Multifaceted interventions improve medication adherence and reduce acute hospitalization rates in medicaid patients prescribed asthma controllers.

OBJECTIVE: To measure the effectiveness of managed care-led interventions in Medicaid subjects with asthma on medication adherence and acute hospitalization in Pennsylvania. METHODS: A total of 3589 members (age range, 5-64 years) served by two Pennsylvania-based Medicaid managed care plans (southeastern Pennsylvania [SEPA] and Lehigh-Capital/New West Pennsylvania [LCNWPA]) with low adherence rates (proportion of days covered [PDC]; 20%-67%) for asthma controller prescription fills in 2012 were guided through a care continuum by a comprehensive asthma strategy, consisting of adherence-improvement interventions (grouped as general intervention [GI] or personalized intervention [PI] for higher-risk subjects). Medication adherence and acute hospitalization rates (emergency department [ED] and inpatient [IP]) were compared at baseline versus one-year post-intervention using paired t-test or signed-rank tests. Repeated measures analysis of variances detected the interaction effect of time by intervention group after controlling for sociodemographic covariates. RESULTS: Member profiles in SEPA (n = 2 796) and LCNWPA (n = 793) were racially and ethnically distinct. Both cohorts experienced statistically significant improvements in mean PDC rate (+4.9% and +7.2%; p = 0.01 and p = 0.03, respectively), accompanied by significant reductions in ED visits (asthma-related: -23.0% and -17.5%, respectively; p < 0.01), and IP admissions (asthma-related: -37.1% and -40.0%, respectively; p < 0.01). The PI subcohorts showed significantly greater improvements in mean PDC versus GI subcohorts (p ≤ 0.04), whereas acute hospitalization rates were statistically comparable in the SEPA cohort, despite its greater asthma burden. CONCLUSIONS: Managed care-led interventions can effectively improve medication adherence and reduce acute hospitalizations in high-risk Medicaid populations.

The prognostic meaning of the full spectrum of aVR ST-segment changes in acute myocardial infarction.

AIMS: ST-elevation in lead aVR is known to be associated with a worse prognosis in patients with acute ST elevation myocardial infarction (MI) but the significance of ST depression in lead aVR has been unclear. Infarction of the inferior apex of the left ventricle may not be appreciated on the standard 12-lead electrocardiogram (ECG) except by observing ST depression in lead aVR which is reciprocal to lead V(7). We therefore determined the prognostic value of the full spectrum of aVR ST changes in patients presenting with acute ST elevation MI. METHODS AND RESULTS: Lead aVR ST level was measured on randomization and 60 min ECGs in 15 315 patients with normal conduction from the HERO-2 trial. The outcome measure was 30-day mortality. aVR ST elevation ≥1 mm was associated with higher 30-day mortality for both inferior (22.5% for ≥1.5 mm and 13.2% for 1 mm) and anterior (23.5% for ≥1.5 mm and 11.5% for 1 mm) infarction. In contrast, deeper aVR ST depression (0, 0.5, 1, and ≥1.5 mm) was associated with higher mortality for anterior infarction (9.8, 13.2, 12.8, and 16.8%, respectively, trend P-value <0.0001) but not for inferior infarction. The resolution of aVR ST depression and ST elevation 60 min after fibrinolysis was associated with lower mortality. CONCLUSION: There is a U-shaped relationship between 30-day mortality and aVR ST level in patients presenting with anterior but not inferior ST elevation MI.

Correlates of cervical cancer screening among Vietnamese American women.

OBJECTIVE: Vietnamese American women are at the greatest risk for cervical cancer but have the lowest cervical cancer screening rates. This study was to determine whether demographic and acculturation, healthcare access, and knowledge and beliefs are associated with a prior history of cervical cancer screening among Vietnamese women. METHODS: Vietnamese women (n = 1450) from 30 Vietnamese community-based organizations located in Pennsylvania and New Jersey participated in the study and completed baseline assessments. Logistic regression analyses were performed. RESULTS: Overall levels of knowledge about cervical cancer screening and human papillomavirus (HPV) are low. Factors in knowledge, attitude, and beliefs domains were significantly associated with Pap test behavior. In multivariate analyses, physician recommendation for screening and having health insurance were positively associated with prior screening. CONCLUSION: Understanding the factors that are associated with cervical cancer screening will inform the development of culturally appropriate intervention strategies that would potentially lead to increasing cervical cancer screening rates among Vietnamese women.

