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.

Insulin resistance during puberty: results from clamp studies in 357 children.

Insulin resistance may be an important cause of a constellation of cardiovascular risk factors in adults, and onset of this syndrome may occur in childhood. However, children normally experience transient insulin resistance at puberty. There were 357 normal children (159 girls, 198 boys) age 10-14 years who underwent euglycemic clamp studies to assess the effects of Tanner stage (T), sex, ethnicity, and BMI on insulin resistance. Insulin resistance increased immediately at the onset of puberty (T2), but returned to near prepubertal levels by the end of puberty (T5). Its peak occurred at T3 in both sexes, and girls were more insulin resistant than boys at all T stages. White boys appeared to be more insulin resistant than black boys; no difference was seen between white and black girls. Insulin resistance was strongly related to BMI, triceps skinfold thickness, and waist circumference, and this relationship was independent of Tanner stage or sex. Differences in BMI and adiposity did not, however, entirely explain the insulin resistance of puberty. These results demonstrate that 1) significant differences in insulin resistance are present between boys and girls; 2) insulin resistance increases significantly at T2, T3, and T4, but decreases to near prepubertal levels at T5; and 3) while insulin resistance is related to BMI and anthropometric measures of fatness, these factors do not completely explain the insulin resistance that occurs during the Tanner stages of puberty.

Estimated contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality: the Minnesota Heart Survey.

OBJECTIVES: This study assessed the possible contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality in the Minneapolis-St. Paul metropolitan area population between 1970 and 1984. BACKGROUND: Coronary artery bypass graft surgery is a major contemporary therapeutic approach for coronary heart disease. Its use has increased over the past two decades because it provides relief of symptoms and, in certain circumstances, prolongs life. During the period that age-adjusted coronary heart disease mortality has decreased, the use of coronary artery bypass graft surgery has increased dramatically, suggesting a relation. METHODS: All 30- to 74-year old Minneapolis-St. Paul area residents undergoing coronary artery bypass graft surgery between 1970 and 1984 (9,548 patients) were registered; their medical records were abstracted; and their survival was ascertained. These data were used in a medical survival probability model using a multivariate analytical approach developed from registries of patients treated medically. The model assumed that coronary artery bypass graft surgery was not available. Two annual mortality rates were compared: the observed Minneapolis-St. Paul annual coronary heart disease mortality rate and the modeled annual coronary heart disease mortality rate. The difference between these rates was the estimated contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality rates. RESULTS: Between 1970 and 1984, the estimated surgical contribution increased from 0.2% (increased mortality) to +6.6% of the annual decrease in Minneapolis-St. Paul coronary heart disease mortality. CONCLUSIONS: Between 1970 and 1984, the contribution of coronary artery bypass graft surgery to the decline in coronary heart disease mortality, although small, gradually increased. This change appeared to be related to an increased frequency of coronary artery bypass graft surgery, improved operative mortality and changes in the clinical mix of surgical patients.

Identification of preoperative variables needed for risk adjustment of short-term mortality after coronary artery bypass graft surgery. The Working Group Panel on the Cooperative CABG Database Project.

OBJECTIVES: The purpose of this consensus effort was to define and prioritize the importance of a set of clinical variables useful for monitoring and improving the short-term mortality of patients undergoing coronary artery bypass graft surgery (CABG). BACKGROUND: Despite widespread use of data bases to monitor the outcome of patients undergoing CABG, no consistent set of clinical variables has been defined for risk adjustment of observed outcomes for baseline differences in disease severity among patients. METHODS: Experts with a background in epidemiology, biostatistics and clinical care with an interest in assessing outcomes of CABG derived from previous work with professional societies, government or academic institutions volunteered to participate in this unsponsored consensus process. Two meetings of this ad hoc working group were required to define and prioritize clinical variables into core, level 1 or level 2 groupings to reflect their importance for relating to short-term mortality after CABG. Definitions of these 44 variables were simple and specific to enhance objectivity of the 7 core, 13 level 1 and 24 level 2 variables. Core and level 1 variables were evaluated using data from five existing data bases, and core variables only were examined in an additional two data bases to confirm the consensus opinion of the relative prognostic power of each variable. RESULTS: Multivariable logistic regression models of the seven core variables showed all to be predictive of bypass surgery mortality in some of the seven existing data sets. Variables relating to acuteness, age and previous operation proved to be the most important in all data sets tested. Variables describing coronary anatomy appeared to be least significant. Models including both the 7 core and 13 level 1 variables in five of the seven data sets showed the core variables to reflect 45% to 83% of the predictive information. However, some level 1 variables were stronger than some core variables in some data sets. CONCLUSIONS: A relatively small number of clinical variables provide a large amount of prognostic information in patients undergoing CABG.

