Use of angiotensin-converting enzyme inhibitors at discharge in patients with acute myocardial infarction in the United States: data from the National Registry of Myocardial Infarction 2

AbstractObjectives: This study was undertaken to examine recent trends in the use of angiotensin-converting enzyme (ACE) inhibitor therapy in patients discharged after acute myocardial infarction (AMI) and to identify clinical factors associated with ACE inhibitor prescribing patterns.Background: Clinical trials have demonstrated a significant mortality benefit in patients treated with ACE inhibitors after AMI. Numerous studies have demonstrated underuse of other beneficial treatments for patients with AMI, such as beta-adrenergic blocking agents, aspirin and immediate reperfusion therapy.Methods: Demographic, procedural and discharge medication data from 190,015 patients with AMI were collected at 1,470 U.S. hospitals participating in the National Registry of Myocardial Infarction 2.Results: Prescriptions for ACE inhibitor therapy at hospital discharge increased from 25.0% in 1994 to 30.7% in 1996. Patients with a left ventricular ejection fraction ≤40% or evidence of congestive heart failure while in the hospital were discharged with ACE inhibitor treatment 42.6% of the time. Of patients experiencing an anterior wall myocardial infarction and no evidence of heart failure, 26.1% of patients were discharged with this treatment. Of the remaining patients, 15.6% received ACE inhibitors at discharge. ACE inhibitors were prescribed more often to elderly and diabetic patients as well as those requiring intraaortic balloon pump placement. This therapy was given less often to patients who underwent revascularization with coronary angioplasty or coronary artery bypass graft surgery or were treated with calcium channel blocking agents.Conclusions: Physicians are prescribing ACE inhibitors in patients with myocardial infarction with increasing frequency. Those patients with the greatest expected benefit receive ACE inhibitor treatment most often. However, the majority of even these high risk patients were not discharged with this life-saving therapy

Reperfusion therapy for acute myocardial infarction: observations from the National Registry of Myocardial Infarction 2

The National Registry of Myocardial Infarction 2 (NRMI-2) provides a unique opportunity to evaluate the practice patterns among participating cardiology and emergency medicine departments involved in the care of patients with acute myocardial infarction. The data from NRMI-2 suggest that almost 1/3 of all non-transfer-in and non-transfer-out patients are eligible for reperfusion therapy. Furthermore, of those patients who are clearly eligible for reperfusion therapy, 24% are not given this proven therapy. Specifically, women, the elderly, patients without chest pain on presentation, and those patients at highest risk for in-hospital mortality were least likely to be treated with reperfusion therapy. The reason for underuse of reperfusion therapy may in part reflect a concern for adverse bleeding events associated with the use of thrombolytic therapy. The data from NRMI-2 also suggest that patients with contraindications to thrombolysis may be very appropriate for primary angioplasty. Realizing the full potential benefits of reperfusion therapy in terms of reduced cardiovascular morbidity and mortality will require that clinical practice patterns be aligned more closely with the recommended national guidelines, which are based on extensive clinical trial data that show the benefit of reperfusion therapy in a wide range of patients with acute myocardial infarction. By using observational databases, such as the NRMI-2, which describe how clinical care is administered in nonclinical trial settings, we can continually monitor our progress and initiate changes to ensure that patients are given access to the many therapies that have been shown to improve their quality of life and survival

Coronary artery caliber in normal children and patients with Kawasaki disease but without aneurysms: An echocardiographic and angiographic study

A total of 110 children aged 3 months to 16 years underwent two-dimensional echocardiography of the coronary arteries. Forty-two normal subjects and 68 patients with Kawasaki disease were evaluated. All 68 patients with Kawasaki disease underwent selective coronary arteriography. The objectives of this study were to 1) develop a normal profile of the proximal left and right coronary arteries as to caliber and shape in infants, toddlers and children using echocardiography; 2) compare the dimensions and shape of the coronary arteries of patients with Kawasaki disease but no obvious aneurysms with those of the coronary arteries of normal children; and 3) develop criteria that would permit distinguishing a large but normal coronary artery from a true aneurysm in patients with Kawasaki disease.In the normal subjects and patients with Kawasaki disease, the caliber of the coronary arteries showed little variability from the ostium to 10 mm distally, and ranged in size from 2 mm in infants to 5 mm in teenagers. There was no significant difference between male and female subjects. The feature that distinguished the large but normal coronary artery without aneurysm from that with an aneurysm was its uniformity of caliber. Also, the caliber of the opposite coronary artery was generally at the lower limits of normal. It appears that the proximal coronary arteries of infants and children can be accurately assessed using high resolution two-dimensional echocardiography, and that sequential evaluation of subtle changes over time may be performed

Neighborkeepers: Buddies for Better HealthAn Intervention to Improve Physical Activity Habits

Introduction: associated health complications have increased steadily across the United States. As a result, physical activity considerations have become a more significant focus of healthcare providers and government agencies. Recent studies suggest that social support network approaches, such as the buddy-system, improve participant adherence to physical activity regimens. To improve physical activity frequency and adherence, we implemented a buddy system approach with participants involved in a community outreach organization.https://scholarworks.uvm.edu/comphp_gallery/1014/thumbnail.jp

Acute Reperfusion Therapy in ST-elevation Myocardial Infarction from 1994-2003

Background—Appropriate utilization of acute reperfusion therapy is not a national performance measure for ST-elevation myocardial infarction at this time, and the extent of its contemporary use among ideal patients is unknown. Methods—From the National Registry of Myocardial Infarction, we identified 238,291 patients enrolled from June 1994 to May 2003 who were ideally suited for acute reperfusion therapy with fibrinolytic therapy or primary percutaneous coronary intervention. We determined rates of not receiving therapy across 3 time periods (June 1994–May 1997, June 1997–May 2000, June 2000– May 2003) and evaluated factors associated with underutilization. Results—The proportion of ideal patients not receiving acute reperfusion therapy decreased by one-half throughout the past decade (time period 1: 20.6%; time period 2: 11.4%; time period 3: 11.6%; P\u3c0.001). Utilization remained significantly lower in key subgroups in the most recent time period: those without chest pain (OR, 0.29; 95% CI, 0.27–0.32); those presenting 6 to 12 hours after symptom onset (OR, 0.57; 95% CI, 0.52–0.61); those 75 years or older (OR, 0.63 compared with patients \u3c55 years old; 95% CI, 0.58–0.68); women (OR, 0.88; 95% CI, 0.84–0.93); and non-whites (OR, 0.90; 95% CI, 0.83–0.97). Conclusions—Utilization of acute reperfusion therapy in ideal patients has improved over the last decade, but more than 10% remain untreated. Measuring and improving its use in this cohort represents an important opportunity to improve care