Previous studies have indicated that sex differences may exist in the pharmacological management of acute myocardial infarction (AMI), with female patients being treated less aggressively.
To determine if previously reported sex differences in AMI medication use were also evident among all AMI patients treated at hospitals in an urban Canadian city.
All patients who had a primary discharge diagnosis of AMI from all three adult care hospitals in Calgary, Alberta, in the 1998/1999 fiscal year were identified from hospital administrative records (n=914). A standardized, detailed chart review was conducted. Information collected from the medical charts included sociodemographic and clinical characteristics, comorbid conditions, and cardiovascular medication use during hospitalization and at discharge.
Similar proportions of female and male patients were treated with thrombolytics, beta-blockers, angiotensin-converting enzyme inhibitors, nitrate, heparin, diuretics and digoxin. Among patients aged 75 years and over, a smaller proportion of female patients received acetylsalicylic acid in hospital than did male patients (87% versus 95%; P=0.026). Multivariable logistic regression analysis revealed that, after correction for age, use of other anticoagulants/antiplatelets and death within 24 h of admission, sex was no longer an independent predictor for receipt of acetylsalicylic acid in hospital. Medications prescribed at discharge were similar between male and female patients.
The results from this Canadian chart review study, derived from detailed clinical data, indicate that the pattern of pharmacological treatment of female and male AMI patients during hospitalization and at discharge was very similar. No sex differences were evident in the treatment of AMI among patients treated in an urban Canadian centre.
Cox proportional hazards regression models are frequently used to determine the association between exposure and time-to-event outcomes in both randomized controlled trials and in observational cohort studies. The resultant hazard ratio is a relative measure of effect that provides limited clinical information.
A method is described for deriving absolute reductions in the risk of an event occurring within a given duration of follow-up time from a Cox regression model. The associated number needed to treat can be derived from this quantity. The method involves determining the probability of the outcome occurring within the specified duration of follow-up if each subject in the cohort was treated and if each subject was untreated, based on the covariates in the regression model. These probabilities are then averaged across the study population to determine the average probability of the occurrence of an event within a specific duration of follow-up in the population if all subjects were treated and if all subjects were untreated.
Risk differences and numbers needed to treat.
Absolute measures of treatment effect can be derived in prospective studies when Cox regression is used to adjust for possible imbalance in prognostically important baseline covariates.
The prevalence of acquired angioedema (AAE) is hitherto unknown and, to date, less than 200 patients have been reported worldwide. AAE is associated with lymphoproliferative conditions and autoantibodies against C1 inhibitor (C1INH). Rituximab (RTX) is increasingly used in the treatment of AAE patients.
A nationwide study of AAE patients was performed in Denmark. Clinical features, associated disorders, treatments and outcomes were registered.
Eight AAE patients were identified. The diagnostic delay was on average 1 year and 8 months. Patients were treated with C1INH concentrate or icatibant on demand. Six patients were diagnosed with a clonal B-cell disorder during follow-up, on average 2.5 years after the first swelling. Two patients had monoclonal B-cell lymphocytosis (MBL). Two patients received RTX.
AAE is a rare condition occurring in less than 10% of patients with C1INH deficiency in Denmark. AAE is highly associated with haematologic disorders, and we recommend yearly follow-up visits with clinical examination and blood tests including flow cytometry to diagnose B-cell conditions at an early stage. We report 2 patients with AAE and associated MBL, which is a benign expansion of clonal B lymphocytes. MBL can be the precursor of chronic lymphocytic leukaemia or is associated with non-Hodgkin's lymphoma. If angioedema is poorly controlled with standard treatment regimens, we suggest treatment of the associated haematologic disorder. Based on a review of the literature and our own data, we recommend therapy with RTX, especially in patients with anti-C1INH autoantibodies.
Acute esophageal variceal bleeding (EVB) is a major cause of morbidity and mortality in patients with liver cirrhosis. Guidelines have been published in 1997; however, variability in the acute management and prevention of EVB rebleeding may occur.