Changes in physician practice for the prevention of cardiovascular disease.

To determine recent changes in physicians' practices for cardiovascular disease risk reduction, a randomly selected sample of practicing primary care physicians in the upper Midwest was interviewed by telephone in 1987 and again in 1989 (response rates, greater than 90%; N = 241). The reported mean cutoff levels for labeling a total serum cholesterol level as abnormal dropped from 5.84 to 5.43 mmol/L (226 to 210 mg/dL) and for initiating medication, from 7.34 to 6.54 mmol/L (284 to 253 mg/dL). The proportion of physicians using diuretics as preferred step 1 antihypertensive agents dropped from 60% to 32%. Preferences became evenly divided among diuretics, angiotensin-converting enzyme inhibitors, and beta-blockers. Advice about physical exercise changed little, but consensus among practicing physicians was high. Substantial improvements were found in smoking cessation activities. Practicing physicians are proving to be responsive to new scientific evidence and education in the prevention of cardiovascular disease.

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.

Twelve-year trends in cardiovascular disease risk factors in the Minnesota Heart Survey. Are socioeconomic differences widening?

BACKGROUND: Inverse associations of educational level and household income (as proxy indicators of socioeconomic status) with cardiovascular disease risk factors are fairly well established. Whether differences in cardiovascular disease risk factors across education or income levels have widened in the last decade remains an issue of considerable public health importance. METHODS: Analysis by mixed-regression models of trends in cardiovascular disease risk factors, in population-based samples (n = 3334 in 1980-1982, n = 4538 in 1985-1987, and n = 4517 in 1990-1992) of Minneapolis-St Paul residents 25 to 74 years old. RESULTS: Education level was inversely related to serum cholesterol level, systolic blood pressure, smoking prevalence, and body mass index and positively related to leisure-time physical activity and health knowledge in both sexes. Household income was inversely associated with systolic blood pressure and body mass index in women and with smoking prevalence in both sexes. Income level was positively associated with leisure-time physical activity and health knowledge in both sexes. There were overall favorable downward secular trends in serum cholesterol level and systolic blood pressure, favorable upward trends in health knowledge, and unfavorable upward trends in body mass index across all socioeconomic status groups. Throughout the decade, trends in smoking prevalence differed by education level in men (P = .01), such that declines were observed only in those with a college degree or some college education. With respect to trends in leisure-time physical activity, there were greater gains among men with low socioeconomic status (P = .03 for education; P = .02 for income) and among less affluent women (P = .001). CONCLUSIONS: These data support the inverse association between socioeconomic status and cardiovascular disease risk factors but suggest no widening (with the exception of smoking by education level in men) of socioeconomic differences in risk factor trends during the last decade in a representative sample of the Minneapolis-St Paul population.

Nutrient intake in a metropolitan area, 1973-74 vs 1980-82: the Minnesota Heart Survey.

Trends in dietary intake in the Twin Cities metropolitan area were measured by comparing data from two independent surveys conducted in 1973-74 and 1980-82. Dietary information was collected by 24-h recall and coded by a single coding center. For men reported caloric intake declined significantly and fat, protein, and carbohydrate each declined approximately 6%; changes in reported dietary intake for women were smaller and mostly nonsignificant. Few trends were observed for either sex in nutrient intake relative to energy intake. Changes in mean serum total-cholesterol levels and body mass indices between 1973-74 and 1980-82 were not consistent with the direction of dietary trends. The proportion of subjects whose 24-h intake met five selected US dietary goals was calculated. In 1980-82, less than 15% of persons reached the goals for carbohydrate and fat intake on the day surveyed; the cholesterol-intake goal (less than or equal to 300 mg/d) was met by 39% of men and 64% of women during the 24-h period surveyed.