Prognostic value of lead V1 ST elevation during acute inferior myocardial infarction.

BACKGROUND: Lead V(1) directly faces the right ventricle and may exhibit ST elevation during an acute inferior myocardial infarction when the right ventricle is also involved. Leads V(1) and V(3) indirectly face the posterolateral left ventricle, and ST depression ("mirror-image" ST elevation) in V(1) through V(3) may reflect concomitant posterolateral infarction. The prognostic significance of V(1) ST elevation during an acute inferior myocardial infarction may therefore be dependent on V(3) ST changes. METHODS AND RESULTS: In 7967 patients with acute inferior myocardial infarction in the Hirulog and Early Reperfusion or Occlusion-2 (HERO-2) trial, V(1) ST levels were analyzed with adjustment for lead V(3) ST level for predicting 30-day mortality. V(1) ST elevation at baseline, analyzed as a continuous variable, was associated with higher mortality. Unadjusted, each 0.5-mm-step increase in ST level above the isoelectric level was associated with approximately 25% increase in 30-day mortality; this was true whether V(3) ST depression was present or not. The odds ratio for mortality was 1.21 (95% confidence interval, 1.07 to 1.37) after adjustment for inferolateral ST elevation and clinical factors and 1.24 (95% confidence interval, 1.09 to 1.40) if also adjusted for V(3) ST level. In contrast, lead V(1) ST depression was not associated with mortality after adjustment for V(3) ST level. V(1) ST elevation >or=1 mm, analyzed dichotomously in all patients, was associated with higher mortality. The odds ratio was 1.28 (95% confidence interval, 1.01 to 1.61) unadjusted, 1.51 (95% confidence interval, 1.19 to 1.92) adjusted for V(3) ST level, and 1.35 (95% confidence interval, 1.04 to 1.76) adjusted for ECG and clinical factors. Persistence of V(1) ST elevation >or=1 mm 60 minutes after fibrinolysis was associated with higher mortality (10.8% versus 5.5%, P=0.001). CONCLUSIONS: V(1) ST elevation identifies patients with acute inferior myocardial infarction who are at higher risk.

Metformin versus insulin for the treatment of gestational diabetes.

BACKGROUND: Metformin is a logical treatment for women with gestational diabetes mellitus, but randomized trials to assess the efficacy and safety of its use for this condition are lacking. METHODS: We randomly assigned 751 women with gestational diabetes mellitus at 20 to 33 weeks of gestation to open treatment with metformin (with supplemental insulin if required) or insulin. The primary outcome was a composite of neonatal hypoglycemia, respiratory distress, need for phototherapy, birth trauma, 5-minute Apgar score less than 7, or prematurity. The trial was designed to rule out a 33% increase (from 30% to 40%) in this composite outcome in infants of women treated with metformin as compared with those treated with insulin. Secondary outcomes included neonatal anthropometric measurements, maternal glycemic control, maternal hypertensive complications, postpartum glucose tolerance, and acceptability of treatment. RESULTS: Of the 363 women assigned to metformin, 92.6% continued to receive metformin until delivery and 46.3% received supplemental insulin. The rate of the primary composite outcome was 32.0% in the group assigned to metformin and 32.2% in the insulin group (relative risk, 0.99 [corrected]; 95% confidence interval, 0.80 [corrected] to 1.23 [corrected]). More women in the metformin group than in the insulin group stated that they would choose to receive their assigned treatment again (76.6% vs. 27.2%, P<0.001). The rates of other secondary outcomes did not differ significantly between the groups. There were no serious adverse events associated with the use of metformin. CONCLUSIONS: In women with gestational diabetes mellitus, metformin (alone or with supplemental insulin) is not associated with increased perinatal complications as compared with insulin. The women preferred metformin to insulin treatment. (Australian New Zealand Clinical Trials Registry number, 12605000311651.).

Role of sociocultural factors in hepatitis B screening among Asian Americans.

