Decade-long trends (1986 to 1997) in the medical treatment of patients with acute myocardial infarction: A community-wide perspective.

BACKGROUND: Although there are an increasing number and variety of medications available for the treatment of patients with acute myocardial infarction (AMI), few data are available describing recent, and changes over time in, use of different cardiac medications in patients with AMI from a more generalizable, community-wide perspective. Moreover, it is unclear whether the demographic and clinical profile of patients receiving these agents is similar or varies according to the type of agent prescribed. METHODS AND RESULTS: The purpose of this study was to examine recent patterns and changes over a decade-long period (1986 to 1997) in the use of cardiac medications during the acute hospitalization and at the time of hospital discharge in metropolitan Worcester, Mass, residents (1990 census estimate, 437,000) hospitalized with confirmed AMI. There was a marked increase in the use of angiotensin-converting enzyme inhibitors, aspirin, beta-blockers, lipid-lowering agents, and thrombolytic therapy between 1986 and 1997. The use of calcium antagonists, lidocaine, and other antiarrhythmic agents declined over this period. Similar trends were observed in the use of these agents in hospital survivors at the time of hospital discharge. Patient age, presence of comorbidities, and AMI-associated characteristics influenced the use of these therapies; sex differences in the use of several of these medications were also noted. CONCLUSIONS: The results of this population-based observational study provide insights into changing prescribing patterns in the hospital treatment of patients with AMI. Despite encouraging increases in the use of several of these agents, considerable opportunities for increased utilization remain.

Temporal trends (1986-1997) in cholesterol level assessment and management practices in patients with acute myocardial infarction: a population-based perspective.

BACKGROUND: Elevated serum cholesterol levels are associated with increased risk for acute myocardial infarction (AMI) and adverse patient outcomes. It is unclear what proportion of patients have their serum cholesterol levels measured during hospitalization for AMI and are given hypolipidemic therapy. OBJECTIVE: To examine decade-long trends in measurement of serum cholesterol levels during hospitalization for AMI and use of hypolipidemic therapy. METHODS: Observational study of 5204 residents of the Worcester, Mass, metropolitan area hospitalized with validated AMI in all greater Worcester hospitals in seven 1-year periods from 1986 through 1997. RESULTS: Increases in the measurement of serum cholesterol levels during hospitalization for AMI were observed between 1986 and 1991, followed by a progressive decrease; only 24% of patients with AMI in 1997 underwent cholesterol level testing. Younger age, male sex, and absence of a history of cardiovascular disease were associated with an increased likelihood measurement of serum cholesterol levels. Although the relative use of hypolipidemic therapy increased significantly over time (0.4% in 1986 vs 10.7% in 1997), the absolute rate of use remained low. In patients with elevated serum cholesterol levels (>/=6.2 mmol/L [>/=240 mg/dL]), 1.9% received hypolipidemic therapy in 1986 and 36.6% in 1997. CONCLUSIONS: These findings suggest recent declines in the assessment of total cholesterol levels in patients hospitalized with AMI. Although the use of hypolipidemic therapy during hospitalization for AMI has increased over time, considerable room for improvement remains.

Twenty-two year (1975 to 1997) trends in the incidence, in-hospital and long-term case fatality rates from initial Q-wave and non-Q-wave myocardial infarction: a multi-hospital, community-wide perspective.

