Water Cultures Are More Sensitive Than Swab Cultures for the Detection of Environmental Legionella.

Water cultures were significantly more sensitive than concurrently collected swab cultures (n=2,147 each) in detecting Legionella pneumophila within a Veterans Affairs healthcare system. Sensitivity for water versus swab cultures was 90% versus 30% overall, 83% versus 48% during a nosocomial Legionnaires' disease outbreak, and 93% versus 22% post outbreak. Infect Control Hosp Epidemiol 2018;39:108-110.

Improving the Diagnosis of Legionella Pneumonia within a Healthcare System through a Systematic Consultation and Testing Program.

RATIONALE: Legionella testing is not recommended for all patients with pneumonia, but rather for particular patient subgroups. As a result, the overall incidence of Legionella pneumonia may be underestimated. OBJECTIVES: To determine the incidence of Legionella pneumonia in a veteran population in an endemic area after introduction of a systematic infectious diseases consultation and testing program. METHODS: In response to a 2011-2012 outbreak, the VA Pittsburgh Healthcare System mandated infectious diseases consultations and testing for Legionella by urine antigen and sputum culture in all patients with pneumonia. MEASUREMENTS AND MAIN RESULTS: Between January 2013 and December 2015, 1,579 cases of pneumonia were identified. The incidence of pneumonia was 788/100,000 veterans per year, including 352/100,000 veterans per year and 436/100,000 veterans per year with community-associated pneumonia (CAP) and health care-associated pneumonia, respectively. Ninety-eight percent of patients with suspected pneumonia were tested for Legionella by at least one method. Legionella accounted for 1% of pneumonia cases (n = 16), including 1.7% (12/706) and 0.6% (4/873) of CAP and health care-associated pneumonia, respectively. The yearly incidences of Legionella pneumonia and Legionella CAP were 7.99 and 5.99/100,000 veterans, respectively. The sensitivities of urine antigen and sputum culture were 81% and 60%, respectively; the specificity of urine antigen was >99.97%. Urine antigen testing and Legionella cultures increased by 65% and 330%, respectively, after introduction of our program. CONCLUSIONS: Systematic testing of veterans in an endemic area revealed a higher incidence of Legionella pneumonia and CAP than previously reported. Widespread urine antigen testing was not limited by false positivity.

The importance of clinical surveillance in detecting legionnaires' disease outbreaks: a large outbreak in a hospital with a Legionella disinfection system-Pennsylvania, 2011-2012.

BACKGROUND: Healthcare-associated Legionnaires' disease (LD) is a preventable pneumonia with a 30% case fatality rate. The Centers for Disease Control and Prevention guidelines recommend a high index of suspicion for the diagnosis of healthcare-associated LD. We characterized an outbreak and evaluated contributing factors in a hospital using copper-silver ionization for prevention of Legionella growth in water. METHODS: Through medical records review at a large, urban tertiary care hospital in November 2012, we identified patients diagnosed with LD during 2011-2012. Laboratory-confirmed cases were categorized as definite, probable, and not healthcare associated based on time spent in the hospital during the incubation period. We performed an environmental assessment of the hospital, including collection of samples for Legionella culture. Clinical and environmental isolates were compared by genotyping. Copper and silver ion concentrations were measured in 11 water samples. RESULTS: We identified 5 definite and 17 probable healthcare-associated LD cases; 6 case patients died. Of 25 locations (mostly potable water) where environmental samples were obtained for Legionella-specific culture, all but 2 showed Legionella growth; 11 isolates were identical to 3 clinical isolates by sequence-based typing. Mean copper and silver concentrations were at or above the manufacturer's recommended target for Legionella control. Despite this, all samples where copper and silver concentrations were tested showed Legionella growth. CONCLUSIONS: This outbreak was linked to the hospital's potable water system and highlights the importance of maintaining a high index of suspicion for healthcare-associated LD, even in the setting of a long-term disinfection program.

Impact of endoscopic versus open saphenous vein harvest technique on late coronary artery bypass grafting patient outcomes in the ROOBY (Randomized On/Off Bypass) Trial.