OBJECTIVE: To apply the proposed Sociocultural Health Behavior Model to determine association of factors related to hepatitis B virus (HBV) screening among Asian Americans. METHODS: A cross-sectional design of 1312 Asian men and women 18 years and older. The frequency distribution analysis and chi square analysis were used for the initial screening of the following variables: access/satisfaction with health care, enabling, predisposing, cultural, and health belief factors. Univariate and multivariate analyses were conducted on factors for HBV screening using logistic regression analysis. RESULTS: Correlates to HBV screening included demographics, cultural factors, enabling factors, and family/social support factors. Enabling factors were more likely to be associated with HBV screening. CONCLUSION: The model highlights the role sociocultural factors play in HBV screening. Findings reinforce the need for HBV screening programs and indicate programs could be more effective if they included these components and were sensitive to ethnic and cultural factors.

aVR ST elevation: an important but neglected sign in ST elevation acute myocardial infarction.

AIM: This study evaluated the prognostic implications of aVR ST elevation during ST elevation acute myocardial infarction (AMI). METHODS AND RESULTS: The Hirulog and Early Reperfusion/Occlusion-2 study randomized 17 073 patients with acute ST elevation AMI within 6 h of symptom onset to receive either bivalirudin or heparin, in addition to streptokinase and aspirin. The treatments had no effect on the primary endpoint of 30-day mortality. Electrocardiographic recordings were performed at randomization and at 60 min after commencing streptokinase. aVR ST elevation > or =1 mm was associated with higher 30-day mortality in 15 315 patients with normal intraventricular conduction regardless of AMI location (14.7% vs. 11.2% for anterior AMI, P = 0.0045 and 16.0% vs. 6.4% for inferior AMI, P < 0.0001). After adjusting for summed ST elevation and ST depression in other leads, associations with higher mortality were found with aVR ST elevation of > or =1.5 mm for anterior [odds ratio 1.69 (95% CI 1.16 to 2.45)] and of > or =1 mm for inferior AMI [odds ratio 2.41 (95% CI 1.76 to 3.30)]. There was a significant interaction between aVR ST elevation and infarct location. Thirty-day mortality was similar with anterior and inferior AMI when aVR ST elevation was present (11.5% vs. 13.2%, respectively, P = 0.51 with 1 mm and 23.5% vs. 22.5% respectively, P = 0.84 with > or = 1.5 mm ST elevation). After fibrinolytic therapy, resolution of ST elevation in aVR to <1 mm was associated with lower mortality, while new ST elevation > or =1 mm was associated with higher mortality. CONCLUSION: aVR ST elevation is an important adverse prognostic sign in AMI.

Predicting opioid use disorder and associated risk factors in a Medicaid managed care population.

OBJECTIVES: Medicaid managed care organizations are developing comprehensive strategies to reduce the impact of opioid use disorder (OUD) among their members. The goals of this study were to develop and validate a predictive model of OUD and to predict future OUD diagnosis, resulting in proactive, person-centered outreach. STUDY DESIGN: We utilized machine learning methodology to select a multivariate logistic regression and identify predictors. METHODS: Using 2016-2018 data, we used a staged approach to test and validate the predictive accuracy of our model. We identified OUD, the dependent variable, using an industry-standard definition. We included a series of patient demographic, chronic condition, social determinants of health (SDOH), opioid-related, and health utilization indicators captured in administrative data. RESULTS: Caucasian (odds ratio [OR], 1.65), male (OR, 1.57), and younger (aged 40-64 years compared with 18-39 years: OR, 0.75) members had greater odds of being diagnosed with an OUD. Members with an SDOH vulnerability had 26% higher odds than those without a documented issue. From a prescribing perspective, we found that having an opioid dose of 120 morphine milligram equivalents and contiguous 5-day supply increased odds of OUD by 1.87 times, and an opioid supply of 30 days or longer increased the odds of OUD by 1.56 times. CONCLUSIONS: We built the necessary machine learning infrastructure to identify members with greater than 50% probability of developing OUD. The generated list strategically informs and guides person-centered care and interventions. Through application of these results, we strive to proactively reduce OUD-related structural barriers and prevent OUD from occurring.

Impact of current and past intimate partner violence on maternal mental health and behaviour at 2 years after childbirth: evidence from the Pacific Islands Families Study.

