Identification and characterization of HIV positive Ethiopian elite controllers in both Africa and Israel.

OBJECTIVES: HIV elite controllers (ECs) are a unique subgroup of HIV-positive patients who are long-term virologically suppressed in the absence of antiretroviral treatment (ART). The prevalence of this subgroup is estimated to be < 1%. Various cohorts of ECs have been described in developed countries, most of which have been demographically heterogeneous. The aim of this study was to identify ECs in two large African cohorts and to estimate their prevalence in a relatively genetically homogenous population. METHODS: We screened two cohorts of HIV-positive Ethiopian patients. The first cohort resided in Mekelle, Ethiopia. The second was comprised of HIV-positive Ethiopian immigrants in Israel. In the Mekelle cohort, ART-naïve subjects with stable CD4 counts were prospectively screened using two measurements of viral load 6 months apart. Subjects were defined as ECs when both measurements were undetectable. In the Israeli cohort, subjects with consistently undetectable viral loads (mean of 17 viral load measurements/patient) and stable CD4 count > 500 cells/µL were defined as ECs. RESULTS: In the Mekelle cohort, 16 of 9515 patients (0.16%) fitted the definition of EC, whereas seven of 1160 (0.6%) in the Israeli cohort were identified as ECs (P = 0.011). CONCLUSIONS: This is the first large-scale screening for HIV-positive ECs to be performed in entirely African cohorts. The overall prevalence of ECs is within the range of that previously described in developing countries. The significant difference in prevalence between the two cohorts of similar genetic background is probably a consequence of selection bias but warrants further investigation into possible environmental factors which may underlie the EC state.

Cross-cultural comparison of the sleep-disordered breathing prevalence among Americans and Japanese.

The aim of the present study was to compare the prevalence of sleep-disordered breathing among Hispanic and white Americans and Japanese. A 1-night sleep study using a single-channel airflow monitor was performed on 211 Hispanics and 246 Whites from the Minnesota field centre (St Paul, MN, USA) of the Multi-Ethnic Study of Atherosclerosis (MESA), and 978 Japanese from three community-based cohorts of the Circulatory Risk in Communities Study (CIRCS) in Japan. The respiratory disturbance index and sleep-disordered breathing, defined as a respiratory disturbance index of > or =15 events x h(-1), were estimated. The prevalence of sleep-disordered breathing was higher in males (34.2%) than females (14.7%), and among Hispanics (36.5%) and Whites (33.3%) than among Japanese (18.4%), corresponding to differences in body mass index. Within body mass index strata, the race difference in sleep-disordered breathing was attenuated. This was also true when body mass index was adjusted for instead of stratification. The strong association between body mass index and sleep-disordered breathing was similar in Japanese and Americans. The prevalence of sleep-disordered breathing was lower among Japanese than among Americans. However, the association of body mass index with sleep-disordered breathing was strong, and similar among the race/ethnic groups studied. The majority of the race/ethnic difference in sleep-disordered breathing prevalence was explained by a difference in body mass index distribution.

Trends in acute coronary heart disease mortality, morbidity, and medical care from 1985 through 1997: the Minnesota heart survey.

BACKGROUND: Coronary heart disease (CHD) mortality continued to decline from 1985 to 1997. METHODS AND RESULTS: We tabulated CHD deaths (ICD-9 codes 410 through 414) in the Minneapolis/St Paul, Minnesota, area. For 1985, 1990, and 1995, trained nurses abstracted the hospital records of patients 30 to 74 years old with a discharge diagnosis of acute CHD (ICD-9 codes 410 or 411). Acute myocardial infarction (AMI) events were validated and followed for 3-year all-cause mortality. Between 1985 and 1997, age-adjusted CHD mortality rates in Minneapolis/St Paul fell 47% and 51% in men and women, respectively; the comparable declines in US whites were 34% and 29%. In-hospital mortality declined faster than out-of-hospital mortality. The rate of AMI (ICD-9 code 410) hospital discharges declined almost 20% between 1985 and 1995, whereas the discharge rate for unstable angina (ICD-9 code 411) increased substantially. The incidence of hospitalized definite AMI declined approximately 10%, whereas recurrence rates fell 20% to 30%. Three-year case fatality rates after hospitalized AMI decreased consistently by 31% and 41% in men and women, respectively. In-hospital administration of thrombolytic therapy, emergency angioplasty, ACE inhibitors, beta-blockers, heparin, and aspirin increased greatly. CONCLUSIONS: Declining out-of-hospital death rates, declining incidence and recurrence of AMI in the population, and marked improvements in the survival of AMI patients all contributed to the 1985 to 1997 decline of CHD mortality in the Minneapolis/St Paul metropolitan area. The effects of early and late medical care seem to have had the greatest contribution to rates during this time period.

