HbA 1c as a risk factor for heart failure in persons with diabetes: the Atherosclerosis Risk in Communities (ARIC) study.

AIMS/HYPOTHESIS: Heart failure (HF) incidence in diabetes in both the presence and absence of CHD is rising. Prospective population-based studies can help describe the relationship between HbA(1c), a measure of glycaemia control, and HF risk. METHODS: We studied the incidence of HF hospitalisation or death among 1,827 participants in the Atherosclerosis Risk in Communities (ARIC) study with diabetes and no evidence of HF at baseline. Cox proportional hazard models included age, sex, race, education, health insurance status, alcohol consumption, BMI and WHR, and major CHD risk factors (BP level and medications, LDL- and HDL-cholesterol levels, and smoking). RESULTS: In this population of persons with diabetes, crude HF incidence rates per 1,000 person-years were lower in the absence of CHD (incidence rate 15.5 for CHD-negative vs 56.4 for CHD-positive, p<0.001). The adjusted HR of HF for each 1% higher HbA(1c) was 1.17 (95% CI 1.11-1.25) for the non-CHD group and 1.20 (95% CI 1.04-1.40) for the CHD group. When the analysis was limited to HF cases which occurred in the absence of prevalent or incident CHD (during follow-up) the adjusted HR remained 1.20 (95% CI 1.11-1.29). CONCLUSIONS/INTERPRETATIONS: These data suggest HbA(1c) is an independent risk factor for incident HF in persons with diabetes with and without CHD. Long-term clinical trials of tight glycaemic control should quantify the impact of different treatment regimens on HF risk reduction.

ABO blood group, other risk factors and incidence of venous thromboembolism: the Longitudinal Investigation of Thromboembolism Etiology (LITE).

BACKGROUND: Numerous case-control studies have reported higher prevalence of non-O blood type among venous thromboembolism (VTE) patients than controls, but potential mechanisms or effect modifiers for the association are not fully established. PATIENTS/METHODS: Using a nested case-control design combining the Atherosclerosis Risk in Communities and the Cardiovascular Health Study cohort, ABO blood type and other VTE risk factors were measured on pre-event blood samples of 492 participants who subsequently developed VTE and 1008 participants who remained free of VTE. RESULTS: A total of 64.4% of cases and 52.5% of controls had non-O blood type. Among controls, mean values of factor VIIIc (FVIIIc) and von Willebrand factor among the non-O blood type group were higher than among the O group. Compared with O blood type, the age-adjusted odds ratio (OR) of VTE for non-O blood type was 1.64 (95% CI, 1.32-2.05) and was similar for the two parent studies and race groups. Further adjustment for sex, race, body mass index, diabetes mellitus and FVIIIc reduced the OR: 1.31 (95% CI, 1.02-1.68). Factor V Leiden (FV Leiden) appeared to modify the non-O blood type association with VTE in a supra-additive fashion, with an age-, sex- and race-adjusted OR of 6.77 (95% CI, 3.65-12.6) for having both risk factors. CONCLUSIONS: Non-O blood type was independently associated with risk of VTE, and added to the risk associated with FV Leiden.

Prospective study of subclinical atherosclerosis as a risk factor for venous thromboembolism.

BACKGROUND: Whether atherosclerotic disease predisposes to venous thrombosis is uncertain. OBJECTIVE: To determine whether subclinical atherosclerosis, manifested as increased carotid intima-media thickness (IMT) or presence of carotid plaque, is associated with increased incidence of venous thromboembolism (VTE). PATIENTS AND METHODS: The Atherosclerosis Risk in Communities study is a prospective cohort of adults aged 45-64 years, examined at baseline (1987-89) and followed for cardiovascular events. Bilateral carotid ultrasound for IMT measurements was done at baseline for portions of the common and internal carotid arteries, and carotid bifurcation and also to detect the presence of carotid plaque. Exclusion criteria included baseline anticoagulant use, history of coronary heart disease, stroke, or VTE, and incomplete data. First VTE during follow-up was validated using abstracted medical records. RESULTS: Among 13,081 individuals followed for a mean of 12.5 years, 225 first VTE events were identified. Unadjusted hazard ratios (HR) (95% CI) of VTE across quartiles of baseline IMT were 1.0, 1.16 (0.77-1.75), 1.64 (1.12-2.40), and 1.52 (1.03-2.25). However, this association disappeared after adjustment for age, sex, and ethnicity (HRs: 1.0, 1.06, 1.40, and 1.18). Further adjustment for body mass index and diabetes weakened the relative risks even further. Presence of carotid plaque at baseline also was not associated with VTE occurrence; adjusted HR = 0.97, 95% CI = 0.72-1.29. CONCLUSION: Increased carotid IMT or presence of carotid plaque was not associated with an increased incidence of VTE in this middle-aged cohort, suggesting subclinical atherosclerosis itself is not a VTE risk factor.