OBJECTIVE: In the Randomized On/Off Bypass (ROOBY) Trial, the efficacy of on-pump versus off-pump coronary artery bypass grafting was evaluated. This ROOBY Trial planned subanalysis compared the effects on postbypass patient clinical outcomes and graft patency of endoscopic vein harvesting and open vein harvesting. METHODS: From April 2003 to April 2007, the technique used for saphenous vein graft harvesting was recorded in 1471 cases. Of these, 894 patients (341 endoscopic harvest and 553 open harvest) also underwent coronary angiography 1 year after coronary artery bypass grafting. Univariate and multivariable analyses were used to compare patient outcomes in the endoscopic and open groups. RESULTS: Preoperative patient characteristics were statistically similar between the endoscopic and open groups. Endoscopic vein harvest was used in 38% of the cases. There were no significant differences in both short-term and 1-year composite outcomes between the endoscopic and open groups. For patients with 1-year catheterization follow-up (n=894), the saphenous vein graft patency rate for the endoscopic group was lower than that in the open harvest group (74.5% vs 85.2%, P<.0001), and the repeat revascularization rate was significantly higher (6.7% vs 3.4%, P<.05). Multivariable regression documented no interaction effect between endoscopic approach and off-pump treatment. CONCLUSIONS: In the ROOBY Trial, endoscopic vein harvest was associated with lower 1-year saphenous vein graft patency and higher 1-year revascularization rates, independent of the use of off-pump or on-pump cardiac surgical approach.

Hypercholesterolemia paradox in relation to mortality in acute coronary syndrome.

BACKGROUND: Hypercholesterolemia is a risk factor for coronary artery disease, yet is associated with lower risk of adverse outcomes in patients with acute coronary syndromes (ACS). HYPOTHESIS: We explored this paradox in 84,429 patients with non-ST-segment elevation ACS in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines registry. METHODS: We examined the association between a history of hypercholesterolemia and in-hospital mortality after adjusting for clinical covariates. After excluding patients with previously diagnosed hypercholesterolemia, we repeated the analysis, examining the association between newly diagnosed hypercholesterolemia (in-hospital low-density lipoprotein cholesterol [LDL-C] > or = 100 mg/dL) and mortality. RESULTS: A history of hypercholesterolemia was associated with lower in-hospital mortality (unadjusted odds ratio [OR]: 0.58; 95% confidence interval [CI]: 0.55, 0.62). This protective association persisted after adjusting for baseline characteristics (OR: 0.71; 95% CI: 0.66, 0.76) and prior statin use (OR: 0.74; 95% CI: 0.68, 0.80). Among 22,711 patients with no history of hypercholesterolemia, 12,809 had a new in-hospital diagnosis of hypercholesterolemia. Unadjusted mortality in these patients was lower than among those with normal LDL levels (OR: 0.58; 95% CI: 0.50, 0.67); however, this difference was not significant after multivariable adjustment (OR: 0.86; 95% CI: 0.73, 1.01). CONCLUSIONS: The association of hypercholesterolemia with better outcomes highlights a major challenge in observational analyses. Our results suggest this paradox may result from confounding due to other clinical characteristics, impact of statin treatment, and perhaps most importantly, the fact that previously diagnosed hypercholesterolemia is a marker for patients with more prior medical contact.

Clinical significance of borderline elevated troponin I levels across different assays in patients with suspected acute coronary syndrome.