OBJECTIVES: The goal of this study was to examine long-term trends in the incidence, in-hospital and long-term mortality patterns in patients with an initial non-Q-wave myocardial infarction (NQWMI) as compared with those with an initial Q-wave myocardial infarction (QWMI). BACKGROUND: Limited data are available describing trends in the incidence and mortality from an initial QWMI and NQWMI from a multi-hospital community-wide perspective. METHODS: Our study was an observational study of 5,832 metropolitan Worcester, Massachusetts residents (1990 census = 437,000) hospitalized with validated initial acute MI in all greater Worcester hospitals during 11 annual periods between 1975 and 1997. RESULTS: The incidence of QWMI progressively decreased between 1975/78 (incidence rate = 171/100,000 population) and 1997 (101/100,000 population). In contrast, the incidence of NQWMI progressively increased between 1975/78 (62/100,000 population) and 1997 (131/100,000 population). Hospital death rates were 19.5% for patients with QWMI and 12.5% for those with NQWMI. After controlling for various covariates, patients with QWMI remained at significantly increased risk for hospital mortality (adjusted odds ratio = 1.63; 95% confidence interval: 1.35, 1.97). While the hospital mortality of QWMI has progressively declined over time (1975/78 = 24%; 1997 = 14%), the in-hospital mortality for NQWMI has remained the same (1975/78 = 12%; 1997 = 12%). These trends remained after adjusting for potentially confounding prognostic factors. The multivariable adjusted two-year mortality after hospital discharge declined over time for patients with QWMI and NQWMI. CONCLUSIONS: Despite impressive declines in the incidence, in-hospital and long-term mortality associated with QWMI, NQWMI is increasing in frequency and has the same in-hospital mortality now as it did 22 years ago.

Outcomes and early revascularization for patients > or = 65 years of age with cardiogenic shock.

Hospital survival of patients with acute myocardial infarction (AMI) complicated by cardiogenic shock has improved during recent years. It is unclear whether this mortality benefit also applies to elderly patients with cardiogenic shock. Elderly residents (age > or = 65 years) of the Worcester, Massachusetts metropolitan area (1990 census population = 437,000) hospitalized with confirmed AMI and cardiogenic shock in all metropolitan Worcester, Massachusetts hospitals between 1986 and 1997 constituted the sample of interest. We examined the use of coronary reperfusion strategies, adjunctive therapy, and hospital mortality in a cohort of 166 cardiogenic patients treated early in the reperfusion era (1986 to 1991) compared with 144 patients with AMI treated approximately 1 decade later (1993 to 1997). There was a significant increase in the use of an early revascularization strategy over time (2% vs 16%, p <0.001). Marked increases in use of antiplatelet therapy, beta blockers, and angiotensin-converting enzyme inhibitors were also observed over the decade-long experience. In-hospital case fatality declined significantly over time, from 80% (1986 to 1991) to 69% (1993 to 1997) in elderly patients who developed cardiogenic shock (p = 0.03). After adjusting for differences in potentially confounding prognostic characteristics between patients hospitalized in the 2 study periods, an even more pronounced reduction in hospital mortality (42%) was observed for the most recently hospitalized cohort. The most powerful predictor of in-hospital survival was use of an early revascularization approach to treatment. Thus, hospital mortality has declined for patients > or = 65 years of age with AMI complicated by cardiogenic shock, and this decline has occurred in the setting of broader use of early revascularization and adjunctive medical therapy for this high-risk population.

Sex differences in 2-year mortality after hospital discharge for myocardial infarction.

BACKGROUND: An interaction between sex and age is thought to affect hospital mortality after myocardial infarction; younger, but not older, women have been shown to have higher mortality rates than men. It is currently unknown whether findings are similar after hospital discharge. OBJECTIVE: To determine whether an interaction between sex and age affects 2-year mortality after myocardial infarction. DESIGN: Community-based prospective cohort study. SETTING: 16 community hospitals serving the Worcester, Massachusetts, metropolitan area. PATIENTS: 6826 patients who survived hospitalization for acute myocardial infarction during ten 1-year periods between 1975 and 1995. MEASUREMENTS: Mortality 2 years after hospital discharge. RESULTS: The overall 2-year mortality rate was higher in women (28.9%) than in men (19.6%). When patients were examined by age group, however, only women younger than 60 years of age had a higher mortality rate than men of similar age. The sex difference decreased with increasing age; among the oldest patients, women had a lower mortality rate than men (P = 0.009 for the interaction between sex and age). This relationship was not affected by adjustment for demographic characteristics and medical history, clinical characteristics, and hospital and discharge treatments; the hazard of 2-year death for women compared with men increased 15.4% (95% CI, 4.3% to 27.6%) for every 10-year decrease in age. In absolute terms, after adjustment for demographic characteristics and medical history, among patients younger than 60 years of age women were at greater risk than men (risk difference, 1.8 percentage points). At older ages, however, women were at lower risk than men. CONCLUSIONS: Younger, but not older, women who survive hospitalization for myocardial infarction have a higher long-term mortality rate than men. This provides additional evidence that younger women with myocardial infarction are at greater risk for death than men.