Prospective study of markers of hemostatic function with risk of ischemic stroke. The Atherosclerosis Risk in Communities (ARIC) Study Investigators.

BACKGROUND: Several markers of hemostatic function and inflammation have been associated with increased risk of coronary heart disease, but prospective evidence for their role in ischemic stroke is scant. METHODS AND RESULTS: The Atherosclerosis Risk in Communities (ARIC) Study measured several of these markers in more than 14 700 participants 45 to 64 years old who were free of cardiovascular disease and were followed up for 6 to 9 years for occurrence of ischemic stroke (n=191). There was no apparent association between ischemic stroke incidence and factor VIIc, antithrombin III, platelet count, or activated partial thromboplastin time. After adjustment for multiple cardiovascular risk factors, von Willebrand factor, factor VIIIc, fibrinogen, and white blood cell count were positively associated and protein C was negatively but nonsignificantly associated with ischemic stroke incidence in regression analyses based on either continuous variables or fourths of the variable distributions. The adjusted relative risk (and 95% CI) for ischemic stroke in those in the highest versus lowest fourth were: von Willebrand factor, 1.71 (1.1 to 2.7); factor VIIIc, 1.93 (1.2 to 3.1); white blood cell count, 1.50 (0.9 to 2.4); fibrinogen, 1.26 (0.8 to 2.0); and protein C, 0.65 (0.4 to 1.0). CONCLUSIONS: This study offers modest support for the hypothesis that some markers of hemostatic function and inflammation can identify groups of middle-aged adults at increased risk of stroke. These factors may play a role in the pathogenesis of ischemic stroke.

A prospective study of cytomegalovirus, herpes simplex virus 1, and coronary heart disease: the atherosclerosis risk in communities (ARIC) study.

BACKGROUND: Conflicting evidence exists implicating infectious disease in the pathological processes leading to coronary heart disease (CHD). The objective of this article is to describe the relationship of previous infection with cytomegalovirus (CMV) and herpes simplex virus 1 to incident CHD in a population-based cohort study. METHODS: Using a nested case-cohort design from the Atherosclerosis Risk in Communities Study, antibody levels to CMV and herpes simplex virus 1 were determined in serum samples that had been frozen at the baseline examination in participants free of CHD. Determinations were made in those who developed incident CHD (n=221) during follow-up of up to 5 years from baseline and in a stratified random sample of all participants (n=515). RESULTS: The population with the highest antibody levels of CMV (approximately the upper 20%) showed an increased relative risk (RR) of CHD of 1.76 (95% confidence interval, 1.00-3.11), adjusting for age, sex, and race. After adjustment for additional covariates of hypertension, diabetes, years of education, cigarette smoking, low-density lipoprotein and high-density lipoprotein cholesterol levels, and fibrinogen level, the RR increased slightly. Based on a priori hypotheses, the RR of CHD at the highest antibody levels in individuals with diabetes was particularly large but with wide confidence intervals (RR, 9.2; 95% confidence interval, 1.8-47.0), and the interaction between high levels of antibody to CMV and diabetes was statistically significant (P=.05). There was no association of CHD with the highest herpes simplex virus 1 antibody levels (adjusted RR, 0.77; 95% confidence interval, 0.36-1.62). CONCLUSIONS: High levels of CMV antibodies are significantly associated with incident CHD. Infection with CMV, particularly in more susceptible disease states such as diabetes, may be an important risk factor for CHD.

Trends in cholesterol knowledge and screening and hypercholesterolemia awareness and treatment, 1980-1992. The Minnesota Heart Survey.