We aimed to elucidate the clinical significance of borderline troponin I (TnI) increases and see if such increases are of similar significance across different assays. Markedly increased TnI is a strong predictor of adverse cardiac events. It is not clear if borderline increases with different commercially available TnI assays provide similar prognostic information. From January 2001 to February 2004, 3 different TnI assays (Beckman Access TnI, Beckman Access AccuTnI, and Vitros ECI Troponin) were used to evaluate the peak TnI value in 1,152 consecutive patients admitted with suspected acute coronary syndrome/non-ST-elevation myocardial infarction (MI). Recommended cutoffs were used to differentiate borderline from marked increases reported as consistent with MI. Clinical data and 30-day death/new MIs were determined by chart abstraction. Demographics and cardiac risk factors were similar for the 3 groups. Frequency of borderline TnI ranged widely among assays (18.7% to 42.1%) but was significantly less with the Vitros ECI Troponin assay (p <0.0001). Prognostic significance of borderline increased TnI values also varied greatly by assay, with borderline Beckman Access AccuTnI increases being predictive of adverse 30-day outcomes (odds ratio 4.0, 95% confidence interval 1.46 to 10.97, p = 0.007), but not with the other 2 assays. Borderline increases were significantly associated with chronic renal insufficiency (CRI; serum creatine >1.5); the relation to adverse 30-day outcomes and borderline increases persisted after correcting for CRI in a multivariate logistic regression model. In conclusion, although borderline increased TnI levels are common and significantly associated with CRI, they do not all portend the same clinical prognosis. This study highlights the need for standardization of TnI levels across different assays.

Factors associated with the use of preventive care for contrast-induced acute kidney injury.

BACKGROUND: The factors that affect the implementation of preventive care for contrast-induced acute kidney injury (CIAKI) are unknown. OBJECTIVE: To assess patient and provider factors associated with the use of preventive care for CIAKI. DESIGN: Prospective cohort study. PARTICIPANTS: Patients with kidney disease undergoing procedures with intravascular iodinated radiocontrast. MEASUREMENTS: We recorded the use of preventive care defined as the administration of: (1) pre- and post-procedure isotonic intravenous (IV) fluid, (2) N-acetylcysteine, and (3) iso-osmolal radiocontrast. We surveyed patients' providers to assess their knowledge, experience, and training on CIAKI and used multiple logistic regression to assess the independent associations of patient and provider factors with the use of these preventive interventions. RESULTS: We enrolled 660 patients and 87 providers. Patient factors associated with use of IV fluid and N-acetylcysteine were higher baseline serum creatinine (OR 1.5 and 5.0, p < 0.05) and inpatient status (OR 3.0 and 6.3, p < 0.05), while higher baseline serum creatinine was associated with the use of iso-osmolal contrast (OR = 13.4, p < 0.01). The primary provider characteristics associated with the use of IV fluid and N-acetylcysteine were a greater degree of prior training on CIAKI (OR 1.9 and 2.8, p < 0.05) and higher number of prior patients with CIAKI (OR 2.7 and 2.6, p < 0.05). CONCLUSIONS: Patient baseline kidney function and provider training and experience with CIAKI are independently associated with the use of preventive care. Efforts to increase and intensify the training providers receive on CIAKI may help decrease the incidence of this costly iatrogenic condition.

Veterans' decision-making preferences and perceived involvement in care for chronic heart failure.

BACKGROUND: Patients with heart failure require a great deal of information about their disease, but it is also important to know about their preferences for involvement in medical decision making and about factors that may influence their preferences so that patients' needs, values, and preferences can be met by clinicians. OBJECTIVES: We assessed patients' preferred role and perceived level of involvement in medical decision making and tested the effects of patients' age and role preference on perceived involvement in medical decision making. METHODS: We conducted a telephone survey of 90 adults being treated for heart failure by a Veterans Affairs primary care provider or cardiologist. Patients' preferred role in treatment decisions was assessed using the Control Preferences Scale. Perceptions about their involvement in decision making during the most recent clinic visit was measured using a subscale of the Perceived Involvement in Care Scale. Descriptive, correlational, and generalized linear regression analyses were conducted. RESULTS: Most patients were elderly (mean = 70.1 years), male (94.4%), and white (85.6%), and had New York Heart Association class II disease (55.6%). Forty-three patients (47.8%) preferred a passive role in decision making, 19 patients (21.1%) preferred an active role, and 28 patients (31.1%) preferred a collaborative role. Most patients believed that their decision-making involvement was relatively passive, as indicated by a mean score of .96 (range, 0-4) on the Perceived Involvement in Care Scale decision-making subscale. Older age was associated with passive role preference (r = .263; P < .05) and less perceived involvement in decision making (r = -.279; P < .01). In addition, less perceived involvement in decision making during the last clinic visit was associated with a preference for a more passive decision-making role (r = rho.355; P < .01). Generalized linear regression analysis indicated that when patients' perceived decision-making involvement was regressed on age and patients' role preferences, age was no longer significantly associated with involvement (beta = -.196; P = .061), but that control preferences continued to exhibit an independent effect on perceived involvement in medical decision making (beta = -.341; P = .003). CONCLUSION: The results suggest that the preferences of patients with heart failure for a more passive role in decision making may be a stronger independent predictor of patients' perceived involvement in decision making than patients' age.

