Results of a Hospital-Based Palliative Care Intervention for Patients With an Acute Exacerbation of Chronic Heart Failure.

BACKGROUND: Palliative interventions are an important part of advanced heart failure (HF) care. However, these interventions are historically underutilized, particularly by African Americans. METHODS AND RESULTS: We performed a prospective randomized intervention trial in patients with advanced HF who were hospitalized for acute decompensation at 3 urban hospitals, comparing the effect of palliative care consultation (PCC) with that of usual care. The primary end point was the proportion choosing comfort-oriented care (hospice and/or "do not resuscitate" [DNR] order) 3-6 months after randomization. A total of 85 patients (mean age 68 years, 91.8% African American) were enrolled over a 2-year period. Four of the 43 patients (9.3%) randomized to the PCC group chose comfort-oriented care versus 0 of the 42 control group members (risk difference = 9.3%; 95% confidence interval = -11.8% to 30.0%). CONCLUSIONS: In this predominantly African-American cohort of hospitalized patients with advanced HF, PCC did not lead to a greater likelihood of comfort care election compared with usual care. More robust palliative interventions should be developed to meet the needs of diverse groups of patients with HF.

Study design for the Immediate Myocardial Metabolic Enhancement During Initial Assessment and Treatment in Emergency Care (IMMEDIATE) Trial: A double-blind randomized controlled trial of intravenous glucose, insulin, and potassium for acute coronary syndromes in emergency medical services.

BACKGROUND: Experimental studies suggest that metabolic myocardial support by intravenous (IV) glucose, insulin, and potassium (GIK) reduces ischemia-induced arrhythmias, cardiac arrest, mortality, progression from unstable angina pectoris to acute myocardial infarction (AMI), and myocardial infarction size. However, trials of hospital administration of IV GIK to patients with ST-elevation myocardial infarction (STEMI) have generally not shown favorable effects possibly because of the GIK intervention taking place many hours after ischemic symptom onset. A trial of GIK used in the very first hours of ischemia has been needed, consistent with the timing of benefit seen in experimental studies. OBJECTIVE: The IMMEDIATE Trial tested whether, if given very early, GIK could have the impact seen in experimental studies. Accordingly, distinct from prior trials, IMMEDIATE tested the impact of GIK (1) in patients with acute coronary syndromes (ACS), rather than only AMI or STEMI, and (2) administered in prehospital emergency medical service settings, rather than later, in hospitals, after emergency department evaluation. DESIGN: The IMMEDIATE Trial was an emergency medical service-based randomized placebo-controlled clinical effectiveness trial conducted in 13 cities across the United States that enrolled 911 participants. Eligible were patients 30 years or older for whom a paramedic performed a 12-lead electrocardiogram to evaluate chest pain or other symptoms suggestive of ACS for whom electrocardiograph-based acute cardiac ischemia time-insensitive predictive instrument indicated a ≥75% probability of ACS, and/or the thrombolytic predictive instrument indicated the presence of a STEMI, or if local criteria for STEMI notification of receiving hospitals were met. Prehospital IV GIK or placebo was started immediately. Prespecified were the primary end point of progression of ACS to infarction and, as major secondary end points, the composite of cardiac arrest or in-hospital mortality, 30-day mortality, and the composite of cardiac arrest, 30-day mortality, or hospitalization for heart failure. Analyses were planned on an intent-to-treat basis, on a modified intent-to-treat group who were confirmed in emergency departments to have ACS, and for participants presenting with STEMI. CONCLUSION: The IMMEDIATE Trial tested whether GIK, when administered as early as possible in the course of ACS by paramedics using acute cardiac ischemia time-insensitive predictive instrument and thrombolytic predictive instrument decision support, would reduce progression to AMI, mortality, cardiac arrest, and heart failure. It also tested whether it would provide clinical and pathophysiologic information on GIK's biological mechanisms.