Screening for neuroblastoma is ineffective in reducing the incidence of unfavourable advanced stage disease in older children.

Neuroblastoma exhibits many characteristics which would suggest that preclinical detection may improve outcome. The Quebec Neuroblastoma Screening Project was initiated to determine whether mass screening could reduce mortality in a large cohort of infants. All 476,603 children born in the province of Quebec during a 5-year period of time (1 May 1989 to 30 April 1994) were eligible for determinations of urinary catecholamine metabolites at 3 weeks and 6 months of age. Children with positive screening were referred to one of four paediatric cancer centres in Quebec for uniform evaluation and treatment. Standardised incidence ratios (SIRs) were calculated for neuroblastoma in Quebec and two comparable population-based controls during the same period of time using similar ascertainment procedures. Compliance with screening in Quebec was 91% at 3 weeks (n = 425,816) and 74% at 6 months (n = 349,706). Up to 31 July 1995 with a follow-up of the birth cohort of 15-75 months, 118 cases of neuroblastoma were diagnosed, 43 detected preclinically by screening, 20 detected clinically prior to screening at 3 weeks of age and 55 detected clinically after 3 weeks of age having normal screens (n = 52) or never screened (n = 3). Based on data from concurrent control populations, 54.5 cases of neuroblastoma would have been expected in Quebec during the study period for an SIR of 2.17 (95% CI 1.79-2.57, P < 0.0001). For the two control groups, the overall SIR was 1.00 (NS). SIRs for Quebec by age at diagnosis in yearly intervals show a marked increased incidence under 1 year of age (SIR = 2.85, 95% CI 2.26-3.50), with no reduction in incidence in subsequent years. We conclude that screening for neuroblastoma markedly increases the incidence in infants without decreasing the incidence of unfavourable advanced stage disease in older children. It is unlikely that screening for neuroblastoma in infants will reduce the mortality of this disease.

Current status of cholesterol treatment in the community: the Minnesota Heart Survey.

There is a consensus on the importance of lowering blood cholesterol in individuals and populations. To determine trends in the detection and treatment of elevated cholesterol, a series of studies known as the Minnesota Heart Survey evaluated cardiovascular disease, risk, and health behavior among adults in the upper Midwest between 1980 and 1992. Over 25,000 adult residents of large and small communities were surveyed for information on risk factors and health habits, including status of cholesterol detection and treatment. During those years, population levels of blood cholesterol declined significantly for both men and women, largely as the result of changes in diet. Levels of clinical detection of hypercholesterolemia, initially low, also rose. However, subjects who had been informed that they had increased lipids reported that recommendations from their physicians for dietary therapy declined, while recommendations for weight loss increased during the survey period. Medication use for elevated blood cholesterol, always low, rose slightly, but many subjects discontinued medications due to side effects, the perception that their cholesterol was controlled, lack of perceived benefit, or cost. A total of 274 primary care physicians were also surveyed. Physicians reported that they screen more frequently than in the past and initiate drug therapy at a lower threshold. Despite improving trends in detection, treatment, and follow-up for elevated blood cholesterol in the general population, > 50% of U.S. citizens are still unaware of their elevated cholesterol levels and a growing segment of the population that has been identified as having elevated blood cholesterol remains untreated. Dietary therapy needs to be better utilized. Physicians also need to educate their patients about the importance of maintaining desirable cholesterol levels and to encourage compliance with medications for those who require them.

Characteristics and outcomes among patients undergoing coronary artery bypass grafting in western Sweden and Minneapolis-St Paul, Minnesota.