"They diagnosed bad heart": a qualitative exploration of patients' knowledge about and experiences with heart failure.

BACKGROUND: Patient education is central to the management of individuals with heart failure; therefore, it is important to know what these patients understand and experience both clinically and personally. OBJECTIVES: This study qualitatively explored patients' knowledge regarding a heart failure diagnosis, their understanding of their cardiac care providers' treatment recommendations, and their views concerning the impact of heart failure on their daily lives and prognosis. METHODS: A qualitative study was conducted whereby data were collected through 25 telephone interviews with adults being followed for heart failure at a Veterans Affairs medical center. Subjects were interviewed using semistructured open-ended questions. Audiotaped responses were analyzed using grounded theory methods. RESULTS: The majority of participants were elderly, male, and white, and had New York Heart Association class II disease. Participants without angina typically experienced a lengthy and difficult diagnostic delay, with symptoms misattributed to comorbid diseases. Most understood the importance of self-monitoring and adhering to physician recommendations, and their discussions of life-changing effects typically focused on loss of physical functioning and decreased quality of life. Although participants wanted to know their prognosis, most had not received information about it or about advance care planning. CONCLUSION: Patients require opportunities for enhanced communication with physicians and health care team members during the challenging diagnostic period and subsequently need more information about their medical condition and prognosis.

Prevention, incidence, and outcomes of contrast-induced acute kidney injury.

BACKGROUND: Little is known about whether health care providers (physicians) implement preventive care for contrast-induced acute kidney injury (CIAKI). The objectives of our prospective cohort study were (1) to assess provider use of preventive strategies for CIAKI, (2) to determine the incidence of CIAKI, and (3) to examine the association of CIAKI with adverse outcomes at 30 days, including death, need for dialysis, and hospital admission. METHODS: We prospectively identified patients with estimated glomerular filtration rates less than 60 mL/min/1.73 m(2) undergoing procedures with intravascular radiocontrast agents and recorded the use of intravenous fluids and N-acetylcysteine and the discontinuation of nonsteroidal anti-inflammatory medications. We measured postprocedure serum creatinine levels to quantify the incidence of CIAKI and tracked 30-day mortality and need for dialysis or hospitalization to evaluate the association of CIAKI with these outcomes. RESULTS: Preprocedure and postprocedure intravenous fluids were administered to 264 of 660 study patients (40.0%), more commonly with coronary angiography than with computed tomography (91.2% vs 16.6%, P < .001). N-acetylcysteine was administered to 39.2% of patients, while only 6.8% of patients using nonsteroidal anti-inflammatory drugs were instructed to discontinue the medication. In a propensity analysis, the use of intravenous fluids was associated with a reduced rate of CIAKI. The incidence of CIAKI was lowest following computed tomography (range, 0.0%-10.9%) and was highest following noncoronary angiography (range, 1.9%-34.0%). Eleven patients (1.7%) died, 1 patient (0.2%) required dialysis, and 83 patients (12.6%) were hospitalized; however, CIAKI was not independently associated with hospital admission or death. CONCLUSIONS: Strategies to prevent CIAKI are implemented nonuniformly. Although biochemical evidence of CIAKI is relatively common, clinically significant CIAKI is rare. These findings should help health care providers focus the use of preventive care on the highest-risk patients and have important implications for future clinical trials.

The incidence of clinically significant contrast-induced nephropathy following non-emergent coronary angiography.

