People of South Asian (SA) ancestry are susceptible to coronary artery disease (CAD). Although studies suggest that SA with CAD has a worse prognosis compared with Europeans, it is unknown whether corresponding differences in functional status and quality-of-life (QOL) measures exist. Accordingly, we compared symptoms, function, and QOL in SA and European Canadians with CAD using the Seattle Angina Questionnaire (SAQ).
Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease, an outcomes registry that captures patients undergoing cardiac catheterization in Alberta, Canada, we identified 635 SA and 18,934 European patients with angiographic CAD from January 1995 to December 2006 who reported health status outcomes using the SAQ at 1 year after the index catheterization. To obtain comparable clinical variables among SA and Europeans, we used a propensity score-matching technique.
One-year adjusted mean (SD) scores were significantly lower in SA compared with European Canadians for most SAQ domains: exertional capacity (75  vs 80 , P = .011), anginal stability (77  vs 77 , P = .627), anginal frequency (86  vs 88 , P
Low income is associated with adverse cardiovascular outcomes. Diabetes is more prevalent among low income groups, and low income patients with diabetes have been shown to have a greater burden of cardiovascular risk factors and worse cardiovascular outcomes. The objective of this study was to determine whether income status was associated with burden of coronary atherosclerosis in patients with diabetes.
All patients with diabetes presenting for cardiac catheterization between January 1, 2000, and December 31, 2002, in Calgary, Canada, were identified through the use of the Alberta Provincial Project for Assessing Outcomes in Coronary Heart Disease (APPROACH) database. This clinical database was merged with Canadian 2001 Census data on median household income per dissemination area using patient postal code data, and income quintiles were derived. Clinical profiles, severity of coronary atherosclerosis, and myocardial jeopardy were compared across income quintiles. Mean scores for severity and jeopardy were compared across income quintiles using analysis of variance. Multivariate linear regression was used to control for baseline differences across income groups. A total of 4596 patients were eligible for inclusion in this study. Clinical profiles differed significantly across income quintiles, with the highest income quintile being younger (P
This study on patients undergoing coronary angiography for acute myocardial infarction demonstrated that 2.8% of patients had angiographically normal coronary arteries and that these patients have a better prognosis than patients with angiographically verified coronary artery disease. The trend toward a higher prevalence of malignancy in this unique patient group raises the possibility of malignancy-induced hypercoagulability or inflammation as an underlying etiologic factor.
Comment In: Am J Cardiol. 2005 Dec 15;96(12):1755-616360374
Comment In: Am J Cardiol. 2005 Dec 1;96(11):1612-316310452
The efficacy of coronary artery bypass graft surgery (CABG) and percutaneous coronary intervention (PCI) in patients with coronary artery disease has been well defined by randomized controlled trials. However, patients with severe left ventricular dysfunction (ejection fraction
Surnames have the potential to accurately identify ancestral origins as they are passed on from generation to generation. In this study, we developed and validated a Chinese surname list to define Chinese ethnicity.
We conducted a literature review, a panel review, and a telephone survey in a randomly selected sample from a Canadian city in 2003 to develop a Chinese surname list. The list was then validated to data from the Canadian Community Health Survey. Both surveys collected information on self-reported ethnicity and surname.
Of the 112,452 people analyzed in the Canadian Community Health Survey, 1.6% were self-reported as Chinese. This was similar to the 1.5% identified by the surname list. Compared with self-reported Chinese ethnicity (reference standard), the surname list had 77.7% sensitivity, 80.5% positive predictive value, 99.7% specificity, and 99.6% negative predictive value. When stratifying by sex and marital status, the positive predictive value was 78.9% for married women and 83.6% for never married women.
The Chinese surname list appears to be valid in identifying Chinese ethnicity. The validity may depend on the geographic origins and Chinese dialects in given populations.
Alberta Blue Cross (ABC) provides copayment-based coverage for residents older than 65 years. A prior authorization (PA) process for patients prescribed clopidogrel following stent insertion was changed to an authorized prescriber (AP) list process in March 2002.
To determine the effect of a policy change in medication coverage for clopidogrel on patients' filling of prescriptions and outcomes following stent insertion.
Consecutive patients who received a coronary stent between September 1, 2001, and August 31, 2002, at the University of Alberta Hospital and were eligible for ABC coverage were identified. Data were obtained from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease and ABC databases.
One hundred twelve patients (45 in the PA period and 67 in the AP period) who received a coronary stent were eligible for ABC coverage during the study period. The two cohorts of patients were similar with respect to demographics. Fewer patients in the PA period than in the AP period had their prescription filled on the day of discharge (31% versus 54%; P=0.02), and the median time to fill was four days versus zero days in the PA and AP periods, respectively (Wilcoxon P=0.04). There was no significant difference in the proportion of patients filling their prescriptions after 28 days from discharge (67% versus 75%, P = not significant) or in the overall comparison of time to fill (log rank P=0.22). Two repeat revascularization procedures were necessary within six weeks after stent placement; both were in PA period patients who delayed or failed to fill their prescription.