OBJECTIVE: The present study examined the association between maternal intimate partner violence (IPV) at 6 weeks and 24 months postpartum and maternal health problems in a cohort of Pacific families with 2-year-old children in New Zealand. METHODS: Data were gathered from the Pacific Islands Families Study. Mothers of a cohort of Pacific infants born in Auckland, New Zealand during 2000 were interviewed when the children were 6 weeks and 24 months of age. There were 828 mothers cohabiting in married or de facto partnerships who completed measures of IPV, mental health, and health-related behaviour such as smoking and high-risk alcohol use at both data points. The main statistical method used was logistic regression analysis. RESULTS: Compared to mothers who did not experience physical violence at either data point, the odds of reporting psychological distress were 2.42 (95% confidence interval (CI) = 1.07-5.44) for those experiencing physical violence at 6 weeks only, 3.47 (95%CI = 1.75-6.86) for those experiencing physical violence at 24 months only, and 3.84 (95%CI = 1.78-8.30) for those experiencing physical violence at both data points after controlling for sociodemographic factors. Mothers experiencing verbal aggression or physical violence at both data points were more likely to report smoking or high-risk alcohol use at 24 months than those who did not, but the associations were no longer significant after controlling for sociodemographic factors. CONCLUSION: Being a victim of intimate partner physical violence at any time (past, recent and repeated) may contribute to an increase in maternal psychological distress. Health-related behaviours such as smoking and high-risk alcohol use at 24 months postpartum may to some degree be attributable to repeated victimization of physical violence and verbal aggression, but the relationships are not convincing and deserve further research in longitudinal studies.

Maternal intimate partner violence and behavioural problems among Pacific children living in New Zealand.

AIMS: To examine (1) the association between maternal intimate partner violence (IPV) perpetration and victimisation and behavioural problems among two- and four-year-old Pacific children, and (2) the socio-demographic and parenting factors that may impact on this association. DESIGN: Mothers of the Pacific Islands Families (PIF) cohort of Pacific infants born in New Zealand during 2000 were interviewed when the children were two and four years of age. This data set was based on mothers who were cohabiting in married or de-facto partnerships (N = 920) and who completed measures of IPV at the two-year assessment point and the Child Behaviour Checklist (CBCL) at the two-or four-year assessment points. Of these, 709 mothers completed the CBCL at both assessment points. RESULTS: There were no significant associations between IPV and the prevalence rates of clinically relevant cases of behavioural problems in the two-year-old child cohort. However, the prevalence rates of clinically relevant internalising, externalising and total problem cases were significantly higher among four-year-old children of mothers who reported severe perpetration of IPV. The odds of being in clinical range of internalising were 2.16 times higher for children of mothers who were perpetrators of severe physical violence than for those children of mothers who were not, and for externalising and total problems they were 2.38 and 2.36 times higher respectively. Socio-demographic and parenting factors did not significantly influence the association between IPV and child behaviour problems. CONCLUSION: These findings contribute to the complex picture of the consequences that exposure to parental violence may have on the behaviour of young children. The effectiveness of preventative strategies may be maximised if implemented in these early years before such problems become entrenched and lead on to future behavioural problems and impaired family relationships.

Maternal smoking during pregnancy and behaviour problems in a birth cohort of 2-year-old Pacific children in New Zealand.

AIM: The present study investigated associations between maternal smoking during pregnancy and child behaviour problems in a cohort of Pacific Islands two-year-old children in New Zealand. STUDY DESIGN: Data were gathered as part of the Pacific Islands Families (PIF) Study. Mothers of a cohort of 1398 Pacific infants born in South Auckland, New Zealand were interviewed when their children were six-weeks, 12 and 24 months of age. Within the context of a wider interview, data regarding cigarette smoking during pregnancy was obtained from 1038 biological mothers at the six-week interview and reports of child behaviour using the Child Behaviour Checklist were gathered when the children were 24 months old. RESULTS: The prevalence rates of clinically relevant cases were higher in children of smokers compared to non-smokers for internalising (22.6% versus 15.2%), externalising (9.6% versus 5.7%) and total problem scores (20% versus 12.4%). Following adjustment for potential confounding factors, smoking was associated with a moderately increased prevalence of total behaviour problems (OR=1.75, 95% CI=(1.12, 2.74); p=0.015). For internalising scores, the effects of smoking appeared to be raised for children of non-partnered mothers (OR=3.35, 95% CI=(1.29, 8.67); p=0.013). For externalising scores, smoking appeared to have a greater detrimental effect on girls (OR=2.37, 95% CI=(1.12, 5.04); p=0.024). CONCLUSIONS: Findings indicate there are significant effects of prenatal tobacco exposure on problem behaviour among young children. Smoking is a modifiable factor worthy of increased early preventive efforts.