Gastroenterologists in the provinces of British Columbia, Alberta, Manitoba and Saskatchewan were sent a self-reporting questionnaire.
The response rate was 70.4% (86 of 122). Intravenous octreotide was recommended by 93% for EVB patients but the duration was variable. The preferred timing for endoscopy in suspected acute EVB was within 12 h in 75.6% of respondents and within 24 h in 24.6% of respondents. Most (52.3%) gastroenterologists do not routinely use antibiotic prophylaxis in acute EVB patients. The preferred duration of antibiotic therapy was less than three days (35.7%), three to seven days (44.6%), seven to 10 days (10.7%) and throughout hospitalization (8.9%). Methods of secondary prophylaxis included repeat endoscopic therapy (93%) and beta-blocker therapy (84.9%). Most gastroenterologists (80.2%) routinely attempted to titrate beta-blockers to a heart rate of 55 beats/min or a 25% reduction from baseline. The most common form of secondary prophylaxis was a combination of endoscopic and pharmacological therapy (70.9%).
Variability exists in some areas of EVB treatment, especially in areas for which evidence was lacking at the time of the last guideline publication. Gastroenterologists varied in the use of prophylactic antibiotics for acute EVB. More gastroenterologists used combination secondary prophylaxis in the form of band ligation eradication and beta-blocker therapy rather than either treatment alone. Future guidelines may be needed to address these practice differences.
Department of Community Health Sciences, Centre for Health and Policy Studies, University of Calgary, Quality Improvement and Health Information, Calgary Health Region, Alberta. hquan@ucalgary.ca
The current survival trends in patients with acute myocardial infarction (AMI) are not known. A population-based study using administrative data to examine the short and long term survival of patients after AMI in Alberta between 1994 and 1999 was conducted.
AMI patients were identified from hospital discharge data. Temporal changes in the adjusted (age, sex, AMI anatomical location and comorbidities) fatality rate were analyzed in 19,928 AMI patients.
The age- and sex-adjusted incidence of hospitalization for AMI in Alberta significantly declined from 169.6 per 100,000 population in 1994 to 160.8 per 100,000 in 1999 (P=0.03). The risk-adjusted in-hospital case fatality rate from all causes was 11.4% (95% CI 10.6% to 12.3%) in 1994 versus 9.2% (8.4% to 10.1%) in 1999; the 30-day case fatality rate was 12.6% (11.7% to 13.6%) in 1994 versus 10.1% (9.1% to 11.0%) in 1999; and the one-year case fatality rate was 19.0% (17.8% to 20.1%) in 1994 versus 14.9% (13.8% to 16.0%) in 1999. The percentage of hospitalized AMI patients who underwent coronary angiography within one year after admission rose from 48.2% in 1994 to 52.4% in 1999; percutaneous transluminal coronary angioplasty increased from 25.5% to 35.0% and coronary artery bypass surgery increased from 9.7% to 12.6%. Prescriptions for pharmacological drugs at discharge increased from 1994 to 1999 among patients aged 65 and older: from 29.5% in 1994 to 41.0% in 1999 for beta-blockers, from 5.2% to 18.7% for lipid lowering agents and from 14.0% to 20.5% for angiotensin-converting enzyme inhibitors.
There was a modest improvement in patient survival after AMI between 1994 and 1999. The improvements may be associated with increasing use of revascularization and pharmacological therapy provided in the management of AMI.
The Skaraborg Hypertension Project was undertaken in 1977-1981, and 1428 male and 1812 female hypertensives aged 40-69 years were involved at hypertension out-patient clinics in primary health care. Their long-term risk of acute myocardial infarction during a follow-up of 8.3 years was compared to that of age- and sex-matched controls drawn from the census register at the beginning of surveillance and to normotensive untreated controls identified in a population survey in 1977. Relative risks (with a 95% confidence interval) for acute myocardial infarction morbidity compared to the population was 0.99 (0.78, 1.25) in men and 1.36 (0.95, 1.94) in women. Corresponding figures for acute myocardial infarction mortality were 0.97 (0.68, 1.38) and 1.15 (0.67, 1.99). With normotensive controls used as reference and adjusting for smoking habits and body mass index, the relative risks for acute myocardial infarction morbidity were 1.48 (1.12, 1.98) in men and 2.34 (1.43, 3.85) in women, and for acute myocardial infarction mortality 1.66 (1.07, 2.57) and 1.71 (0.84, 3.48), respectively. Treated hypertension is a weak risk factor for acute myocardial infarction in unselected hypertensive patients.