Temporal trends and associated factors of inpatient cardiac rehabilitation in patients with acute myocardial infarction: a community-wide perspective.

PURPOSE: Cardiac rehabilitation (CR) has been shown to be an important therapeutic intervention after the development of acute myocardial infarction (AMI), but historically has been underused. Inpatient CR often represents cardiac patients' first exposure to risk factor modification education and acts as a gateway to outpatient programs. METHODS: The authors performed a longitudinal study of the use of inpatient CR in 5204 Worcester residents hospitalized with validated AMI in seven 1-year periods between 1986 and 1997. RESULTS: The overall rate of referral to inpatient CR was 68%, with a slight decline in use to less than 60% in the authors' most recent study year of 1997. Referred patients were significantly more likely to be younger, male, or enrolled in a health maintenance organization; they were less likely to have a history of heart failure or stroke. They were significantly more likely to receive medications shown to be of benefit in the management of AMI and to undergo cardiac interventional procedures. In 1997, patients participating in inpatient CR were more likely to have documented inpatient counseling about nutrition, exercise, smoking, and stress reduction. DISCUSSION: The results of this multihospital community-wide study suggest relatively stable, but recently decreasing, use of inpatient CR over the past decade. Women and the elderly are underrepresented in these programs. Patients not referred to inpatient rehabilitation were less likely to be prescribed effective cardiac medications and undergo risk factor modification counseling prior to discharge. Further studies are needed to better understand the reasons for patient exclusion from the benefits of inpatient CR.

The impact of the stent era on the management strategy for acute myocardial infarction: A population-based perspective.

We determined trends in the use of invasive diagnostic and revascularization strategies from a multihospital community-wide perspective for patients suffering acute myocardial infarction (AMI). Comparing 3,824 patients treated in the prestent era (1986-1993) to 1,915 patients hospitalized during the stent era (1995-1997), there was a significant increase in the use of invasive procedures and revascularization techniques across a broad spectrum of AMI patients during their index hospitalization. This resulted in a higher-risk profile of patients referred for invasive management of AMI in the stent era. Cathet. Cardiovasc. Intervent. 51:255-258, 2000.

Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: the Worcester Heart Attack study.

BACKGROUND: Duration of prehospital delay in patients with acute myocardial infarction (AMI) is receiving increasing attention given the time-dependent benefits associated with prompt use of coronary reperfusion strategies. OBJECTIVE: To examine trends (1986-1997) in time to hospital presentation and factors associated with prolonged delay in a community-wide study of patients with AMI. METHODS: Longitudinal study of 3837 residents of the Worcester, Mass, metropolitan area hospitalized with AMI in 7 one-year periods between 1986 and 1997 in whom information about prehospital delay was available. RESULTS: The mean, median, and distribution of delay times exhibited either inconsistent or no changes over time. In 1986, the mean and median prehospital delay times were 4.1 and 2.2 hours, respectively; these times were 4.3 and 2.0 hours, respectively, in patients hospitalized in 1997. Overall, with no significant differences noted over time, approximately 44% of patients with AMI presented to area-wide hospitals in less than 2 hours after the onset of acute coronary symptoms. Increasing age, history of angina or diabetes, onset of symptoms in the afternoon or evening, and hospitalization in the most recent study year (1997) were significantly associated with delays of more than 2 hours in seeking hospital care after controlling for a variety of factors that might affect delay. CONCLUSIONS: The results of this population-based study suggest that a large proportion of patients with AMI continue to exhibit prolonged delay. The characteristics of many of these individuals can be identified in advance for targeted educational efforts. Arch Intern Med. 2000;160:3217-3223.