Intimate partner violence and unplanned pregnancy in the Pacific Islands Families Study.

OBJECTIVE: To examine the association between maternal intimate partner violence (IPV) victimization and unplanned pregnancy. METHOD: Mothers of the Pacific Islands Families (PIF) Study cohort of Pacific infants born in Auckland, New Zealand during 2000 were interviewed when the children were 6 weeks old. A total of 1088 mothers cohabiting in married or de-facto partnerships were questioned about IPV and whether their pregnancy had been planned. RESULTS: Women identified as victims of physical violence were more likely to report an unplanned pregnancy than those who were not victims (68.7% vs 55.1%, odds ratio [OR] 1.78; 95% confidence interval [CI], 1.32-2.40). The adjusted odds remained statistically significant (OR 1.52; 95% CI, 1.01-2.26). CONCLUSION: The findings of this study suggest an association between IPV and unplanned pregnancy in the Pacific birth cohort.

Factors affecting uptake of cervical cancer screening among Chinese women in New Zealand.

OBJECTIVE: To examine the factors affecting uptake of cervical cancer screening among women born in China now living in Auckland, New Zealand. METHOD: A community-based pilot study of 260 women surveyed by questionnaire between November 2006 and February 2007 to ascertain the uptake of cervical screening. RESULTS: Of 234 returned questionnaires, 152 women (65%) reported being screened in New Zealand and 56% had been screened in the last 3 years. The 4 most important predictive factors affecting uptake were the women's belief that cervical smear tests are necessary for asymptomatic women, having a family doctor, having received gynecologic, obstetric, and family planning services in New Zealand, and having ever received a recommendation for a cervical smear test. CONCLUSION: The most important influential factors affecting uptake of cervical screening among Chinese women in New Zealand are women's belief in its value and their engagement in general and women's health services.

Postdischarge engagement decreased hospital readmissions in Medicaid populations.

OBJECTIVES: To investigate the effect of managed care organization (MCO)-implemented postdischarge engagement, supported by other broadly focused interventions, on 30-day hospital readmissions in 6 at-risk Medicaid populations. STUDY DESIGN: Prospective cohort study. METHODS: One-year follow-up analysis of member claims data was performed following an intervention period from January 1, 2014, to December 31, 2014. Postdischarge engagement, supported by additional MCO-initiated interventions, was implemented to reduce 30-day hospital readmissions in Medicaid members having 1 or more dominant chronic conditions. Hospital readmission rates were calculated at baseline and at 1 year post intervention. Bivariable and multivariable generalized estimating equation analysis was used to quantify the likelihood of hospital readmissions. RESULTS: Following implementation, postdischarge engagement rates increased significantly, whereas provider follow-up rates remained unchanged. Increased member engagement resulted in statistically significant reductions in weighted readmission rates enterprise-wide (-10.1%; P <.01) and in 3 of 6 MCOs (-3.9% to -15.8%; P ≤.05) in 2014. Compared with nonparticipants, members who were successfully reached for postdischarge engagement displayed a 33% decrease in 30-day readmissions enterprise-wide (adjusted odds ratio, 0.67; 95% CI, 0.62-0.73) and a comparable decrease (-23% to -39%) in 5 of the 6 MCOs. In this context, greater frequency of postdischarge engagement was associated with proportionally decreased likelihood of readmissions. CONCLUSIONS: Postdischarge engagement, against the backdrop of multifaceted MCO-implemented interventions, was associated with significantly reduced hospital readmissions in at-risk Medicaid subjects. Reduced likelihood of readmissions was observed at both the enterprise-wide and plan levels in a manner proportional to the frequency of engagement, a novel reported outcome for this population.