BACKGROUND: National cholesterol education initiatives were implemented in the middle to late 1980s. This study examines whether there were significant increases in population cholesterol knowledge and screening and hypercholesterolemia awareness and treatment from 1980 to 1992. METHODS: Three population-based surveys were conducted among adults aged 25 to 74 years in 1980-1982 (N = 4086), 1985-1987 (N = 5735) and 1990-1992 (N = 6305) in the Minneapolis-St Paul, Minn, metropolitan area as part of the Minnesota Heart Survey. Personal interviews about knowledge of cholesterol level and hypercholesterolemia awareness and treatment were conducted. Total serum cholesterol was measured; hypercholesterolemia was defined as having a total cholesterol level of 6.21 mmol/L or more (> or = 240 mg/dL) or current use of cholesterol-lowering medications. Hypercholesterolemia awareness was defined as the belief of a participant with hypercholesterolemia that her or his total cholesterol was high. RESULTS: Knowledge increased from 15% in 1980-1982 to 17% in 1985-1987 to 55% in 1990-1992 (P < .001) in women; similar trends were observed for men (19%, 22%, and 47%, respectively; P < .001). Hypercholesterolemia awareness doubled during the decade (women: 17%, 1980-1982; 24%, 1985-1987; 60%, 1990-1992; P < .001; men: 25%, 30%, and 55%, respectively; P < .001). Among participants who reported physician-diagnosed hypercholesterolemia, the prevalence of current pharmacological treatment increased from 9% in 1980-1982 to 14% in 1990-1992 in women, and from 7% to 13%, respectively, in men. CONCLUSIONS: Cholesterol knowledge and hypercholesterolemia awareness and treatment increased substantially during the 1980s, concurrent with educational initiatives of the National Cholesterol Education Program and other efforts.

A community-based study of explanatory factors for the excess risk for early renal function decline in blacks vs whites with diabetes: the Atherosclerosis Risk in Communities study.

CONTEXT: The explanation for the excess risk for diabetic renal disease in blacks is uncertain. OBJECTIVES: To compare the incidence of early renal function decline in black and white adults with diabetes and to examine possible explanatory factors for racial differences. DESIGN: Prospective cohort study. SETTING: Four US communities participating in the Atherosclerosis Risk in Communities study. PARTICIPANTS: Community-based sample of 1434 diabetic adults aged 45 to 64 years. MEASUREMENTS: Detailed baseline assessment using structured interview, results of physical examination, and laboratory measurements. MAIN OUTCOME: Development of early renal function decline defined by an increase in serum creatinine of at least 35.4 micromol/L (0.4 mg/dL) during 3 years of follow-up. RESULTS: During 3 years of follow-up, early renal function decline developed in 45 blacks (28.4 per 1000 person-years [PY]) and 25 whites (9.6 per 1000 PY). After adjustment for age, sex, and baseline serum creatinine level, early renal function decline was more than 3 times as likely to develop in blacks than whites (odds ratio, 3.15; 95% confidence interval, 1.86-5.33). Additional adjustment for education, household income, health insurance, fasting glucose level, mean systolic blood pressure, smoking history, and physical activity level reduced the relative odds in blacks to 1.38 (95% confidence interval, 0.71-2.69), corresponding to a 82% reduction in excess risk. CONCLUSIONS: These data suggest that early renal function decline is 3 times more likely to develop in blacks than whites and that potentially modifiable factors, including lower socioeconomic status, suboptimal health behaviors, and suboptimal control of glucose level and blood pressure, account for more than 80% of this disparity.

Glycosylated hemoglobin level and carotid intimal-medial thickening in nondiabetic individuals. The Atherosclerosis Risk in Communities Study.