Therapy for management of acute myocardial infarction (AMI) varies according to patient, prescriber and geographical characteristics.
To describe the in-hospital use of reperfusion therapy for ST elevation MI (STEMI) and discharge use of acetylsalicylic acid, beta-blockers, angiotensin-converting enzyme inhibitors (ACEIs) and statins in patients presenting with either STEMI or non-STEMI in Canada from 1999 to 2002.
Four Canadian registries (FASTRAK II, Canadian Acute Coronary Syndromes, Enhanced Feedback for Effective Cardiac Treatment and Improving Cardiovascular Outcomes in Nova Scotia) were used to identify patients with AMI in Canada and to measure in-hospital reperfusion and medication use. Use rates were compared by age, sex, time period and geographical area, according to available data.
Use rates for reperfusion in STEMI patients ranged from 60% to 70%, primarily representing fibrinolytic therapy. A delay in presentation to hospital after symptom onset represented an impediment to timely therapy, which was particularly pronounced for women and elderly patients. Overall, less than 50% of patients met the door-to-needle target of less than 30 min. Medication use rates at discharge increased from 1999/2000 to 2000/2001 across the different data sources: acetylsalicylic acid, 83% to 88%; beta-blockers, 74% to 89%; ACEIs, 54% to 67%; statins, 41% to 53%; and calcium antagonists, 21% to 32%.
Canadian and provincial rates of use of evidence-based medications for the treatment of AMI have increased over time, although there remains room for improvement. A single, comprehensive data source would supply better insights into the management of AMI in Canada.
The Sahlgrenska Academy, Faculty of Health and Caring Sciences, Institute of Nursing, Göteborg University, Box 457, SE 405 30, Göteborg, Sweden. inger.ekman@fhs.gu.se
OBJECTIVE: Many patients with chronic heart failure (CHF) are thought to be non-adherent to their prescribed medications. The objective was to describe perceptions about and adherence to regular medicines and study medication at baseline and study end in CHF patients participating in a clinical trial. METHODS: In the carvedilol or metoprolol European trial (COMET), patients (N = 3029) with CHF were randomised and followed during a 58-month period. Patients at some Swedish centres answered a questionnaire at baseline and study end concerning their perception of their regular heart medication and study medication. Adherence was established through estimation of drug usage. RESULTS: In the Swedish sub-study, 302 patients responded once to the questionnaire while 107 patients responded both at baseline and at follow-up. At baseline, 94% of the patients stated that they believed that the study medication would make them feel better and 82% believed that their regular heart medication would do so. During the study, patients' belief in their regular cardiac medication significantly increased. Lack of belief in medication at the start of the study was a strong predictor of withdrawal from the trial (64% versus 6.8%; p
Population studies of statin adherence are generally restricted to one to two years of follow-up and do not analyze adherence to other drugs.
To report long-term adherence rates for statins, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers in patients who recently experienced a first cardiovascular event.
Linked administrative databases in the province of Saskatchewan were used in this retrospective cohort study. Eligible patients received a new statin prescription within one year of their first cardiovascular event between 1994 and 2001. Adherence to statins, beta-blockers and ACE inhibitors was assessed from the first statin prescription to a subsequent cardiovascular event.
Of 1221 eligible patients, the proportion of patients adherent to statin medications dropped to 60.3% at one year and 48.8% at five years. The decline in the proportion of adherent patients was most notable during the first two years (100% to 53.7%). Several factors were associated with statin adherence, including age (P = 0.012), number of physician service days (P = 0.037), chronic disease score (P = 0.032), beta-blocker adherence (P