Risk stratification of patients with acute anterior myocardial infarction and right bundle-branch block: importance of QRS duration and early ST-segment resolution after fibrinolytic therapy.

BACKGROUND: Patients with an acute anterior ST-segment elevation myocardial infarction and right bundle-branch block (RBBB) have a high mortality risk, which may be stratified by early ECG changes. METHODS AND RESULTS: In the Hirulog Early Reperfusion Occlusion (HERO-2) trial, 17 073 patients with acute myocardial infarction (AMI) within 6 hours of symptom onset were treated with streptokinase and randomized to receive bivalirudin or heparin. There was no difference in the primary end point of 30-day mortality. ECGs were recorded at randomization and 60 minutes after fibrinolytic therapy was begun. The 30-day mortality rate was 31.6% in the 415 patients with RBBB and anterior AMI at randomization and 33% in the 100 patients who developed new RBBB at 60 minutes from normal baseline conduction accompanying an anterior AMI. An increase in QRS duration by 20-ms increments was associated with increasing 30-day mortality rate in both RBBB groups on multivariable analyses with covariates of age, Killip class, systolic blood pressure, pulse, and prior infarction. Patients with QRS duration > or = 160 ms had higher 30-day mortality rate than those with QRS duration < 160 ms (37.2% versus 27.2%, P = 0.03, and 46.2% versus 24.5%, P = 0.025, in the 2 groups, respectively). For the patients with RBBB and anterior MI at randomization, RBBB resolved at 60 minutes in 40 patients, but 30-day mortality rate was unchanged. For those with persisting RBBB at 60 minutes, 30-day mortality rate was lower if ST-segment elevation had resolved by > or = 50% (20.4% versus 35.3%, P = 0.006). CONCLUSIONS: In patients with anterior AMI and RBBB, increasing QRS duration is associated with increasing 30-day mortality. Early ST-segment resolution after fibrinolytic therapy despite persisting RBBB is associated with lower mortality rate.

Initial Q waves accompanying ST-segment elevation at presentation of acute myocardial infarction and 30-day mortality in patients given streptokinase therapy: an analysis from HERO-2.

BACKGROUND: The presence of pathological Q waves in the infarct leads on the surface electrocardiogram in an ST-elevation acute myocardial infarction indicates myocardial necrosis. Clinically it might be difficult to ascertain the onset of acute myocardial infarction. Our aim was to assess whether the presence or absence of Q waves at presentation could be used as an indicator of the duration of acute myocardial infarction and predict mortality. METHODS: 15,222 patients with ST-elevation acute myocardial infarction and normal intraventricular conduction were randomly assigned streptokinase and aspirin plus bivalirudin or unfractionated heparin in the HERO-2 trial; randomisation did not alter 30-day mortality. 10,244 patients (67%) had Q waves in the infarct territory at the time of randomisation, and 4978 (33%) did not. The primary endpoint was 30-day mortality. FINDINGS: There were more deaths at 30 days in patients with initial Q waves than in those without (1044 [10%] vs 344 [7%], p<0.0001). These findings were similar in patients with a first acute myocardial infarction and when stratified by time to randomisation (0-2, >2-4, >4 h) and by acute myocardial infarction location (anterior or inferior). Both the presence of initial Q waves and time to randomisation were positive univariate predictors, but only the presence of initial Q waves independently predicted 30-day mortality on multivariate analysis (adjusted OR 1.44, 95% CI 1.25-1.65 with clinical indices, and 1.31, 1.12-1.54 with clinical plus ST indices included as predictors). INTERPRETATION: The presence of Q waves in the infarct leads at presentation of ST-elevation acute myocardial infarction independently predicts higher 30-day mortality in patients treated with fibrinolytic therapy. Therefore, a more aggressive approach to reperfusion might be warranted in these patients.

Patients with prolonged ischemic chest pain and presumed-new left bundle branch block have heterogeneous outcomes depending on the presence of ST-segment changes.