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

The benefits of coronary reperfusion and antiplatelet therapy for patients with Q-wave acute myocardial infarction (Q-AMI) are well established in the context of randomized, controlled trials. The use and recent impact of these and other therapies on the broader, community-wide 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 decade 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, beta 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 of broader use of reperfusion and adjunctive therapy (including primary angioplasty).

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.

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 11 1-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.

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.

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-year 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.

A two-decades (1975 to 1995) long experience in the incidence, in-hospital and long-term case-fatality rates of acute myocardial infarction: a community-wide perspective.

OBJECTIVES: The purpose of the present study is to describe changes over two decades (1975 to 1995) in the incidence, in-hospital and long-term case-fatality rates associated with acute myocardial infarction (AMI) from a multihospital community-wide perspective. BACKGROUND: Despite the magnitude of, and mortality associated with acute myocardial infarction (AMI), relatively limited population-based data are available to describe recent and temporal trends in the attack and case-fatality rates associated with AMI from a representative population-based perspective. METHODS: The community-based study included 5,270 residents of the Worcester, Massachusetts, metropolitan area hospitalized with confirmed initial AMI in all metropolitan Worcester, Massachusetts, hospitals (1990 census population = 437,000) in 10 one-year periods between 1975 and 1995. RESULTS: The age-adjusted incidence rates of initial AMI increased between 1975 (244 per 100,000) and 1981 (272 per 100,000), after which time these rates declined through 1995 (184 per 100,000). The crude and multivariable-adjusted in-hospital case-fatality rates exhibited a consistent decline between 1975/1978 (17.8%), 1986/1988 (17.0%) and 1993/1995 (11.7%). Although there were no statistically significant differences in the unadjusted long-term case-fatality rates of discharged hospital survivors over the periods under study, declines in the multivariable-adjusted risk of dying within the first year after hospital discharge were observed between the earliest and most recently discharged patients with AMI. CONCLUSIONS: The results of this population-based study of patients with validated initial AMI provide encouragement for efforts directed at the primary and secondary prevention of AMI given declining incidence and case-fatality rates.

Temporal trends in cardiogenic shock complicating acute myocardial infarction.

BACKGROUND: Limited information is available on trends in the incidence of and mortality due to cardiogenic shock complicating acute myocardial infarction. We studied the incidence of cardiogenic shock complicating acute myocardial infarction and in-hospital death rates among patients with this condition in a single community from 1975 through 1997. METHODS: We conducted an observational study of 9076 residents of metropolitan Worcester, Massachusetts, who were hospitalized with confirmed acute myocardial infarction in all local hospitals during 11 one-year periods between 1975 and 1997. Our study included periods before and after the advent of reperfusion therapy. RESULTS: The incidence of cardiogenic shock remained relatively stable over time, averaging 7.1 percent among patients with acute myocardial infarction. The results of a multivariable regression analysis indicated that the patients hospitalized during recent study years were not at a substantially lower risk for shock than patients hospitalized in the mid-to-late 1970s. Patients in whom cardiogenic shock developed had a significantly greater risk of dying during hospitalization (71.7 percent) than those who did not have cardiogenic shock (12.0 percent, P<0.001). A significant trend toward an increase in in-hospital survival among patients with cardiogenic shock in the mid-to-late 1990s was found in crude and adjusted analyses. CONCLUSIONS: Our findings indicate no significant change in the incidence of cardiogenic shock complicating acute myocardial infarction over a 23-year period. However, the short-term survival rate has increased in recent years at the same time as the use of coronary reperfusion strategies has increased.

Use of aspirin, beta-blockers, and lipid-lowering medications before recurrent acute myocardial infarction: missed opportunities for prevention?