OBJECTIVE: People with diabetes are at increased risk for cardiovascular events. However, questions remain about what role, if any, homeostatic glucose control plays in the development of cardiovascular disease among nondiabetic individuals. We investigated the relationship between HbA1c level and carotid intimal-medial thickening in normoglycemic individuals. RESEARCH DESIGN AND METHODS: We conducted a case-control study among 208 normoglycemic individuals (fasting glucose < or = 6.4 mmol/l and no history of diabetes) who had carotid initial-medial thickening (case subjects) and 208 normoglycemic control subjects individually matched for age, sex, race, field center, and date of exam. Subjects were free-living men and women, aged 45-64 years at baseline, who participated in the Atherosclerosis Risk in Communities (ARIC) Study. RESULTS: HbA1c levels, expressed as percent of total hemoglobin, ranged from 4 to 7% and correlated only modestly with single measurements of fasting glucose (r = 0.16) and fasting insulin (r = 0.14). The mean level of HbA1c was 5.18% among case subjects and 5.07% among control subjects (P = 0.004, paired t test). As compared with the first quartile of HbA1c the matched relative odds of being a case were 1.15, 1.33, and 2.30 for the second, third, and fourth quartiles, respectively (P = 0.005 for linear trend). After multivariate adjustment for age, fasting glucose, fasting insulin, BMI, smoking status, hypertension, LDL cholesterol, HDL cholesterol, fibrinogen, and education level, the respective relative odds estimates were 0.98, 1.07, and 1.88 (P = 0.16 for linear trend). When modeled linearly as a continuous variable and after adjustment for the above-mentioned covariates, a 1% point increment in HbA1c level was associated with 1.77 greater odds of being a case (95% CI, 0.9-3.5). CONCLUSIONS: These data provide some support to the hypothesis that in the absence of diabetes, homeostatic glycemic control is a risk factor for atherosclerosis.

Genotypic variation of HIV-1 reverse transcriptase and protease: comparative analysis of clade C and clade B.

OBJECTIVE: To compare drug-resistant variants from untreated (naive) and treated patients infected with clade B or C virus. METHODS: Consecutive samples (165) from patients throughout Israel were analyzed. All those in the treated group were failing highly active antiretroviral therapy. RESULTS: There were 87 clade B (14 naive) and 78 clade C (20 naive) [corrected] with significant differences in the prevalence of known drug-resistance mutations between the clades: in naive patients in the protease region M36I 7% and 95% (P < 0.0001), K20R 0% and 27% (P = 0.063), A71V 18% and 0% (P = 0.063), M46I 0% and 13%, and V77I 18% and 0% (P = 0.063), respectively, and in the reverse transcriptase region A98G/S 0% and 20% (P = 0.12), respectively. Most clade C viruses also showed significant differences from clade B consensus sequence at additional protease sites: R41K 100%, H69K/Q 85%, L89M 95% and I93L 80% (P < 0.0001). There were also significant differences (P < 0.03 to < 0.0001) in treated patients in clades B and C: in the protease region L10I 40% and 12%, M36I 26% and 95%, L63P 67% and 40%, A71I 38% and 7%, G73I and V77I 18% and 0%, I84V 16% and 3%, and L90M 40% and 12%, respectively; in the reverse transcriptase M41L 41% and 17%, D67N 41% and12%, K70R 30% and 7%, T215Y 48% and 29%, K219Q 21% and 7%, and A98G/S 3% and 24%, respectively. CONCLUSION: Significantly differences between clade B and C viruses may be associated with development of differing resistance patterns during therapy and may affect drug utility in patients infected with clade C.

Plasma fatty acid composition as an indicator of habitual dietary fat intake in middle-aged adults. The Atherosclerosis Risk in Communities (ARIC) Study Investigators.

We compared the plasma fatty acid (FA) composition of the habitual diet, measured by a 66-item semiquantitative food-frequency questionnaire (FFQ), with the corresponding plasma phospholipid and cholesterol ester (CE) FA composition measured by gas chromatography in 3570 free-living, middle-aged adults. Pearson correlations between dietary and plasma FA (expressed as % of total FAs) for phospholipid and CE, respectively, were as follows: saturated FA (r = 0.15 and 0.23), monounsaturated FA (r = 0.05 and 0.01), polyunsaturated FA (r = 0.25, 0.31), linoleic acid (r = 0.22 and 0.28), linolenic acid (r = 0.15 and 0.21), eicosapentaenoic acid (r = 0.20 and 0.23), and docosahexaenoic acid (r = 0.42 and 0.42). The correlations between diet and plasma FAs held relatively constant regardless of whether participants were overweight, had chronic diseases, were alcohol drinkers, or were cigarette smokers. However, at similar reported dietary intakes, the plasma lipid concentration of saturated FAs was higher and/or that of linoleic acid was lower in people with these characteristics compared with those without these characteristics.

Pediatric cerebrovascular disease. Alterations of regional cerebral blood flow detected by TC 99m-HMPAO SPECT.