OBJECTIVES: The purpose of this research was to examine the prognostic value of ST-segment changes (concordant ST-segment elevation and/or precordial V1 to V3 ST-segment depression) during presumed-new left bundle branch block (LBBB) in patients receiving fibrinolytic therapy. BACKGROUND: These patients are often considered high-risk, but their outcome is not well-defined. METHODS: The Hirulog and Early Reperfusion or Occlusion (HERO)-2 trial compared bivalirudin with heparin in patients receiving streptokinase for ST-segment elevation or presumed-new LBBB. Each patient with LBBB was matched with a control (with normal intraventricular conduction) for age, gender, pulse rate, systolic blood pressure, Killip class, and region. RESULTS: A total of 300 patients had LBBB (92 with and 208 without ST-segment changes) and 15,340 had normal conduction. Acute myocardial infarction (AMI) occurred in 80.7% of LBBB patients and 88.7% of controls (p = 0.006). ST-segment changes were specific (96.6%) but not sensitive (37.8%) for enzymatic diagnosis of AMI. Mortality at 30 days was similar in LBBB patients with ST-segment changes (21.7%) and controls (25.0%, p = 0.563), but lower in LBBB patients without ST-segment changes than in controls (13.5% vs. 21.6%, p = 0.022). In the whole HERO-2 cohort, the LBBB patients with ST-segment changes had higher mortality than patients with normal conduction (odds ratio [OR] 1.37, 95% confidence interval [CI] 0.78 to 2.42). The LBBB patients without ST-segment changes had lower mortality than patients with normal conduction (OR 0.52, 95% CI 0.33 to 0.80). CONCLUSIONS: ST-segment changes during LBBB are specific for the diagnosis of AMI and predict 30-day mortality; LBBB patients without ST-segment changes have lower adjusted 30-day mortality than those with normal conduction. Trials are required to determine the best treatment for high-risk and low-risk patients with LBBB.

Relationship between initial white blood cell counts, stage of acute myocardial infarction evolution at presentation, and incidence of Thrombolysis In Myocardial Infarction-3 flow after streptokinase.

BACKGROUND: The initial white cell counts in patients with acute myocardial infarction (AMI) may reflect the stage of AMI evolution, and may also be related to the efficacy of thrombolytic agents in recanalizing occluded epicardial arteries. METHODS: In 312 patients with a first AMI, we divided the initial white cell counts into quartiles and investigated their relationship with the time to treatment and the incidence of Thrombolysis In Myocardial Infarction (TIMI)-3 flow at 90 minutes after commencement of streptokinase. RESULTS: A longer time from symptom onset to treatment was independently associated with a higher neutrophil count and a lower non-neutrophil count. These times were 2.6, 2.9, and 3.8 hours, respectively, in the lowest, combined second and third (ie, middle), and highest neutrophil quartiles (P =.003), and 4.3, 3, and 1.9 hours, respectively, in the lowest, combined middle, and highest non-neutrophil quartiles (P <.0001). TIMI-3 flow was achieved in 44% of the lowest total white cell quartile, 41% of the combined middle quartile, and 60% of the highest quartile (P =.05). The corresponding figures were 47%, 49%, and 46% (P =.657) for the neutrophil quartiles, and 32%, 46%, and 68% for the non-neutrophil quartiles (P =.001). On multivariable analysis, the incidence of TIMI-3 flow was independently and positively associated with the initial non-neutrophil count. Patients with non-neutrophil counts in the highest quartile had a higher incidence of TIMI-3 flow than those in the lowest quartile (odds ratio 2.86, 95% CI 1.32-6.23, P =.008). CONCLUSIONS: A longer time from symptom onset to thrombolysis for AMI is associated with a higher neutrophil count and a lower non-neutrophil count at presentation. A higher neutrophil count is not associated with worse epicardial blood flow at 90 minutes after streptokinase, and a higher non-neutrophil count predicts a greater likelihood of achieving TIMI-3 flow.

A score predicts failure of reperfusion after fibrinolytic therapy for acute myocardial infarction.