BACKGROUND: For patients who have had a previous myocardial infarction (MI), the use of aspirin, beta-blockers, and lipid-lowering agents reduces the risk of recurrent MI and death. OBJECTIVE: To examine trends in and determinants of receipt of these 3 medications before hospitalization for recurrent acute MI (AMI). METHODS: The study population consisted of 1710 patients with a previous history of MI hospitalized with a validated recurrent AMI in all hospitals in Worcester, Mass, during 1986, 1988, 1990, 1991, 1993, and 1995. Logistic regression analyses were used to assess the effect of demographic, clinical, and temporal factors on the receipt of aspirin, beta-blockers, and lipid-lowering medications before hospital admission for recurrent AMI. RESULTS: More than 47% of patients in each study year were not receiving each medication before admission, although significant increases in use were noted over time for aspirin (from 13.5% to 52.6%), beta-blockers (from 33.2% to 44.4%), and lipid-lowering medications (from 0.8% to 11.7%). In multivariate analyses, advancing age was associated with not receiving aspirin (odds ratio [OR], 0.67; 95% confidence interval [CI], 0.51-0.89), lipid-lowering medications (OR, 0.14; 95% CI, 0.08-0.25), and beta-blockers (OR, 0.75; 95% CI, 0.57-1.00), although this effect was of borderline significance for beta-blockers. Being a woman was associated with not receiving aspirin (OR, 0.78; 95% CI, 0.62-0.98) but was positively associated with receiving lipid-lowering medications (OR, 1.59; 95% CI, 1.04-2.43). Coexisting medical conditions and concurrent use of other cardiovascular medications were also associated with receipt of each medication. CONCLUSION: Despite encouraging increases over time, the low absolute levels of receipt of medications shown to be efficacious in the long-term treatment of patients after an MI, and their variation by age and sex, suggest that substantial opportunities may exist to prevent recurrent AMIs through the increased use of aspirin, beta-blockers, and lipid-lowering medications.

Differences in discharge medication after acute myocardial infarction in patients with HMO and fee-for-service medical insurance.

OBJECTIVE: To assess the impact of fee-for-service (FFS) versus HMO medical insurance coverage on receipt of aspirin, beta-blockers, and calcium channel blockers at the time of hospital discharge following an acute myocardial infarction. DESIGN: Prospective, population-based study. SETTING: All 16 community and tertiary care hospitals in the metropolitan area of Worcester, Massachusetts. PATIENTS: The study population consisted of patients under 65 years of age hospitalized with a validated acute myocardial infarction in all hospitals in the Worcester (Massachusetts) Standard Metropolitan Statistical Area (1990 census estimate, 437,000) during 1986, 1988, 1990, 1991, and 1993. MEASUREMENTS AND MAIN RESULTS: After adjustment for demographic and clinical variables as well as study year, the odds ratios for receipt of each medication for patients with HMO insurance compared with FFS were 1.05 (95% confidence interval [CI] 0.77, 1.44) for aspirin, 1.32 (95% CI 0.98, 1.76) for beta-blockers, and 0.72 (95% CI 0.54, 0.96) for calcium channel blockers. Examination of temporal trends in utilization of these agents suggests that observed decreases in use of calcium channel blockers and increases in use of beta-blockers over the period under study occurred more rapidly for HMO than for FFS patients. CONCLUSIONS: Overall, use of aspirin and beta-blockers was comparable among HMO and FFS patients and use of calcium channel blockers (deemed less effective or ineffective for secondary prevention) was lower among HMO patients. Differential adoption, over time, of evidence-based prescribing practices for medications between HMO and FFS patients who have had a myocardial infarction warrants further study.

Age-related trends in short- and long-term survival after acute myocardial infarction: a 20-year population-based perspective (1975-1995).