Regional cerebral blood flow (rCBF) alterations, as determined by single photon emission computed tomography (SPECT) using technetium Tc 99m hexamethyl propylenamine oxime (Tc 99m-HM-PAO), were studied in 15 infants and children presenting with cerebrovascular disorders between the ages of 2 weeks and 16 years. The rCBF patterns were correlated with clinical presentation, electroencephalographic patterns, radiologic studies, including computed tomography and magnetic resonance imaging of the head, and cerebral angiography. All patients presented with motor weakness that was accompanied in some with dysphasia, defects in visual fields, obtundation, seizures, and high temperature. Perturbations of rCBF with Tc 99m-HMPAO SPECT brain scanning were detected in all patients investigated, with no adverse effects related to the radiotracer. All patients had a focal area of decreased rCBF, with adjacent hyperemia in 3 patients. In 7 patients, there was an rCBF decrease in a vascular distribution, mainly that of the middle cerebral artery, that correlated with the clinical findings and a focal electroencephalogram, as well as computed tomography and magnetic resonance imaging of the head. Impairment of rCBF was more extensive in 3 children, while early abnormal SPECT findings preceded abnormal computed tomographic findings in another 2 children. In 2 patients, Tc 99m-HMPAO SPECT was the only positive radiologic test to correlate with focal clinical and electroencephalographic abnormalities, in view of repeated normal computed tomographic scans. We conclude that Tc 99m-HMPAO SPECT brain scanning is a sensitive, complementary diagnostic measure in the early detection, localization, and estimation of rCBF alterations in pediatric cerebrovascular disease.

Plasma phospholipid fatty acid composition and factor VII coagulant activity.

Plasma phospholipid fatty acid composition reflects, to a moderate degree, the fatty acid composition of the diet. To determine whether plasma phospholipid fatty acid composition might influence factor VII coagulant activity (factor VIIc), we examined 2207 middle-aged adults free of diabetes and cardiovascular disease. Factor VIIc was associated positively with the percentage of fatty acids that was saturated, and it was associated negatively with the linoleic acid percentage and the phospholipid polyunsaturated/saturated fatty acid ratio. For example, a 1.9% greater saturated fatty acid level was associated with approximately a 5% higher factor VIIc. These results suggest a role for dietary fat composition, or related dietary patterns, in determining levels of factor VIIc.

Past infection by Chlamydia pneumoniae strain TWAR and asymptomatic carotid atherosclerosis. Atherosclerosis Risk in Communities (ARIC) Study Investigators.

PURPOSE: To determine whether past infection by Chlamydia pneumoniae strain TWAR is associated with asymptomatic atherosclerosis. Previous studies have linked this organism with symptomatic coronary heart disease. SUBJECTS AND METHODS: Between 1986 and 1989, 15,800 men and women aged 45 to 64 years were examined as part of the Atherosclerosis Risk in Communities Study, a prospective cohort study of atherosclerosis being conducted in 4 United States communities. The examination included B-mode ultrasonography of the carotid arteries and an assessment of cardiovascular disease risk factors. Carotid wall thickening (blood-intima to medial-adventitial interface) in the absence of clinical cardiovascular disease was considered evidence of asymptomatic atherosclerosis. In 1991, IgG antibody titers to TWAR were assayed by microimmunofluorescence in stored sera from 326 case-control pairs matched by age group, race, sex, examination period, and field center. A titer of 1:8 or higher was considered a positive TWAR antibody response. RESULTS: Seventy-three percent of atherosclerosis cases had serologic evidence of past TWAR infection versus 63% of controls (matched odds ratio 1.76; 95% confidence interval, 1.21 to 2.57). After adjustment for age, hypertension, diabetes, cigarette smoking, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and education, the odds ratio for atherosclerosis was essentially unchanged at 2.00 (95% confidence interval, 1.19 to 3.35). The association was stronger for individuals aged 45 to 54 years than for those aged 55 to 64 years. CONCLUSION: There was a significant cross-sectional association between past TWAR infection and asymptomatic atherosclerosis. This organism may be a contributor to the pathogenesis of atherosclerosis.

Amiodarone in control of sustained tachyarrhythmias in children with Wolff-Parkinson-White syndrome.