The PA process may have delayed patients filling clopidogrel prescriptions following hospital discharge and has the potential to contribute to negative clinical consequences.
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To assess the effects of socioeconomic status on mortality in patients with acute myocardial infarction.
We studied a retrospective cohort of 5622 patients who presented to a hospital emergency department with an initial episode of acute myocardial infarction between April 1998 and March 2002 in the Province of Alberta, Canada. Our main outcome measure was 1-year all-cause mortality following the index emergency department visit; we used socioeconomic status (measured by neighborhood median household income) as our main predictor after controlling for patient and hospital characteristics and revascularization.
Socioeconomic status profoundly affected the rate of emergency department presentation and the process and outcome of acute myocardial infarction care. In patients belonging to the lowest versus the highest socioeconomic status quartile, the risk of presenting to the emergency department was 72% higher (P
The recently published Michigan outcome prediction model (MM) for inhospital mortality was developed and validated on a series of consecutive patients undergoing percutaneous coronary intervention (PCI). Our purpose was to externally validate the performance of the MM in 2 separate cohorts of patients with acute coronary syndrome (ACS) undergoing PCI in Canada.
A validation of the MM and development of an extended MM were performed on data describing 10,050 patients from the APPROACH prospective cohort study between January 1995 and December 2000. Performance of both models was assessed on an external data set of 3259 PCI cases from the British Columbia Cardiac Registries. Only patients with a diagnosis of ACS were included in the study.
The original MM predicted death rates ranging from 0.1% to 60.6%, but lacked accuracy to predict inhospital mortality as severity increased. The extended MM predicted death rates more widely from 0.0% to a high of 91.0% with better accuracy to predict inhospital death in patients with ACS undergoing PCI. The areas under the receiver operating characteristic curve for the MM and the extended MM on the external validation data set were 0.93 and 0.95, respectively.
The MM predicts death after PCI in patients with ACS and identifies a clear gradient of risk. However, the enhanced MM developed specifically for the subset of patients with ACS demonstrated better prediction and cross-validated performance. These prediction rules can be useful for risk-adjustment analyses and for prognostication for individual patients.
Hospital discharge data are used extensively in health research. Given the clinical differences between ST segment elevation myocardial infarction (STEMI) and non-ST segment elevation myocardial infarction (NSTEMI), it is important that these entities be distinguishable in a medical record. The authors sought to determine the extent to which the type of MI is recorded in medical records, as well as the consistency of this designation within individual records.
Records of all MI patients admitted to a tertiary care centre in Canada from April 1, 2000, to March 31, 2001, were reviewed. Documentation and consistency of the use of the terms STEMI (Q wave, ST elevation or transmural MI) or NSTEMI (non-Q wave, subendocardial or nontransmural MI) were assessed in the admission history, progress notes, coronary care unit summary and discharge summary sections of each record.
Missing data were common; each chart section mentioned MI type in fewer than one-half of charts. When information was combined, it was possible to determine the type of MI in 81.1% of cases. MI type was consistently described as STEMI in 48.7% of cases, and as NSTEMI in 32.4%. Of concern, MI type was discrepant across sections in 10.5% of cases and missing entirely in 8.4% of cases.
The designation of MI cases as STEMI or NSTEMI is both incomplete and inconsistent in hospital records. This has implications for health services research conducted retrospectively using medical record data, because it is difficult to comprehensively study processes and outcomes of MI care if the type cannot be retrospectively determined.
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Department of Medicine and Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; The Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada. Electronic address: email@example.com.
Frailty is superior to chronological age as a predictor of outcome. The Edmonton Frail Scale (EFS) is a simple valid measure of frailty, covering multiple important domains, with scores ranging from 0 (not frail) to 17 (very frail). The purpose of this pilot study was to assess the EFS in a group of elderly patients with acute coronary syndrome (ACS).
The EFS was administered to 183 consecutive patients with ACS aged = 65 years admitted to a single centre in Edmonton, Alberta, Canada.
Scores ranged from 0-13. Patients with higher EFS scores were older, with more comorbidities, longer lengths of stay (EFS 0-3: mean, 7.0 days; EFS 4-6: mean, 9.7 days; and EFS = 7: mean, 12.7 days; P = 0.03), and decreased procedure use. Crude mortality rates at 1 year were 1.6% for EFS 0-3, 7.7% for EFS 4-6, and 12.7% for EFS = 7 (P = 0.05). After adjusting for baseline risk differences using a "burden of illness" score, the hazard ratio for mortality for EFS = 7 compared with EFS 0-3 was 3.49 (95% confidence interval [CI], 1.08-7.61; P = 0.002).
The EFS is associated with increased comorbidity, longer lengths of stay, and decreased procedure use. After adjustment for burden of illness, the highest frailty category is independently associated with mortality in elderly patients with ACS. Further work is needed to determine whether the use of a validated frailty instrument would better delineate medical decision making in this important, often disadvantaged population.