学心肌梗死/并发症心肌梗死/药物疗法心肌梗死/流行病学心肌血管重建术/发展趋势比值比老年人女(雌)性人类男(雄)性中年人

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Coronary echocardiography in tetralogy of Fallot: Diagnostic accuracy, resource utilization and surgical implications over 13 years

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 2000年第4期36卷 1371-1377页

作者： Need, LR Powell, AJ del Nido, P Geva, T Childrens Hosp Dept Cardiol Boston MA 02115 USA Childrens Hosp Dept Cardiac Surg Boston MA 02115 USA Harvard Univ Sch Med Dept Pediat Boston MA 02115 USA Harvard Univ Sch Med Dept Surg Boston MA 02115 USA

OBJECTIVES This study sought to determine the diagnostic accuracy and impact of the systematic use of coronary echocardiography in a large group of preoperative patients with tetralogy of Fallot (TOF). BACKGROUND Accurate preoperative identification of an anomalous coronary artery crossing the right ventricular outflow tract (RVOT) in patients with TOF is important to prevent coronary injury during surgical repair. METHODS A retrospective review identified 598 patients with TOF between 1983 to 1995 who underwent an echocardiogram at <2 years old before complete surgical repair. Associated diagnoses included pulmonary stenosis (n = 433), pulmonary atresia (n = 121), common atrioventricular canal (n = 17), absent pulmonary valve syndrome (n = 24) and aortopulmonary window (n = 3). RESULTS Based on intraoperative findings, 32 patients (5.4%) were found to have a major coronary artery crossing the RVOT. The use and diagnostic performance of coronary echocardiography increased over time, while the number of patients undergoing preoperative cardiac catheterization declined. During the most recent study period (1991 to 1995, n = 274), 97% of patients underwent coronary echocardiography yielding a sensitivity of 82%, specificity of 99% and accuracy of 98.5%. Of the 18 patients with TOF and pulmonary stenosis who had abnormal coronary arteries during this period, only 6 (33%) required an extracardiac conduit as part of their complete repair. CONCLUSIONS Coronary echocardiography is an accurate noninvasive tool to delineate coronary anatomy in infants with TOF before complete repair. Routine preoperative cardiac catheterization solely for diagnosis of coronary anatomy is not necessary. The use of an extracardiac conduit can be avoided in the majority of patients with TOF and pulmonary stenosis who have a major coronary artery crossing the RVOT. (J Am Coll Cardiol 2000;36:1371-7) (C) 2000 by the American College of Cardiology.

关键词：畸形多发性/诊断显像畸形多发性/死亡率畸形多发性/外科学冠状血管畸形/诊断显像冠状血管畸形/死亡率冠状血管畸形/外科学冠状血管/诊断显像诊断鉴别超声心动描记术/方法马萨诸塞/流行病学手术前护理/方法结果可重复性回顾性研究存活率法乐四联症/诊断显像法乐四联症/死亡率法乐四联症/外科学儿童学龄前女(雌)性人类婴儿婴儿新生男(雄)性

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Changes over time in the use of aspirin in patients hospitalized with acute myocardial infarction (1975 to 1997): A population-based perspective

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AMERICAN HEART JOURNAL 2002年第2期144卷 259-268页

作者： Jackson, EA Sivasubramian, R Spencer, FA Yarzebski, J Lessard, D Gore, JM Goldberg, RJ Univ Massachusetts Sch Med Dept Med Div Cardiovasc Med Worcester MA 01655 USA