OBJECTIVES: The primary aim of this study was to assess the incidence of clinically significant contrast-induced nephropathy (CIN) among patients undergoing non-emergent coronary angiography. BACKGROUND: Although retrospective analyses have emphasized the association of CIN with adverse patient outcomes, the actual incidence of clinically significant CIN following non-emergent coronary angiography is not clear. METHODS: We prospectively identified patients with baseline estimated glomerular filtration rates (eGFR) < 60 ml/min/1.73 m(2) undergoing non-emergent coronary angiography. We measured serum creatinine 48-96 hr following angiography and assessed the incidence of CIN using two definitions, a rise in Scr > or = 25% and > or = 0.5 mg/dl. We tracked the need for dialysis, hospitalization related to kidney injury, and 30-day mortality to examine the association of CIN with these outcomes. RESULTS: We enrolled 181 patients with a median eGFR of 52 ml/min/1.73 m(2). Of the 165 patients (91%) with post-procedure Scr data, the incidence of CIN was 6.1-8.5%. One patient required dialysis (0.55%) and one (0.55%) died within 30 days. Although 38 patients required hospital admission, CIN was not associated with the need for hospitalization. Patients with an increase in Scr > or = 25% demonstrated a trend toward increased risk for 30-day mortality (P = 0.09), whereas those with increments in Scr > or = 0.5 mg/dl had a marginally higher risk for dialysis (P = 0.06) and 30-day mortality (P = 0.06), although these associations failed to meet the level of statistical significance. CONCLUSIONS: Biochemically defined CIN occurs in a small, but notable proportion of patients undergoing non-emergent coronary angiography. However, clinically significant CIN is very uncommon.

Comparison of frequency of new-onset atrial fibrillation or flutter in patients on statins versus not on statins presenting with suspected acute coronary syndrome.

The effect of statins on the incidence of new-onset atrial fibrillation (AF) in patients presenting with suspicion of acute coronary syndrome (ACS) is unknown. Our study population consisted of patients admitted to a tertiary care Veterans Administration hospital with suspicion of ACS between November 2001 and January 2006. All patients had an electrocardiogram on admission that was compared with a previous electrocardiogram to confirm new-onset AF or atrial flutter. Of 1,526 patients, 164 (10.8%) had new-onset AF and 601 (39.4%) were on a statin on admission. Patients with AF were significantly more likely to be older, Caucasian, have renal insufficiency and anemia, and less likely to be diabetic, on a statin or angiotensin-converting enzyme inhibitor on admission, or have chest pain as a presenting complaint. In univariate analysis, patients on statins were significantly less likely to have new-onset AF (odds ratio 0.40, 95% confidence interval 0.33 to 0.69, p <0.01). This relation persisted in the multivariate model (odds ratio 0.57, 95% confidence interval 0.39 to 0.83, p <0.01) after correcting for age, race, diabetes mellitus, chest pain, and use of angiotensin-converting enzyme inhibitor. In conclusion, patients presenting with suspicion of ACS were much less likely to have newonset AF if they were on a statin at time of presentation.

Effect of hyponatremia (<135 mEq/L) on outcome in patients with non-ST-elevation acute coronary syndrome.

Hyponatremia is associated with adverse outcomes in patients with heart failure and ST-elevation myocardial infarction (STEMI). We evaluated the effect of hyponatremia on outcomes in patients with suspected acute coronary syndrome and non-STEMI. All patients had a sodium level determined at time of admission, at 24 and 48 hours, and at discharge. Of 1,478 patients, 341 (23.1%) were hyponatremic (sodium <135 mEq/L) on presentation. Patients who had hyponatremia on admission were significantly more likely to die or have recurrent myocardial infarction in the next 30 days (odds ratio 1.98, 95% confidence interval 1.35 to 2.89, p <0.001). This relation persisted after adjusting for factors such as age, left ventricular ejection fraction, use of diuretics before admission, hypotension on presentation, anemia, chronic renal insufficiency, pulmonary edema, and high troponin levels (odds ratio 1.7, 95% confidence interval 1.1 to 2.5, p = 0.01). In conclusion, hyponatremia on admission is associated with 30-day adverse outcome in patients presenting with suspected acute coronary syndrome/non-STEMI.

Detectable troponin levels predict poor prognosis in patients with left ventricular dysfunction undergoing internal defibrillator implantation.