Threading the Needle: When a Cranial Burr Hole Is Palliative Therapy.

Subdural hematoma (SDH) impacts up to 58.1 per 100,000 individuals aged ≥65 years. Some patients or proxies elect to focus exclusively on comfort care treatments, whereas others may consider surgical procedures such as a craniotomy or cranial trephination (burr hole) to relieve intracranial pressure. The central lesson of this case report is that the burr hole is a potential palliative care treatment in terms of experiences and outcomes, even among very old adults provided they have excellent baseline function. We present a case of a 95-year-old woman presenting to the emergency department with acute on chronic SDH and aphasia. Neurosurgical consultation and cranial trephination reversed her aphasia, and she continues to live independently with good function three years postsurgery. We discuss how the burr hole is consistent with a palliative care approach as well as the value of interdisciplinary discussions of minimally invasive neurosurgical interventions with potential for enhancing quality of life.

Number of coronary heart disease risk factors and mortality in patients with first myocardial infarction.

CONTEXT: Few studies have examined the association between the number of coronary heart disease risk factors and outcomes of acute myocardial infarction in community practice. OBJECTIVE: To determine the association between the number of coronary heart disease risk factors in patients with first myocardial infarction and hospital mortality. DESIGN: Observational study from the National Registry of Myocardial Infarction, 1994-2006. PATIENTS: We examined the presence and absence of 5 major traditional coronary heart disease risk factors (hypertension, smoking, dyslipidemia, diabetes, and family history of coronary heart disease) and hospital mortality among 542,008 patients with first myocardial infarction and without prior cardiovascular disease. MAIN OUTCOME MEASURE: All-cause in-hospital mortality. RESULTS: A majority (85.6%) of patients who presented with initial myocardial infarction had at least 1 of the 5 coronary heart disease risk factors, and 14.4% had none of the 5 risk factors. Age varied inversely with the number of coronary heart disease risk factors, from a mean age of 71.5 years with 0 risk factors to 56.7 years with 5 risk factors (P for trend < .001). The total number of in-hospital deaths for all causes was 50,788. Unadjusted in-hospital mortality rates were 14.9%, 10.9%, 7.9%, 5.3%, 4.2%, and 3.6% for patients with 0, 1, 2, 3, 4, and 5 risk factors, respectively. After adjusting for age and other clinical factors, there was an inverse association between the number of coronary heart disease risk factors and hospital mortality adjusted odds ratio (1.54; 95% CI, 1.23-1.94) among individuals with 0 vs 5 risk factors. This association was consistent among several age strata and important patient subgroups. CONCLUSION: Among patients with incident acute myocardial infarction without prior cardiovascular disease, in-hospital mortality was inversely related to the number of coronary heart disease risk factors.

A percutaneous coronary intervention-thrombolytic predictive instrument to assist choosing between immediate thrombolytic therapy versus delayed primary percutaneous coronary intervention for acute myocardial infarction.

Based on the thrombolytic predictive instrument (TPI), we sought to create electrocardiographically based, real-time decision support to immediate identification of patients with ST-segment elevation myocardial infarction (STEMI) likely to benefit from primary percutaneous coronary intervention (PCI) compared with thrombolysis. Using data from the Atlantic Cardiovascular Patient Outcomes Research Team (C-PORT) Trial, we tested a mathematical model predicting mortality in patients with STEMI if treated with PCI and if treated with thrombolytic therapy. We adapted the model for incorporation into computerized electrocardiograms as a PCI-TPI. For patients with STEMI in the C-PORT Trial, the model yielded unbiased mortality predictions: for those receiving thrombolysis, it predicted 6.3% mortality and actual mortality was 6.0% (95% confidence interval 3.0 to 10.6); for those receiving PCI, it predicted 4.5% mortality and actual mortality was 3.9% (95% confidence interval 1.4 to 8.2). Excellent discrimination was reflected by its receiver operating characteristic curve area of 0.86. According to the model, and validated by actual trial outcomes, 1/3 of subjects accounted for all the mortality benefit from PCI. In conclusion, for STEMI, the PCI-TPI accurately predicts mortality for treatment with PCI and with thrombolytic therapy. Incorporated into electrocardiogram, it may assist targeting PCI to those who benefit most and identifying patients before hospitalization for whom a receiving hospital should prepare for PCI.