Lung function, respiratory symptoms and venous thromboembolism risk: the Atherosclerosis Risk in Communities Study.

Essentials The association of lung function with venous thromboembolism (VTE) is unclear. Chronic obstructive pulmonary disease (COPD) patterns were associated with a higher risk of VTE. Symptoms were also associated with a higher risk of VTE, but a restrictive pattern was not. COPD may increase the risk of VTE and respiratory symptoms may be a novel risk marker for VTE. SUMMARY: Background The evidence for the association between chronic obstructive pulmonary disease (COPD) and venous thromboembolism (VTE) is limited. There is no study investigating the association between restrictive lung disease (RLD) and respiratory symptoms with VTE. Objectives To investigate prospectively the association of lung function and respiratory symptoms with VTE. Patients/Methods In 1987-1989, we assessed lung function by using spirometry, and obtained information on respiratory symptoms (cough, phlegm, and dyspnea) in 14 654 participants aged 45-64 years, without a history of VTE or anticoagulant use, and followed them through 2011. Participants were classified into four mutually exclusive groups: 'COPD' (forced expiratory volume in 1 s [FEV1 ]/forced vital capacity [FVC] below the lower limit of normal [LLN]), 'RLD' (FEV1 /FVC ≥ LLN and FVC < LLN), 'respiratory symptoms with normal spirometic results' (without RLD or COPD), and 'normal' (without respiratory symptoms, RLD, or COPD). Results We documented 639 VTEs (238 unprovoked and 401 provoked VTEs). After adjustment for VTE risk factors, VTE risk was increased for individuals with either respiratory symptoms with normal spirometric results (hazard ratio [HR] 1.40, 95% confidence interval [CI] 1.12-1.73) or COPD (HR 1.33, 95% CI 1.07-1.67) but not for those with RLD (HR 1.15, 95% CI 0.82-1.60). These elevated risks of VTE were derived from both unprovoked and provoked VTE. Moreover, FEV1 and FEV1 /FVC showed dose-response relationships with VTE. COPD was more strongly associated with pulmonary embolism than with deep vein thrombosis. Conclusions Obstructive spirometric patterns were associated with an increased risk of VTE, suggesting that COPD may increase the risk of VTE. Respiratory symptoms may represent a novel risk marker for VTE.

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.

Ankle-brachial index and 7-year ischemic stroke incidence: the ARIC study.

BACKGROUND AND PURPOSE: Low ankle-brachial index (ABI), which is the ratio of tibial artery systolic blood pressure to brachial systolic artery pressure, is known to be a measure of lower limb peripheral artery disease as well as a marker for other cardiovascular disease events. The ability of ABI to predict incident ischemic stroke, however, is not established in population-based studies. METHODS: ABI was measured in a cohort of 14 839 black and white men and women aged 45 to 64 years. Stroke incidence was calculated during approximately 7 years of follow-up. RESULTS: A total of 206 incident strokes occurred. Adjusted stroke incidence rates were markedly higher for those in the lowest versus the highest categories of ABI for men, women, blacks, and whites. The proportional hazards regression model, adjusted for age, race, gender, and field center, showed an inverse linear trend between ABI and ischemic stroke incidence (P<0.0001). The lowest group (ABI <0.80) had a hazard ratio of 5.68 (95% CI 2.77 to 11.66). After adjustment for major risk factors in a multivariate model, the hazard ratio in the lowest group was elevated (1.93) but no longer statistically significant (95% CI 0.78 to 4.78). There was, however, still an indication of an overall inverse linear trend between ABI and incident stroke (P=0.03). CONCLUSIONS: Low ABI was strongly associated with increased incidence of ischemic stroke, but the relationship was substantially reduced after adjustment for major cardiovascular risk factors.