BACKGROUND: The purpose of this study was to compare patient selection, operative factors, and survival for coronary artery bypass grafting (CABG) for coronary heart disease in Minneapolis-St Paul (MSP), Minnesota, and Western Sweden (WS). METHODS AND RESULTS: All patients from WS between 1988 and 1991 (n = 2365) and a 17% random sample of MSP patients between 1985 and 1990 (n = 1659) who underwent CABG surgery were studied. CABG was 3 times greater in MSP. MSP patients had significantly more obesity, cigarette smoking, prior CABG, and prior coronary angioplasty. WS patients had more and longer angina pectoris, better left ventricular function, and waited longer from previous acute MI until CABG. WS patients had more internal mammary artery graphs and a shorter aortic cross-clamp time. At discharge, WS patients received more beta-blockers and antiplatelet agents, whereas MSP patients received more calcium channel blockers and digitalis. Age-adjusted mortality rate at 28 days was significantly higher in MSP but not at 3 years. Adjustment for patient characteristics and treatment factors reduced or eliminated these differences. CONCLUSIONS: Although coronary heart disease rates were higher in WS, age-adjusted CABG rates were 3-fold higher in MSP. Better survival among WS patients was associated with differences in patient selection and clinical and treatment characteristics because MSP patients were more severely ill and at increased risk. Health system characteristics and practice may account for these differences.

Dyslipoproteinemia in the elderly. Special considerations.

Reduction in blood cholesterol levels has the potential for reducing morbidity and mortality from CHD in elderly adults. Although definitive trials have not been undertaken, the guidelines of the Adult Treatment Panel of the NCEP provide the basis for diagnosis and treatment of the disease. Dietary therapy should be the principal approach in the elderly. A balanced diet low in saturated fats and high in fruits, vegetables, and grains should both reduce cholesterol and confer other healthful benefits. The potential for improvement in this population is large, as is the challenge to the medical community.

Cholesterol screening by primary care pediatricians: a study of attitudes and practices in the Minneapolis-St Paul metropolitan area.

A telephone survey of the 197 board-certified pediatricians actively engaged in primary care in the Minneapolis-St Paul metropolitan area was conducted to assess their cholesterol screening practices and hypercholesterolemia management. The response rate was 95%. Nearly all the pediatricians (90%) do some cholesterol screening, with the majority (58%) screening only children with a strong family history of coronary heart disease. Though only 33% screen all their patients, 66% advocate universal pediatric screening. Most of the pediatricians indicated they would manage hypercholesterolemia patients themselves, nearly always with dietary means. Despite their strong support for screening, the pediatricians expressed skepticism about the significance of childhood cholesterol level as a predictor of adult cardiovascular disease and doubted their effectiveness in getting patients to adopt a cholesterol-reducing diet. Their definition of elevated total cholesterol level in childhood was consistent with published recommendations, but only 29% could define elevated low-density lipoprotein cholesterol level. The pediatricians expressed strong opposition to pediatric cholesterol screening in schools or in any setting other than clinics and hospitals.

The potential costs of upcoding for heart failure in the United States.

Miscoding of hospital discharge diagnoses for heart failure in older adults is common, and the direction favors high levels of reimbursement to hospitals. The potential costs to Medicare may be as high as $993 million per year.

Sex differences in early mortality after acute myocardial infarction (the Minnesota Heart Survey).

Although numerous studies indicate that women have a higher early mortality from acute myocardial infarction (AMI) than men, reasons for the difference are largely unexplained. We studied the role of sex in the prognosis of 1,600 patients with AMI aged 30 to 74 years in the population-based Minnesota Heart Survey. A 50% random sample was taken of all AMI patients hospitalized in 1980 and 1985 in the Twin Cities of Minnesota (Minneapolis-St. Paul) (1,168 men, 432 women). A multiple logistic regression model was used for predicting early death (within 28 days) and included baseline characteristics: sex, age, chest pain on admission, history of previous AMI, angina pectoris, coronary artery bypass surgery or hypertension, presence of heart failure, cardiac arrhythmias requiring direct-current shock, diabetes mellitus, valvular disease, cardiomyopathy, and levels of serum enzymes and blood urea nitrogen. Age-adjusted early mortality rate was significantly higher in women than men, but only in those aged < 65 years (12.5% of women vs 6.5% of men, p < 0.01) versus those aged > or = 65 years (19.5% vs 21.6%, p > 0.05). Multivariate analysis also showed that among those < 65 years, female sex was a strong and independent predictor of early death (odds ratio 2.0, 95% confidence interval 1.2 to 3.5, p < 0.01). Rates of coronary angiography, coronary artery bypass surgery, percutaneous transluminal coronary angioplasty, and thrombolysis performed during hospital stay were higher in men, but after adjustment for age, congestive heart failure, and diabetes mellitus, a statistically significant difference persisted only in the frequency of coronary angiography (26% in men vs 17% in women, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

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.