Comparison of mortality benefit of immediate thrombolytic therapy versus delayed primary angioplasty for acute myocardial infarction.

Primary percutaneous coronary intervention (PPCI) yields superior mortality outcomes compared with thrombolysis in ST-elevation acute myocardial infarction (STEMI) but takes longer to administer. Previous meta-regressions have estimated that a procedure-related delay of 60 minutes would nullify the benefits of PPCI on mortality. Using a combined database from randomized clinical trials and registries (n = 2,781) and an independently developed model of mortality risk in STEMI, we developed logistic regression models predicting 30-day mortality for PPCI and thrombolysis by examining the influence of baseline risk on the treatment effect of PPCI and on the hazard of treatment delay. We used these models to solve mathematically for "time interval to mortality equivalence," defined as the PPCI-related delay that would nullify its expected mortality benefit over thrombolysis, and to explore the influence of baseline risk on this value. As baseline risk increases, the relative benefit of PPCI compared with thrombolytic therapy significantly increases (p = 0.002); patients with STEMI at relatively low risk of mortality accrue little or no incremental mortality benefit from PPCI, but high-risk patients benefit greatly. However, as baseline risk increases, the hazard associated with longer treatment-related delay also increases (p = 0.007). These 2 effects are compensatory and yield a roughly uniform time interval to mortality equivalence of approximately 100 minutes in patients who have at least a moderate degree of mortality risk (> approximately 4%). In conclusion, the mortality benefits of PPCI and the hazard of PPCI-related delay depend on baseline risk. Previous meta-regressions appear to have underestimated the PPCI-related delay that would nullify the incremental benefits of PPCI.

Diagnostic classifications and resource utilization of decedents served by the Department of Veterans Affairs.

BACKGROUND: Given the volume and cost of inpatient care during the last year of life, there is a critical need to identify patterns of dying as a means of planning end-of-life care services, especially for the growing number of older persons who receive services from the Veterans Health Administration (VHA). METHODS: A retrospective computerized record review was conducted of 20,933 VHA patients who died as inpatients between October 1, 2001 and September 30, 2002. Diagnoses were aggregated into one of five classification patterns of death and analyzed in terms of health care resource utilization (mean number of inpatient days and cumulative outpatient visits in the year preceding the patient's death). RESULTS: Cancer deaths were the most common (30.4%) followed by end-stage renal disease (ESRD) (23.2%), cardiopulmonary failure (21.4%), frailty (11.6%), "other" diagnoses (7.3%), and sudden deaths (6.1%). Those with ESRD were more likely to be male and nonwhite (p < 0.05) and those with frailty were more likely to be older and married (p < 0.05). Controlling for demographic variables, those with frailty had the highest number of inpatient days while those with ESRD had the highest number of outpatient visits. Non-married status was associated with more inpatient days, especially among younger decedents. CONCLUSION: As a recognized leader in end-of-life care, the VHA can play a unique role in the development of specific interventions that address the diverse needs of persons with different dying trajectories identified through this research.

Impact of Palliative Care Screening and Consultation in the ICU: A Multihospital Quality Improvement Project.