Determinants of use of emergency medical services in a population with stroke symptoms: the Second Delay in Accessing Stroke Healthcare (DASH II) Study.

BACKGROUND AND PURPOSE: With the advent of time-dependent thrombolytic therapy for ischemic stroke, it has become increasingly important for stroke patients to arrive at the hospital quickly. This study investigates the association between the use of emergency medical services (EMS) and delay time among individuals with stroke symptoms and examines the predictors of EMS use. METHODS: The Second Delay in Accessing Stroke Healthcare Study (DASH II) was a prospective study of 617 individuals arriving at emergency departments in Denver, Colo, Chapel Hill, NC, and Greenville, SC, with stroke symptoms. RESULTS: EMS use was associated with decreased prehospital and in-hospital delay. Those who used EMS had a median prehospital delay time of 2.85 hours compared with 4.03 hours for those who did not use EMS (P:=0.002). Older individuals were more likely to use EMS (odds ratio [OR] 1.21 for each 5-year increase, 95% CI 1.14 to 1.29), as were individuals who expressed a high sense of urgency about their symptoms (OR 1.69, 95% CI 1.09 to 2.62). Knowledge of stroke symptoms was not associated with increased EMS use (OR 0.63, 95% CI 0.40 to 0.98). Patients were more likely to use EMS if someone other than the patient first identified that there was a problem (OR 2.35, 95% CI 1.61 to 3.44). CONCLUSIONS: Interventions aimed at increasing EMS use among stroke patients need to stress the urgency of stroke symptoms and the importance of calling 911 and need to be broad-based, encompassing not only those at high risk for stroke but also their friends and family.

Descriptive epidemiology of blood pressure response to change in body position. The ARIC study.

The epidemiology of a common measure of cardiovascular reactivity, the change in systolic blood pressure (DeltaSBP) from the supine to the standing position, is described in a cohort of 13 340 men and women aged 45 to 65 years enrolled in the Atherosclerosis Risk in Communities (ARIC) Study. The distribution of DeltaSBP was found to be symmetrical and unimodal, with a mean value near zero (-0.45 mm Hg). The range of DeltaSBP was from -63.2 to 54.3 mm Hg, and the standard deviation was 10.8. Stratification of DeltaSBP by race and gender shows a slight shift in distribution toward higher values for black men and women. DeltaSBP was categorized into deciles. Participants in the top 30% and bottom 30% of the distribution were compared with individuals in the middle 40% of the distribution, who had little or no change in SBP on standing. Participants in the bottom 30% (ie, SBP decreased on standing) were significantly older, had a greater prevalence of hypertension and peripheral vascular disease, had higher values of SBP, and had more cigarette-years of smoking. Among participants in the top 30% (ie, SBP increased on standing), a significantly larger proportion were black, mean seated SBP was higher, and the predicted risk of developing coronary heart disease after 8 years was greater. The response of SBP to change in posture showed considerable variability in a population sample of middle-aged adults. Cardiovascular morbidity, sociodemographic factors, and cigarette smoking were associated with the magnitude and direction of the postural change.

Associations of ankle-brachial index with clinical coronary heart disease, stroke and preclinical carotid and popliteal atherosclerosis: the Atherosclerosis Risk in Communities (ARIC) Study.