This study examines age-related differences and temporal trends in hospital and long-term survival after acute myocardial infarction (AMI) over a 2-decade-long (1975 to 1995) experience. A total of 8,070 patients with validated AMI hospitalized in all acute care hospitals in the Worcester, Massachusetts, metropolitan area (1990 census population 437,000) were studied over 10 one-year periods between 1975 and 1995. This population included 1,326 patients aged <55 years (16.4%), 1,768 patients aged 55 to 64 years (21.9%), 2,325 patients aged 65 to 74 years (28.8%), 1,880 patients aged 75 to 84 years (23.3%), and 771 patients aged > or = 85 years (9.6%). Compared with patients <55 years, patients 55 to 64 years were 2.2 times more likely to die during hospitalization for AMI, whereas patients 65 to 74, 75 to 84, and > or = 85 years were at 4.2, 7.8, and 10.2 times greater risk of dying, respectively. Similar age disparities in the risk of dying were seen when controlling for additional prognostic factors. Despite the adverse impact of increasing age on hospital survival after AMI, declining in-hospital death rates were seen in each of the age groups under study, with declining magnitude of these trends with advancing age. Among discharged hospital patients, increasing age was related to a significantly poorer long-term prognosis. Trends toward improving long-term prognosis were seen in patients discharged in the mid-1990s compared with those discharged in the mid- to late 1970s for patients aged <85 years. The present results demonstrate the marked impact of advancing age on survival after AMI. Despite the adverse impact of age on prognosis, encouraging trends in prognosis were observed in all age groups, although to a lesser extent in the oldest elderly patients. These findings emphasize the low death rates in middle-aged patients with AMI and the need for targeted secondary prevention efforts in elderly patients with AMI.

Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective.

OBJECTIVES: To describe sex differences in symptom presentation after acute myocardial infarction (AMI) while controlling for differences in age and other potentially confounding factors. BACKGROUND: Although several studies have examined sex differences in diagnosis, management, and survival after AMI, limited data exist about possible sex differences in symptom presentation in the setting of AMI. METHODS: Community-based study of patients hospitalized with confirmed AMI in all 16 metropolitan Worcester, Mass., hospitals (1990 census population = 437,000). Men (n = 810) and women (n = 550) hospitalized with validated AMI in 1986 and 1988 comprised the study sample. RESULTS: After simultaneously controlling for age, medical history, and AMI characteristics through regression modeling, men were significantly less likely to complain of neck pain (adjusted odds ratio (OR) = 0.52; 95% CI: 0.35, 0.78), back pain (OR = 0.38; 95% CI: 0.26, 0.56), jaw pain (OR = 0.50; 95% CI: 0.31, 0.81), and nausea (O.R. = 0.58; 95% CI: 0.45, 0.75) than women. Conversely, men were significantly more likely to report diaphoresis (OR = 1.27; 95% CI: 1.00, 1.61) than women. There were no statistically significant sex differences in complaints of chest pain though men were more likely to complain of this symptom. CONCLUSIONS: The results of this population-based observational study suggest differences in symptom presentation in men and women hospitalized with AMI. These findings have implications for public and health care provider education concerning recognition of sex differences in AMI-related symptoms and health care seeking behaviors.

Use of lipid-lowering medication in patients with acute myocardial infarction (Worcester Heart Attack Study).

As part of a population-based longitudinal study, we examined the use of lipid-lowering medication in 3,824 patients hospitalized with acute myocardial infarction in the Worcester, Massachusetts metropolitan area between 1986 and 1993. The rate of utilization of lipid-lowering medication either before (1.8%) or during hospitalization (1.9%) for acute myocardial infarction was low.

Health insurance coverage and outcome following acute myocardial infarction. A community-wide perspective.