Management of hypercholesterolemia: evaluation of practical clinical approaches in healthy young adults.

A work site-located clinic screened 6,000 employees (91 percent participation) and identified 146 hypercholesterolemic subjects (100 percent initial participation, 12 percent subsequent dropout rate). The subjects, aged 20 to 50 years, were randomly classified into four groups: Group A, treatment in a lipid intervention clinic with diet for 6 weeks, then diet plus clofibrate for the subsequent 18 weeks; Group B, diet treatment from a clinic nutritionist with the cooperation of the subject's private physician; Group C, referral for treatment by a private physician; and Group D, no intervention. Initial mean cholesterol was 294 mg/100 ml. At 24 weeks, all intervention groups had decreases in serum cholesterol (Group A, 12 percent; Group B, 15 percent; Group C, 17 percent; P less than 0.001). The control group (D) had a small decrease in cholesterol (4 percent). Decreases in cholesterol were correlated with weight loss and decrease in fasting serum triglycerides but not with the use of clofibrate. Serum cholesterol can be reduced in healthy young adults by several practical methods.

Validation of death certificate diagnosis of out-of-hospital sudden cardiac death.

The validity of death certificate diagnosis of out-of-hospital sudden cardiac death (OOH-SCD) was studied among 108,676 30- to 74-year-old residents in 5 Minnesota communities using 6-year mortality data (1985 to 1990). Among 4,244 total deaths, location of death was listed on the certificate as out of hospital in 2,035 cases. Of those, 911 were judged not to have OOH-SCD because they had actually been admitted to the hospital or were noncardiovascular deaths. Among the remaining 1,124, 254 were diagnosed as OOH-SCD using a thorough, physician-based procedure that used clinical records, autopsy reports, and an informant (next-of-kin) interview. We used only death certificate information to define OOH-SCD simply and inexpensively as ICD-9 code 427.5 (cardiac arrest) plus location of death listed as out-of-hospital. Compared with the physician diagnosis, sensitivity was only 24%, whereas specificity was 85%. When the definition of OOH-SCD was expanded to include ICD codes 410-414 (acute myocardial infarction and chronic coronary artery disease), sensitivity improved to 87%, whereas specificity became 66%. However, even with this higher sensitivity and specificity, only 27% of the cases labeled OOH-SCD by death certificate agreed with the physician diagnosis. Death certificate diagnosis of OOH-SCD included many erroneous cases, and may not have been suitable for study of etiologic factors, such as cardiac dysrhythmias. Death certificate diagnosis may be useful to assess population time trends in OOH-SCD, provided that misclassification (false-positive rate) remains constant over time.

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.

Detection of pulmonary edema in acute myocardial infarction.

To evaluate methods for detecting pulmonary edema, pulmonary extravascular water volume was measured at 24 hour intervals (total 72 hours) in 25 patients with acute myocardial infarction. Measured lung water was compared with results of clinical, blood gas, X-ray and hemodynamic methods for detecting pulmonary edema. Increased pulmonary extravascular water volume on one or more measurements was observed in 18 of the 25 patients and was associated with an abnormal chest radiograph and increased pulmonary arterial wedge, pulmonary arterial diastolic and right atrial pressures. It was associated less well with clinical, blood gas and other hemodynamic measurements. Pulmonary arterial diastolic or pulmonary wedge pressure was a significant predictor of lung water 24 hours later. Both "preclinical pulmonary edema" and the "therapeutic phase lag" could be predicted from the pulmonary wedge pressure. Clinical, blood gas, radiographic and other hemodynamic measurements were not predictive.