The resting ankle-brachial index (ABI) is a non-invasive method to assess the patency of the lower extremity arterial system and to screen for the presence of peripheral occlusive arterial disease. To determine how the ABI is associated with clinical coronary heart disease (CHD), stroke, preclinical carotid plaque and far wall intimal-medial thickness (IMT) of the carotid and popliteal arteries, we conducted analyses in 15 106 middle-aged adults from the baseline examination (1987-1989) of the Atherosclerosis Risk in Communities (ARIC) Study. The prevalence of clinical CHD, stroke/transient ischemic attack (TIA) and preclinical carotid plaque increased with decreasing ABI levels, particularly at those of < 0.90. Individuals with ABI < 0.90 were twice as likely to have prevalent CHD as those with ABI > 0.90 (age-adjusted odds ratio (OR) ranging from 2.2 (95% CI: 1.0-5.1) in African-American men to 3.3 (95% CI: 2.1-5.0) in white men). Men with ABI < 0.90 were more than four times as likely to have stroke/TIA as those with ABI > 0.90 (age-adjusted OR: 4.2 (95% CI: 1.8-9.5) in African-American men and 4.9 (95% CI: 2.6-9.0) in white men). In women the association was weaker and not statistically significant. Among those free of clinical cardiovascular disease, individuals with ABI < or = 0.90 had statistically significantly higher prevalence of preclinical carotid plaque compared to those with ABI > 0.90 (age-adjusted ORs ranging from 1.5 (95% CI: 1.0-1.9) in white women to 2.6 (95% CI: 1.0-6.6) in african-american men). The ABI was also inversely associated with far wall IMT of the carotid arteries (in both men and women) and the popliteal arteries (in men only). The associations of ABI with clinical CHD, stroke, preclinical carotid plaque and IMT of the carotid and popliteal arteries were attenuated and often not statistically significant after further adjustment for LDL cholesterol, cigarette smoking, hypertension and diabetes. These data demonstrate that low ABI levels, particularly those of < 0.90, are indicative of generalized atherosclerosis.

Plasma fibrinogen and incident hypertension in the Atherosclerosis Risk in Communities (ARIC) Study.

BACKGROUND: Several cross-sectional studies have reported a positive association between plasma fibrinogen levels and prevalent hypertension. Other studies have reported a positive association between hypertension and whole-blood or plasma viscosity, to which fibrinogen contributes. To our knowledge, there has been no prospective study of fibrinogen and incident hypertension. SUBJECTS AND METHODS: We measured plasma fibrinogen levels in a population-based cohort study of middle-aged adults and related it to the occurrence of incident hypertension (systolic blood pressure > or = 140 mmHg or diastolic blood pressure > or = 90 mmHg or use of antihypertensive medication) over 6 years. RESULTS: There was a moderately strong positive association between fibrinogen levels and prevalent hypertension in both men and women, with the odds of hypertension elevated by 50% for the highest fibrinogen quartile versus the lowest. Among 7884 participants at risk, 1609 developed hypertension over 6 years. Adjusted for age, race, field center and baseline systolic blood pressure, the odds ratio of incident hypertension in relation to fibrinogen quartiles was 1.0, 1.07, 1.21 and 1.43 in men (P= 0.003 for trend) and 1.0, 0.92, 0.99 and 0.99 in women (P= 0.89 for trend). After adjustment for other risk factors, the odds ratios were 1.0, 1.03, 1.15 and 1.29 (P= 0.045 for trend) in men and remained nonsignificant in women. CONCLUSIONS: Despite a moderately strong positive association between fibrinogen levels and prevalent hypertension in both sexes, there was only a weak positive association between fibrinogen levels and incident hypertension in men and no association in women. Whether an elevated fibrinogen level is a risk factor for, or a consequence of, hypertension remains unclear.

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.

Concordance of stroke symptom onset time. The Second Delay in Accessing Stroke Healthcare (DASH II) Study.

PURPOSE: This study examines the concordance between symptom onset obtained during an interview in the emergency department (ED) compared to that recorded in the medical record among patients with stroke-like symptoms and characterizes the frequency of missing symptom onset information in the medical record. METHODS: Interviews with patients presenting with signs and symptoms of acute stroke were completed in the ED of seven hospitals to determine symptom onset time. Symptom onset recorded in the medical record was abstracted after the patient was discharged. RESULTS: Among the patients who presented to the ED with stroke-like symptoms, 60.2% overall and 61.9% among stroke patients had a symptom onset date and time recorded in the medical record. The Pearson correlation of prehospital delay time, comparing symptom onset obtained by interview to that obtained by the medical record was 0.80 and among stroke patients was 0.91. Concordance of prehospital delay time for stroke within +/- 1 h between the interview and the medical record was 60.1%. For stroke patients, concordance was more likely for those who had higher functional status prior to the acute episode. CONCLUSIONS: Symptom onset time was often missing from the medical record. Standardized and systematic recording of delay time in the medical record could increase its utility as a clinical measure and as a research tool for acute stroke.