Objective The purpose of this study was to examine 2 decade-long trends in the use of aspirin and associated outcomes in patients hospitalized with acute myocardial infarction. Background Aspirin has been shown to be beneficial in the seconclary prevention of AML However, little is known about changes over time in the use of aspirin in patients hospitalized with AMI and associated outcomes, particularly from a more generalizable population-based perspective. Methods We examined trends in aspirin use and hospital and long-term outcomes in 9336 metropolitan Worcester, Mass, residents hospitalized with validated AMI in all area hospitals between 1975 and 1997. Results Between 1975 and 1986, the hospital use of aspirin remained stable at approximately 20%. Use of aspirin increased markedly after this time from 49% in 1988 to 91% in 1997. Younger age, male sex, and a history of hypertension or stroke were associated with an increased likelihood of receiving aspirin. Patients with diabetes were less likely to receive aspirin than were patients without diabetes. Patients who received aspirin during hospitalization were more likely to receive beta-blockers and coronary interventions. Patients treated with aspirin were significantly less likely to have heart failure or cardiogenic shock develop or to die during hospitalization as compared with patients not treated with aspirin. Patients treated with aspirin had significantly higher survival rates over a 10-year follow-up period. Conclusion The results of this community-wide study show that aspirin use in patients hospitalized with AMI has dramatically increased over time. Despite the beneficial effects associated with the use of aspirin, this therapy remains under-used in several high-risk groups.

关键词：年龄分布阿司匹林/投药和剂量药物利用/统计学和数值数据住院/统计学和数值数据纵向研究马萨诸塞/流行病学多元分析心肌梗死/药物疗法心肌梗死/流行病学人群监测前瞻性研究性别分布存活率老年人女(雌)性人类男(雄)性中年人

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Two-decade-long trends (1975-1997) in the incidence, hospitalization, and long-term death rates associated with complete heart block complicating acute myocardial infarction: A community-wide perspective

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AMERICAN HEART JOURNAL 2003年第3期145卷 500-507页

作者： Spencer, FA Jabbour, S Lessard, D Yarzebski, J Ravid, S Zaleskas, V Hyder, M Gore, JM Goldberg, RJ Univ Massachusetts Sch Med Dept Med Div Cardiovasc Med Worcester MA 01655 USA Lown Cardiovasc Res Fdn Brookline MA USA

Background The purpose of this community-wide study was to describe a >2-decade-long experience (1975-97) in the incidence and death rates associated with complete heart block (CHB) in patients with acute myocardial infarction (AMI). Limited population-based: data exist describing recent, and changes with time therein, incidence and case-fatality rates associated with CHB complicating AMI. Methods We conducted an observational study of 9082 metropolitan Worcester, Mass, residents (1990 census 437,000) hospitalized with validated AMI in all greater Worcester hospitals during 11 1-year periods between 1975 and 1997. Results Overall, CHB developed in 5.0 % of patients with AMI. The incidence rates of CHB declined in the periods studied (6.0% in 1975/78 vs 3.1 % in 1997). Declines in the occurrence of CHB were noted in patients with anterior or inferior/posterior MI. These trends remained after adjustment for other factors that might affect the risk of CHB. Patients in whom CHB developed experienced significantly higher hospital death rates than patients in whom CHB did not develop (46.8% vs.14.6%). However, improving trends in the hospital survival rate of patients with CHB were observed between 1975/78 (47.4% surviving) and 1997 (61.3% surviving). Patients in whom CHB developed during hospitalization were not at increased risk for dying after hospital discharge. Conclusions our findings indicate that the incidence of CHB complicating AMI has declined with time. The hospital prognosis of patients in whom CHB developed has improved, but these patients remain at an increased risk of hospital mortality. The long-term prognosis of patients with inferior MI and CHB is similar to that of patients in whom CHB did not develop. Patients with anterior MI and CHB may beat an increased risk of long-term mortality.

关键词：急性病共病现象心脏传导阻滞/诊断心脏传导阻滞/流行病学心脏传导阻滞/死亡率医院死亡率/发展趋势住院/统计学和数值数据住院/发展趋势发病率纵向研究马萨诸塞/流行病学死亡率/发展趋势心肌梗死/诊断心肌梗死/流行病学存活率分析老年人女(雌)性人类男(雄)性

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Prevalence and correlates of depressive symptoms among Hispanic elders in Massachusetts

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JOURNALS OF GERONTOLOGY SERIES B-PSYCHOLOGICAL SCIENCES AND SOCIAL SCIENCES 2000年第2期55卷 S108-S116页