Oral amiodarone was administered to ten children aged 3 months to 15 years who had recurrent SVT associated with the Wolff-Parkinson-White syndrome. In nine patients, amiodarone was used following failure of oral digoxin, quinidine, propranolol, and verapamil. Each patient received an oral loading dose of 10 to 15 mg/kg followed by 5 mg/kg daily. All children became asymptomatic of tachyarrhythmias within five days of therapy and remained asymptomatic for 5 to 36 months. In one patient, amiodarone therapy was discontinued because of generalized urticaria after a positive initial response. After high-dose oral verapamil failed to eliminate recurrent bouts of SVT, the patient was again given amiodarone and he had a complete recovery. All ten children had normal results on thyroid function tests, and no other adverse effects were detected. Amiodarone has been shown to be highly effective and well tolerated in this series of children. Therefore, we recommend its use for the control and prevention of sustained arrhythmias in pediatric patients with Wolff-Parkinson-White syndrome when the traditional antiarrhythmic drugs fail.

Poliomyelitis-like paralysis during recovery from acute bronchial asthma: possible etiology and risk factors.

A poliomyelitis-like paralytic disease during recovery from an attack of bronchial asthma is described in two young children. They presented at the age of 13 and 22 months, respectively, with acute flaccid paralysis of one or both lower limbs and preserved sensation. Cerebrospinal fluid examinations revealed mild protein elevation in both and pleocytosis in the second infant. Enteroviruses were isolated in a nasal swab and stools of the second patient. Acute onset of flaccid paralysis with absent motor action potential and normal sensory responses, detected by electrophysiologic studies, are highly suggestive of motor anterior horn cell disease in these infants. A multifactorial setup of immune suppression, stress, and neurotoxic drugs during an acute bronchial asthma attack triggered by a viral disease may render the patient vulnerable to viral invasion of the anterior horn cell with enteroviruses other than poliovirus. The overall experience of 22 patients with this serious complication is reviewed.

Weight-loss induced changes in plasma factor VII coagulant activity and relation to the factor VII Arg/Gln353 polymorphism in moderately obese adults.

Elevated plasma factor VII coagulant activity (factor VIIc) may be an independent risk factor for coronary heart disease. Several cross-sectional studies suggest that a polymorphism of the factor VII gene (Arg-Gln353) interacts with plasma triglyceride level in determining factor VIIc, but prospective data are lacking. Factor VII genotype, factor VIIc, and triglyceride level were measured in moderately obese adults aged 25 to 45 who underwent a six-month clinical trial to evaluate strategies for weight loss. A total of 48 men and 50 women who experienced substantial weight loss (mean: 10 kg) provided samples for genetic analysis. Overall, 78% of participants were homozygous for the Arg353 allele, while the remaining 22% were heterozygous (Arg/Gln353). At the baseline examination, heterozygotes had lower mean factor VIIc than Arg353 homozygotes (92% vs. 112%; p<0.001), and genotype explained 18% of the variance of factor VIIc. Average six-month weight loss was similar in both genotypes; mean reductions in factor VIIc following weight loss were greatest among Arg353 homozygotes with high initial values (> 120%). Cross-sectional and longitudinal associations between plasma factor VIIc and triglyceride level were not dependent on genotype. These data confirm that the Gln353 allele is associated with lower factor VII coagulant activity in moderately obese adults, but they do not support the hypothesis that the Arg-Gln353 polymorphism interacts with plasma triglyceride level in determining factor VIIc.

Family history of coronary heart disease and hemostatic variables in middle-aged adults. Atherosclerosis Risk in Communities Investigators and Family Heart Study Research Group.

Individuals with a family history of coronary heart disease (CHD) may be predisposed to atherothrombosis. To investigate this hypothesis, a family CHD risk score was computed for approximately 13,000 men and women aged 45 to 64; hemostatic variables (fibrinogen, factor VIIc, factor VIIIc, von Willebrand factor, antithrombin III. protein C) were also measured in plasma. After adjustment for age and ethnicity, there was a statistically significant, positive association between the family risk score and four of the six hemostatic variables (fibrinogen, factor VIIc, factor VIIIc, von Willebrand factor) in women and all six hemostatic variables in men. In general, these associations were weak and substantially attenuated after adjustment for constitutional, lifestyle, and biochemical covariates. These results indicate that mean levels of selected hemostatic variables, like traditional CHD risk factors, are higher in individuals with a family history of heart disease.