Racial disparities in CHD mortality from 1968-1992 in the state economic areas surrounding the ARIC study communities. Atherosclerosis Risk in Communities.

PURPOSE: This study examined racial variations in CHD (coronary heart disease) mortality rates (1968-1992) of residents aged 35-84 in the state economic areas (SEAs) surrounding the ARIC (Atherosclerosis Risk in Communities) study. The quarter century of CHD mortality rates are discussed in relation to racial and gender differences in baseline risk factors measured in the ARIC cohort and to the incidence of hospitalized myocardial infarction and case fatality rates obtained from the community surveillance component of the ARIC study between 1987 and 1994, inclusive. METHODS: Five-year average annual, gender- and age-specific CHD mortality rates were compared across race groups, based on National Vital Statistics data for state economic areas. RESULTS: Five-year average annual CHD mortality declined 2.6% for white men and women and 1.6% and 2.2% for black men and women, respectively. The black-white mortality rate ratio increased over time for men and women. The black-white mortality age crossover (higher black than white mortality in young men, lower black than white mortality at older ages) had disappeared by the end of the observation. CHD mortality was markedly greater in black than white women at all ages and time periods. The black disadvantage in CHD mortality was increasingly greater in the ARIC SEAs than in the United States as a whole. CONCLUSIONS: Persistent and increasing racial disparities in CHD mortality occurred in the ARIC SEAs concurrently with racial differences in risk factors, the incidence of myocardial infarction, and case fatality rates.

Serum uric acid and risk of coronary heart disease: Atherosclerosis Risk in Communities (ARIC) Study.

PURPOSE: Approximately half of previous studies on serum uric acid have reported it to be an independent risk factor for coronary heart disease (CHD). We tested this hypothesis in the Atherosclerosis Risk in Communities (ARIC) Study. METHODS: A total of 13,504 healthy middle-aged men and women were followed prospectively for up to eight years. We identified 128 fatal and nonfatal CHD events in women and 264 in men. RESULTS: The age-, race-, and ARIC field center-adjusted relative risk of CHD for sex-specific quartiles of serum uric acid were 1.0, 1.39, 1.08, and 2.35 in women (p for trend = 0.009) and 1.0, 1.03, 0.89, and 1.21 in men (p for trend = 0.44), respectively. However, serum uric acid was correlated positively with many risk factors, and after multivariable adjustment, there was little evidence of an association of uric acid with CHD in either sex. CONCLUSIONS: Our results are not consistent with serum uric acid being an independent risk factor for CHD.

Validation of death certificate diagnosis for coronary heart disease: the Atherosclerosis Risk in Communities (ARIC) Study.

The validity of the death certificate in identifying coronary heart disease deaths was evaluated using data from the community surveillance component of the Atherosclerosis Risk in Communities Study (ARIC). Deaths in the four ARIC communities of Forsyth Co., NC; Jackson, MS; Minneapolis, MN; and Washington Co., MD were selected based on underlying cause of death codes as determined by the rules of the ninth revision of the International Classification of Diseases (ICD-9). Information about the deaths was gathered through informant interviews, physician or coroner questionnaires, and medical record abstraction, and was used to validate the cause of death. Sensitivity, specificity, and positive predictive value of the death certificate classification of CHD death (ICD-9 codes 410-414 and 429.2) were estimated by comparison with the validated cause of death based on physician review of all available information. Results from 9 years of surveillance included a positive predictive value 0.67 (95% CI 0.66-0.68), sensitivity of 0.81 (95% CI 0.79-0.83), and a false-positive rate (1-specificity) of 0.28 (95% CI 0.26-0.30). Comparing CHD deaths as defined by the death certificate with validated CHD deaths indicated that the death certificate overestimated CHD mortality by approximately 20% in the ARIC communities. Within subgroups, death certificate overestimation was reduced with advancing age (up to age 74), was consistent over time, was not dependent on gender, and exhibited considerable variation among communities.