INTRODUCTION: Troponin levels have been demonstrated to predict mortality in patients with cardiomyopathy. Implantable cardiac defibrillator (ICD) devices have been demonstrated to improve survival. It is not clear if ICDs would mitigate the negative outcome predicted by elevated troponin levels. METHODS: We collected baseline blood samples for troponin T (TnT) and creatinine kinase-MB fraction in consecutive patients immediately before successful pectoral transvenous ICD implant. Patients were followed for total mortality. For analysis, patients were grouped by TnT detectability (>or=0.01 ng/mL). RESULTS: Fifty-two men, aged 68 +/- 10 years, were studied. Mean ejection fraction was 29 +/- 12% and 65% had ischemic cardiomyopathy. Follow-up duration was 17 +/- 8 months. None of the patients had abnormal creatinine kinase-MB fraction levels (1.7 +/- 1.1 ng/mL). There were 37 patients with no detectable TnT (Group I) and 15 with detectable TnT (Group II). There was no difference between the two groups in terms of age (68 vs 69, P = NS), ejection fraction (30 vs 29%, P = NS), or proportion of patients with ischemic cardiomyopathy (68 vs 60%, P = NS). During follow-up 16 (31%) patients died. Patients in group I had mortality of 16% (6/37) compared to 67% mortality (10/15, P < 0.001) in group II. On multivariate analysis, detectable TnT remained an independent predictor of mortality (HR 4.5, CI 1.4-14.25, P = 0.01). CONCLUSION: In a cohort of patients with cardiomyopathy undergoing ICD implantation for standard clinical indications, presence of detectable TnT was associated with high mortality despite ICD implantation. TnT obtained before ICD implantation may be useful for risk stratification.

Impact of blood transfusions in patients presenting with anemia and suspected acute coronary syndrome.

Anemia has been shown to predict adverse events in patients presenting with acute coronary syndromes and non-ST-elevation myocardial infarctions (MIs). Less is known about the value of blood transfusions in this setting. We sought to evaluate the impact of red blood cell transfusions on outcomes. Transfusion in anemic patients admitted with suspected acute coronary syndrome/non-ST-elevation MIs led to a significant increase in 30-day recurrent MI or death (odds ratio 3.05, 95% confidence interval 1.80 to 5.17, p <0.001). This relation persisted after adjusting for significant univariate predictors: hypotension on presentation, pulmonary edema, and increased troponin-I levels (odds ratio 2.57, 95% confidence interval 1.41 to 4.69, p <0.001). In conclusion, the risk versus benefit of transfusion in patients presenting with an acute coronary syndrome needs careful assessment.

Clinical characteristics, process of care, and outcomes of Hispanic patients presenting with non-ST-segment elevation acute coronary syndromes: results from Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA Guidelines (CRUSADE).

BACKGROUND: Data regarding the management of non-ST-segment elevation acute coronary syndromes (NSTE ACS) in Hispanic patients, the largest and fastest-growing minority in the United States, are scarce. METHODS: We sought to describe the clinical characteristics, process of care, and outcomes of Hispanics presenting with NSTE ACS at US hospitals. We compared baseline characteristics, resource use, and inhospital mortality among 3936 Hispanics and 90280 non-Hispanic whites with NSTE ACS from the CRUSADE Quality Improvement Initiative. RESULTS: The regional distribution of Hispanics in CRUSADE paralleled that in the US Census. Hispanics were younger (65 vs 70 years, P < .0001) and had less hyperlipidemia (45.4% vs 49.0%, P < .0001) but were more likely to be hypertensive (72.2% vs 67.9%, P < .0001) and diabetic (46.5% vs 30.9%, P < .0001). Hispanics were also more likely to be uninsured (12.5% vs 5.1%, P < .001). During hospitalization, Hispanics were more often managed conservatively, undergoing stress tests more frequently (13.0% vs 10.1%, P < .0001), with less use of cardiac catheterization within 48 hours (48.7% vs 55.5%, P < .0001) or percutaneous coronary intervention (39.6% vs 46.4%, P < .0001) at any time. Hispanics received similar discharge treatments but were less frequently referred for cardiac rehabilitation (38.5% vs 49.2%, P < .0001). Adjusted inhospital mortality was similar in both groups (odds ratio 0.87, 95% CI 0.72-1.05). CONCLUSIONS: Although hispanics have a different risk factor profile and are treated less aggressively during hospitalization when they present with NSTE ACS, these treatment differences do not appear to affect inhospital outcomes. Further research is warranted to explore the long-term consequences of these findings.