BACKGROUND: Several studies have suggested that type of medical insurance coverage is associated with hospital utilization rates and receipt of selected diagnostic or treatment approaches. To our knowledge no studies, however, have examined the relation between medical insurance coverage and short-term outcomes following acute myocardial infarction (AMI) from a multihospital, community-wide perspective. OBJECTIVE: To examine the association between medical insurance coverage and in-hospital case-fatality rates as well as length of hospital stay following AMI. METHODS: The study sample consisted of 3735 residents of the Worcester, Mass, metropolitan area hospitalized with validated AMI during 1986, 1988, 1990, 1991, and 1993 at all metropolitan Worcester hospitals. Data were obtained from the review of medical records. Patients were stratified into 5 medical insurance groups for purposes of analysis: private or commercial (n = 711), Medicaid (n = 101), Medicare (n = 1991), health maintenance organization (n = 741), and self-pay or other (n = 191). Crude and multivariable-adjusted analyses were used to examine the relation between medical insurance coverage and length of hospital stay and in-hospital case-fatality rates following AMI. RESULTS: In-hospital case-fatality rates during the period under study were 7.7%, 11.9%, 21.4%, 9.3%, and 10.0% in the 5 medical insurance groups, respectively. After adjusting for several factors that may affect in-hospital mortality, relative to the referent group of private or commercial insurance patients (odds ratio, 1.0), the multivariable-adjusted odds for dying during the acute hospitalization were 0.87 (95% confidence interval [CI], 0.56-1.36) for health maintenance organization patients, 1.22 (95% CI, 0.55-2.68) for Medical patients, 1.25 (95% CI, 0.85-1.84) for Medicare patients, and 1.21 (95% CI, 0.60-2.44) for self-pay or other patients. The mean length of hospitalization after excluding patients with a prolonged hospitalization was 10.1 days for private or commercial insurance patients, 9.4 days for health maintenance organization patients, 10.9 days for Medicaid patients, 11.1 days for Medicare patients, and 9.8 days for self-pay or other patients. No significant differences in the average duration of hospitalization were seen between the medical insurance groups after controlling for potential confounding variables. CONCLUSIONS: The results of this population-based study suggest that patient insurance status is not significantly associated with either length of hospital stay or short-term mortality following AMI. Other demographic and clinical prognostic factors appear to be more important predictors of short-term outcome in this patient population.

Age-related trends (1986-1993) in the use of thrombolytic agents in patients with acute myocardial infarction. The Worcester Heart Attack Study.

OBJECTIVE: To examine age-related differences and temporal trends in the use of thrombolytic therapy in a community-wide study of patients hospitalized with acute myocardial infarction (AMI) between 1986 and 1993. METHODS: All hospitals in the Worcester, Mass, metropolitan area (1990 census population, 4370000) were included. A total of 3824 patients with validated AMI categorized according to age comprised the study sample: younger than 55 years (n = 577), 55 to 64 years (n = 758), 65 to 74 years (n = 1143), and 75 years or older (n = 1346). RESULTS: Use of thrombolytic therapy increased during the period under study in all patients hospitalized with AMI (9% in 1986; 26% in 1993). In 1986, the majority of treated patients received streptokinase; while increases over time in the use of tissue-type plasminogen activator were noted, streptokinase remained the thrombolytic agent of choice in 1993. Marked age-related trends in the use of thrombolytic therapy were observed, with the most striking increases in the use of thrombolytic therapy over time seen in those aged 65 years or older. Between 1986 and 1993 the relative increases in the use of thrombolytic therapy were observed in the following age groups: younger than 55 years (106%), 55 to 64 years (85%), 65 to 74 years (694%), and 75 years or older (571%). Despite these encouraging trends in the use of thrombolytic therapy in older patients, after controlling for a variety of potential confounding variables elderly patients were significantly less likely to receive thrombolytic therapy during hospitalization for AMI. Compared with patients aged 75 years or older, patients younger than 55 years were 6.4 times (95% confidence interval [CI], 4.8-8.5), patients aged 55 to 64 years were 4.9 times (95% CI, 3.8-6.4), and patients aged 65 to 74 years were 3.0 times (95% CI, 2.3-3.9) significantly more likely to receive thrombolytic therapy. These differences were in part related to the proportion of patients with myocardial infarction satisfying eligibility criteria for the receipt of thrombolytic therapy; patients aged 75 years or older were significantly less likely to meet these criteria (19%) than were those younger than 55 years (49%), those aged 55 to 64 years (38%), and those aged 65 to 74 years (28%). CONCLUSIONS: The present results show that while there have been substantial increases over time in the use of thrombolytic therapy in patients with AMI, most particularly in older individuals, the elderly remain appreciably less likely to receive these agents during hospitalization for AMI. These differences may be due to the smaller percentage of elderly patients satisfying criteria for the use of these agents compared with younger patients with coronary heart disease, as well as to a reluctance by physicians to use these agents in older patients. Continued monitoring of these trends remains important for examining changes in physicians' practice patterns regarding the use of thrombolytic therapy in this vulnerable population.