作者： Falcón, LM Tucker, KL Northeastern Univ Dept Sociol Boston MA 02115 USA Tufts Univ USDA Jean Mayer Human Nutr Res Ctr Aging Program Epidemiol Boston MA 02111 USA

Background. Few studies have addressed depression among Puerto Rican and Dominican elders. This study examined the prevalence of depressive symptomatology and associated situational factors, among a representative sample of Hispanic elders in the state of Massachusetts and a neighborhood comparison group of non-Hispanic whites (NHWs). Methods. Participants included 715 Hispanic elders (429 Puerto Rican, 128 Dominican, and 149 other Hispanic) in Massachusetts and 238 NHW elders living in the same neighborhoods. Depressive symptomatology was measured with the Center for Epidemiologic Studies Depression Scale (CES-D). The associations between socioeconomic status, household arrangements, acculturation, health problems, and depression score were examined with multiple linear and logistic regression. Results. Puerto Rican and Dominican elders had significantly greater prevalences of high depression scores when compared with neighborhood NHWs. After controlling for various social, demographic, and health characteristics. the scores of Puerto Ricans remained significantly greater than those of the NHWs, but nor "Other Hispanic" groups. Higher CES-D scores were significantly associated with bring female, living alone, and having a higher number of health problems, but not with income. Effects of acculturation were only found among Dominican elders. Conclusions. Puerto Rican elders experience high rates of depressive symptomatology that are associated with, but not fully explained by, high numbers of chronic health conditions. Further investigation is needed to both understand and treat this prevalent problem.

关键词：文化适应抑郁/人种学家庭/心理学西班牙裔美国人/心理学马萨诸塞/流行病学患病率社会阶级老年人女(雌)性人类男(雄)性

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Changes over time in the incidence and case-fatality rates of primary ventricular fibrillation complicating acute myocardial infarction: Perspectives from the Worcester Heart Attack Study

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AMERICAN HEART JOURNAL 2000年第6期139卷 1014-1021页

作者： Thompson, CA Yarzebski, J Goldberg, RJ Lessard, D Gore, JM Dalen, JE Univ Massachusetts Sch Med Dept Med Div Cardiovasc Med Worcester MA 01655 USA Harvard Univ Brigham & Womens Hosp Lawn Cardiovasc Ctr Sch Med Boston MA 02115 USA Univ Arizona Coll Med Hlth Sci Ctr Dept Hlth Sci Tucson AZ USA

Background Limited population-based data are available that describe temporal and recent trends in the incidence and case-fatality rates in patients with primary ventricular fibrillation (VF) complicating acute myocardial infarction (AMI). The purpose of this study was to describe changes over a 22-year period (1975 through 1997) in the incidence and hospital case-fatality rates of primary VF complicating AMI from a multihospital, community-wide perspective. Methods and Results This was an observational study of metropolitan Worcester residents hospitalized with a validated uncomplicated AMI (n = 5020) in all hospitals in the Worcester, Massachusetts, metropolitan area (1990 census population = 437,000) during 111-year periods between 1975 and 1997. The overall incidence rate of primary VF complicating AMI was 4.7%, The crude as well as multivariable adjusted odds of the development of VF did not change significantly over the 22-year period under study. The overall in-hospital case-fatality rate of patients with primary VF was 44%, which was significantly greater in comparison with AMI patients in whom VF did not develop (5%). Hospital mortality rates associated with primary VF declined over time. Improved survival was observed in patients who had primary VF in the 1990s after adjusting for potential prognostic confounders. Conclusions The results of this community-wide study failed to indicate changes over time in the incidence rates of primary VF in patients hospitalized with AMI between 1975 and 1997. On the other hand, hospital death rates in patients with primary VF have shown encouraging declines during more recent periods. These mortality trends are likely to be the results of improvements in the treatment and more careful surveillance of patients with AMI.

关键词：心电描记术医院死亡率/发展趋势发病率马萨诸塞/流行病学心肌梗死/流行病学心肌梗死/病因学观察预后回顾性研究存活率/发展趋势时间因素心室颤动/并发症心室颤动/流行病学老年人女(雌)性人类男(雄)性中年人

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