Coronary heart disease trends in four United States communities. The Atherosclerosis Risk in Communities (ARIC) study 1987-1996.

OBJECTIVE: The objective of this paper is to report trends in mortality due to coronary heart disease (CHD), rates of first and recurrent hospitalized myocardial infarction, and survival after myocardial infarction in the Atherosclerosis Risk in Communities (ARIC) Study from 1987 through 1996. METHOD: The ARIC study used retrospective community surveillance to monitor admissions to acute care hospitals and deaths due to CHD (both in- and out-of-hospital) among all residents 35-74 years of age. The surveillance areas included over 360 000 men and women in four communities: Forsyth County, North Carolina; the city of Jackson, Mississippi; eight northern suburbs of Minneapolis, Minnesota; and Washington County, Maryland. RESULTS: The annual age-adjusted mortality rate of CHD fell 3.2% (95% CI: 2.0, 4.3) among men and 3.8% (95% CI: 1.9, 5.6) among women. The greater part of the decline took place between 1987 and 1991. Significant declines were observed for both in-hospital and out-of-hospital CHD death. Significant improvements in case-fatality were also observed. Recurrent hospitalized myocardial infarction event rate fell an average of 1.9% per year among men (95% CI: 0.7, 3.1) and 2.1% (95% CI: 0.3, 3.9) among women. Average annual per cent change in incident hospitalized myocardial infarction was not statistically significant, except in blacks where there was evidence of an increase over time. CONCLUSION: Factors associated with the occurrence of recurrent hospitalized myocardial infarction, as well as those creating a better chance of survival after an event (including reductions in sudden death), were likely the prominent components in the recent decline in CHD mortality in ARIC communities.

Apparently coronary heart disease-free patients in the coronary care unit: characteristics, medical care, and 1-year outcome.

BACKGROUND: Coronary care units (CCUs) have contributed significantly to the improved survival rates among patients with acute myocardial infarction. Many patients admitted to CCUs are certified to be free of coronary heart disease (CHD) at discharge. There is little literature on the hospital course and prognosis of such patients. METHODS: We identified and followed 594 patients admitted to six CCUs in the Minneapolis-St Paul metropolitan area in 1990 because of suspected acute myocardial infarction who were eventually discharged without evidence of acute or chronic CHD. Their baseline characteristics, medical care, and 1-year outcome were compared with those of 672 patients with confirmed acute myocardial infarction and 612 patients with a history of CHD but without evidence of an acute coronary event. RESULTS: Similar numbers of men and women were certified to be CHD-free on discharge from hospital. These patients were significantly younger than either patients with acute myocardial infarction or patients with a history of CHD (mean age 57, 65, and 67 years, respectively). CHD-free patients commonly reported current smoking, hypertension, and hypercholesterolemia (26, 50, and 18%, respectively). These patients were less likely than those with acute myocardial infarction or a history of CHD to undergo diagnostic or therapeutic procedures, or to receive pharmacological treatment. Their 1-year mortality rate was 5%, significantly lower (P < 0.05) than the mortality among patients with either acute myocardial infarction (18%) or a history of CHD (13%) but 2.6 times greater than expected in the general population. Older age, previous or current smoking, chest pain leading to admission, and congestive heart failure were independent predictors of 1-year mortality. CONCLUSIONS: Patients certified to be CHD-free after admission to a CCU with suspected acute myocardial infarction have a lower 1-year mortality rate than patients experiencing acute myocardial infarction or chronic CHD. Their mortality rate, however, is substantially higher than expected, probably because of a high prevalence of cigarette smoking and hypertension.

Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults.