BACKGROUND: A rapid, accurate, noninvasive means of predicting the likelihood of failure to achieve Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow within 90 minutes after the start of fibrinolysis with streptokinase could help to identify patients who might benefit from additional therapies that aim to preserve myocytes. METHODS: We measured ST recovery, which was assessed as the sum of ST deviation on a 12-lead electrocardiogram, and blood levels of the myocardial proteins, troponin T, creatine kinase myocardial band (CK-MB), and myoglobin before and 60 minutes after commencing streptokinase infused for 30 to 60 minutes in 107 patients, who presented within 12 hours of symptom onset and underwent angiography at 90 minutes. RESULTS: At 90 minutes, 56% of patients (95% CI 46-66) had TIMI-3 flow. The baseline levels of troponin T, CK-MB, and myoglobin were more commonly below the discrimination values in patients with TIMI-3 flow than in patients without TIMI-3 flow (all P <.005). On multivariate analysis, the factors associated with failure to achieve TIMI-3 flow were ST recovery of <70% (P =.009), a 60-minute/baseline troponin T ratio of < or =5 (P =.0004), a baseline CK-MB level of >4 microg/L (P =.039), or a baseline myoglobin level of >85 microg/L (P =.048). Age and a history of myocardial infarction were added into the multivariate model, and a risk score was developed to predict the likelihood of failure to achieve TIMI-3 flow. A score of < or =2 excluded failure to achieve TIMI-3 flow with 96% accuracy, and a score of > or =7 predicted failure to achieve TIMI-3 flow with 90% accuracy. CONCLUSION: Failure to achieve TIMI-3 flow in the infarct-related artery within 90 minutes after the start of fibrinolysis can be accurately predicted at approximately 60 minutes by a score incorporating clinical variables, ST recovery, and the 60-minute/baseline ratios of troponin T, CK-MB, and/or myoglobin levels. This score may facilitate triage of patients at 60 minutes after fibrinolysis to additional reperfusion therapies.

Potential thrombophilic mutations/polymorphisms in patients with no flow-limiting stenosis after myocardial infarction.

BACKGROUND: Although inherited thrombophilias are more common in patients with venous thromboembolism, their influence on the development of myocardial infarction (MI) requires clarification. METHODS AND RESULTS: To determine whether there are increased frequencies of mutations/polymorphisms in 14 genes potentially causing thrombophilia in patients with no flow-limiting stenoses after MI compared with patients with > or =1 flow-limiting stenosis of >50%, we studied 395 patients (60 with no flow-limiting stenosis) who underwent angiography at approximately 1 month. The mutations/polymorphisms studied included Factor V Leiden, prothrombin variant G20210A, beta-fibrinogen 448 (G/A), endothelial protein C receptor (23-base pair insertion), methyl tetrahydrofolate reductase 677 (C/T), platelet glycoprotein IIIa PlA1/A2, plasminogen activator inhibitor-1 4G/5G, angiotensin II type 1 receptor (A/C), hemochromatosis gene 282 (G/A), nitric oxide synthase (NOS) (3 forms: eNOS, eNOS3, eNOS4), p22 phox of NADPH oxidase C242T, and angiotensin-converting enzyme insertion/deletion polymorphism. The frequencies of Factor V Leiden and the beta-fibrinogen 448 A allele were higher in patients with no flow-limiting stenosis than in patients with > or =1 stenosis (11.7% vs 3.6%, odds ratio [OR] 3.6, 95% CI 1.3-9.4, P =.015; and 42% vs 27%, OR 2.0, 95% CI 1.1-3.5, P =.018, respectively), and there was a trend toward an increased frequency of prothrombin variant G20210A (6.7% vs 2.1%, OR 3.4, 95% CI 0.95-11.8, P =.069). However, in patients with no flow-limiting stenosis after MI the frequencies of the other gene mutations/polymorphisms were not increased. Also, there were no significant interactions between any of these 14 mutation/polymorphisms, major cardiovascular risk factors, and the absence of any flow-limiting stenosis, except for Factor V Leiden and hypertension (OR 6.34, 95% CI 2.67-100, P =.004). CONCLUSIONS: Patients with no flow-limiting stenosis after MI had increased frequencies of 2 inherited thrombophilias (Factor V Leiden and beta-fibrinogen 448 A allele), and there was a trend toward an increased frequency of prothrombin variant G20210A compared with patients with > or =1 stenosis. These data suggest that polymorphisms/mutations in some gene products influencing coagulation may influence the pathogenesis of MI.