Trends in coronary thrombolytic therapy for acute myocardial infarction (the Minnesota Heart Survey Registry, 1990 to 1993).

Between 1990 and 1993, patient selection and relative effectiveness of thrombolytic agents were issues for clinical trials of thrombolytic therapy, particularly the Third International Study of Infarct Survival (ISIS-3) and the Second Gruppo Italiano per Lo Studio della Streptochinasi nell'Infarto Miocardico trials. The purpose of this report is to document the use of coronary thrombolytic therapy in community hospital practice during this period. Patients admitted to the coronary care unit of 6 hospitals with suspect acute myocardial infarction (AMI) between 1990 and 1993 were prospectively enrolled in the Minnesota Heart Survey Registry. Of the 1,225 patients with AMI enrolled, 310 men (37%) and 103 women (26%) received thrombolytic therapy (p < 0.001). The age-adjusted male-to-female odds ratio (95% confidence interval) for receiving thrombolysis among patients with < or = 12 hours since symptom onset was 1.33 (0.94, 1.87). The proportion of those treated receiving tissue plasminogen activator declined from 196 (64%) to 102 (34%) between 1990 and 1991 and 1992 and 1993. Use of streptokinase increased from 48 (16%) to 156 (52%) during the same time period. There were no statistically significant gender or lytic agent type differences in complications from thrombolytic therapy. Changes in type of agent used coincided with the release of results from the ISIS-3 trial.

Electrocardiographic findings in a healthy biracial population. Atherosclerosis Risk in Communities (ARIC) Study Investigators.

It has been well documented that the prevalence of certain electrocardiographic (ECG) findings among individuals free of coronary heart disease (CHD) differs by race. However, it is not known whether these differences exist independently of CHD risk factors (e.g., hypertension). We examined the ECG tracings of 2,686 apparently healthy, middle-aged African-American and white men and women who participated in the Atherosclerosis Risk in Communities Study and were at low risk of CHD. Using the Minnesota Code, among men, 46% of African-Americans, but only 25% of whites, had a minor ECG finding (p < 0.001). In women, 32% of African-Americans and 23% of whites had a minor ECG finding (p < 0.01). Specifically, the age-adjusted prevalences of high-amplitude R wave, ST elevation, T-wave findings, and prolonged P-R interval were statistically significantly higher in African-Americans. As for continuous ECG measurements, the R wave in leads V5 and V6, the S wave in V1, the J-point amplitude in leads V2 and V5, the P-R interval, and the Cornell voltage (¿S V3¿ + R aVL) for left ventricular hypertrophy were all significantly greater in African-Americans than in whites. However, in both men and women, the heart rate corrected QT interval was shorter in African-Americans than in whites. All of these findings remained statistically significant after further adjustment for traditional CHD risk factors. These results suggest that racial differences in electrocardiograms may not be explained entirely by differences in established CHD risk factors, and because current diagnostic ECG criteria are largely based on data from middle-aged white men and women, race should be considered in the interpretation of ECG findings.

Comparison of medical care and one- and 12-month mortality of hospitalized patients with acute myocardial infarction in Minneapolis-St. Paul, Minnesota, United States of America and Göteborg, Sweden.

We compared medical care and mortality through 1-year of hospitalized acute myocardial infarction (AMI) patients in 2 large metropolitan areas in the United States and Sweden. All hospitalized AMI discharges (International Classification of Diseases, 9th revision [ICD9] codes 410) occurring among 30 to 74-year-old residents of the Minneapolis-St. Paul metropolitan area in 1990 and Göteborg, Sweden, in 1990 to 1991 were identified and their medical records examined. There were dramatic differences in medical care during the index hospitalization of AMI patients between Minneapolis-St. Paul and Göteborg. Use of thrombolytic therapy, coronary angioplasty, bypass surgery, calcium antagonists and lidocaine was more common in Minneapolis-St. Paul; beta blockers were more frequently used in Göteborg, and aspirin use was similar. Despite these large differences, neither 28-day nor 1-year mortality of hospitalized AMI patients differed significantly. The marked differences found in the early treatment of AMI between Minneapolis-St. Paul and Göteborg, combined with the negligible differences observed in short- and long-term mortality, raise questions about the most effective and efficient allocation of medical resources.