OBJECTIVE: To evaluate the effectiveness of computer-tailored newsletter interventions in improving the number and variety of fruits and vegetables eaten by adults. DESIGN: The 4-group randomized trial with pre- and postintervention measures consisted of a control group and 3 intervention groups receiving nontailored newsletters, computer-tailored newsletters, or tailored newsletters with tailored goal-setting information. Intervention groups received 1 newsletter each month for 4 months. SUBJECTS: Baseline surveys were completed by 710 health maintenance organization clients. Postintervention surveys administered 6 months after baseline were completed by 573 participants (80.8%). INTERVENTION: All newsletters contained strategies for improving fruit and vegetable consumption. Tailored newsletters used computer algorithms to match a person's baseline survey information with the most relevant newsletter messages for promoting dietary change. MAIN OUTCOME MEASURES: Daily intake and weekly variety of fruits and vegetables were measured using a food frequency questionnaire. STATISTICAL ANALYSES PERFORMED: Analysis of covariance and Tukey's honestly significant difference test were used to assess differences in the number and variety of fruits and vegetables consumed among intervention groups. RESULTS: For persons completing postintervention surveys (n = 573), all 3 newsletter groups had significantly higher daily intake and variety scores compared with the control group. Although there was a trend of improved intake and variety with each added newsletter element, there were no significant differences at follow-up among the newsletter groups. CONCLUSIONS: Newsletters can be effective in improving the fruit and vegetable consumption of adults. In this study, a computer-tailoring system did not significantly enhance the effect of the nutrition newsletters on fruit and vegetable intake.

Rapid response to stroke symptoms: the Delay in Accessing Stroke Healthcare (DASH) study.

OBJECTIVE: To assess the determinants of prehospital delay for patients with presumed acute cerebral ischemia (ACI) in order to provide the background necessary to develop interventions to shorten such delays. METHODS: A prospective registry of patients presenting to the ED with signs and symptoms of stroke was established at a university hospital from July 1995 to March 1996. Trained nurses performed a structured ED interview, which assessed prehospital delay and potential confounders. RESULTS: The median delay (interquartile range) from symptom onset to ED arrival for all patients seeking care for stroke-like symptoms (n = 152) was 3.0 hours (1.5-7.8 hr). The median delay from symptom onset to ED arrival was less in cases where a witness first recognized that there was a serious problem than it was when the patient first identified the problem. A heightened sense of urgency by the patient about his or her symptoms, and use of 911/emergency medical services (EMS) transport were also associated with rapid arrival in the ED within 3 hours of symptom onset. After adjusting for all predictor variables in a multivariable logistic regression model, only recognition of symptoms by a witness and calling 911/EMS transport remained statistically significant. CONCLUSIONS: These data suggest that future efforts to intervene on prolonged prehospital delay for patients with ACI should include strategies for the community as a whole as well as persons at risk for stroke and should reinforce the use of 911 and EMS transport.

Time delays in accessing stroke care in the emergency department.

OBJECTIVE: To delineate components of delay within the hospital ED for patients presenting with symptoms of stroke. METHODS: A prospective registry of patients presenting to the ED with signs or symptoms of stroke was established at a university hospital from July 1995 to March 1996. The ED arrival time, time to being seen by an emergency physician (EP), time to CT scan, and time to neurology consultation were obtained by medical record review. RESULTS: The median delay (interquartile range) from ED arrival to being seen by an EP for the 170 eligible subjects was 0.42 (0.20-0.75) hours. The median delay to CT scan was 1.88 hours (1.25-2.67) and the median delay to neurology consultation was 2.42 hours (1.50-3.48). Age, race, sex, and hospital discharge diagnosis had little influence on delay. Subjects arriving by emergency medical services (EMS) had a significantly shorter time to being seen by an EP (0.33 vs 0.50 hours) when compared with those who arrived by other means. Time to CT scan was shorter by 0.5 hours for patients arriving by EMS as well. These differences persisted when stratified by out-of-hospital delay times. CONCLUSIONS: These data suggest that arriving by EMS is associated with shorter times to being seen by an EP and receiving a CT scan. The influence of EMS on delays associated with rapid medical care of stroke patients reaches beyond the out-of-hospital transport phase.