Perioperative risk of noncardiac surgery associated with aortic stenosis.

The perioperative risk of noncardiac surgery in patients with aortic stenosis (AS) remains ill-defined, and the few studies published have reported conflicting results. A sample of patients from the National Hospital Discharge Survey database diagnosed with AS who underwent any noncardiac surgical procedure was searched. Patients who underwent any cardiac surgery were excluded. Patients with AS were matched by decile of age and surgical risk for twice as many controls. A discharge diagnosis of acute myocardial infarction (AMI) and death was used as the end points for analysis. From 1996 to 2002, 5,149 patients with a diagnosis of AS had undergone noncardiac surgery and were matched with 10,284 controls. The incidence of AMI was greater in patients with AS than in controls (3.86% vs 2.03%, p <0.001). After correcting for gender and the presence of coronary artery disease, hypertension, and diabetes mellitus in a multivariate logistic regression model, the presence of AS was associated with an increased likelihood of AMI (odds ratio 1.55, 95% confidence interval 1.27 to 1.90, p <0.001). There was no significantly increased risk for death in patients with AS versus controls. In the era of more intense perioperative medical management of patients who undergo noncardiac surgery, the presence of AS increases the risk for perioperative AMI but not overall mortality. The impact of the actual severity of AS on outcomes with noncardiac surgery needs further study.

Effect of both elevated troponin-I and peripheral white blood cell count on prognosis in patients with suspected myocardial injury.

We found a high white blood cell count (>11,000/mul) to be of additive prognostic value to high troponin-I levels in predicting risk of recurrent nonfatal myocardial infarctions and all-cause mortality in patients who present with acute coronary syndromes and non-ST-elevation myocardial infarctions. A high troponin-I level or white blood cell count increased the odds ratio of an event to 2.2 (95% confidence interval 1.0 to 4.73, p = 0.05), but high values for the 2 markers increased the odds ratio to 4.5 (95% confidence interval 1.42 to 14.21, p = 0.01).

Racial variations in treatment and outcomes of black and white patients with high-risk non-ST-elevation acute coronary syndromes: insights from CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the ACC/AHA Guidelines?).

BACKGROUND: Black patients with acute myocardial infarction are less likely than whites to receive coronary interventions. It is unknown whether racial disparities exist for other treatments for non-ST-segment elevation acute coronary syndromes (NSTE ACS) and how different treatments affect outcomes. METHODS AND RESULTS: Using data from 400 US hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines?) National Quality Improvement Initiative, we identified black and white patients with high-risk NSTE ACS (positive cardiac markers and/or ischemic ST-segment changes). After adjustment for demographics and medical comorbidity, we compared the use of therapies recommended by the American College of Cardiology/American Heart Association guidelines for NSTE ACS and outcomes by race. Our study included 37,813 (87.3%) white and 5504 (12.7%) black patients. Black patients were younger; were more likely to have hypertension, diabetes, heart failure, and renal insufficiency; and were less likely to have insurance coverage or primary cardiology care. Black patients had a similar or higher likelihood than whites of receiving older ACS treatments such as aspirin, beta-blockers, or ACE inhibitors but were significantly less likely to receive newer ACS therapies, including acute glycoprotein IIb/IIIa inhibitors, acute and discharge clopidogrel, and statin therapy at discharge. Blacks were also less likely to receive cardiac catheterization, revascularization procedures, or smoking cessation counseling. Acute risk-adjusted outcomes were similar between black and white patients. CONCLUSIONS: Black patients with NSTE ACS were less likely than whites to receive many evidence-based treatments, particularly those that are costly or newer. Longitudinal studies are needed to assess the long-term impact of these treatment disparities on clinical outcomes.