CONTEXT: There are few multicenter studies that examine the impact of systematic screening for palliative care and specialty consultation in the intensive care unit (ICU). OBJECTIVE: To determine the outcomes of receiving palliative care consultation (PCC) for patients who screened positive on palliative care referral criteria. METHODS: In a prospective quality assurance intervention with a retrospective analysis, the covariate balancing propensity score method was used to estimate the conditional probability of receiving a PCC and to balance important covariates. For patients with and without PCCs, outcomes studied were as follows: 1) change to "do not resuscitate" (DNR), 2) discharge to hospice, 3) 30-day readmission, 4) hospital length of stay (LOS), 5) total direct hospital costs. RESULTS: In 405 patients with positive screens, 161 (40%) who received a PCC were compared to 244 who did not. Patients receiving PCCs had higher rates of DNR-adjusted odds ratio (AOR) = 7.5; 95% CI 5.6-9.9) and hospice referrals-(AOR = 7.6; 95% CI 5.0-11.7). They had slightly lower 30-day readmissions-(AOR = 0.7; 95% CI 0.5-1.0); no overall difference in direct costs or LOS was found between the two groups. When patients receiving PCCs were stratified by time to PCC initiation, early consultation-by Day 4 of admission-was associated with reductions in LOS (1.7 days [95% CI -3.1, -1.2]) and average direct variable costs (-$1815 [95% CI -$3322, -$803]) compared to those who received no PCC. CONCLUSION: Receiving a PCC in the ICUs was significantly associated with more frequent DNR code status and hospice referrals, but not 30-day readmissions or hospital utilization. Early PCC was associated with significant LOS and direct cost reductions. Providing PCC early in the ICU should be considered.

Challenges in predicting the need for coronary artery bypass grafting at presentation in patients with non-ST-segment elevation acute coronary syndromes.

In the case of non-ST-segment elevation acute coronary syndromes (NSTE-ACSs), the acute use of certain antiplatelet agents is complicated by concerns about perioperative bleeding risks in patients requiring coronary artery bypass grafting (CABG) during the index hospitalization. As a result, clinicians often withhold potentially useful agents, such as clopidogrel, before determining patients' coronary anatomy. An accurate predictive model could allow for a better balance of this safety concern with the demonstrated benefits of agents such as clopidogrel. To create an accurate decision-making tool that would assess, at hospital presentation, the need for CABG in patients with NSTE-ACSs, we studied 61,974 high-risk patients with NSTE-ACS admitted to 311 CABG-capable hospitals participating in Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) from 2001 to 2003. A total of 8,395 patients (14%) underwent CABG during their initial hospital stay. A multivariate model was developed and identified 13 presenting clinical characteristics significantly associated with the likelihood of CABG (previous CABG, male gender, previous heart failure, diabetes, hyperlipidemia, renal insufficiency, ST depression and transient ST elevation, age > or = 75 years, previous percutaneous coronary intervention, family history of coronary artery disease, hypertension, trends in CABG rates, and previous stroke). This model had only modest predictive accuracy and calibration (c-index = 0.67). In conclusion, although certain presenting clinical features are associated with an increased likelihood of CABG in patients with NSTE-ACSs during the index hospitalization, it remains difficult to reliably identify, before diagnostic angiography, those who will subsequently undergo surgical revascularization.

Maslow's hierarchy of needs: a framework for achieving human potential in hospice.

Although the widespread implementation of hospice in the United States has led to tremendous advances in the care of the dying, there has been no widely accepted psychological theory to drive needs assessment and intervention design for the patient and family. The humanistic psychology of Abraham Maslow, especially his theory of motivation and the hierarchy of needs, has been widely applied in business and social science, but only sparsely discussed in the palliative care literature. In this article we review Maslow's original hierarchy, adapt it to hospice and palliative care, apply the adaptation to a case example, and then discuss its implications for patient care, education, and research. The five levels of the hierarchy of needs as adapted to palliative care are: (1) distressing symptoms, such as pain or dyspnea; (2) fears for physical safety, of dying or abandonment; (3) affection, love and acceptance in the face of devastating illness; (4) esteem, respect, and appreciation for the person; (5) selfactualization and transcendence. Maslow's modified hierarchy of palliative care needs could be utilized to provide a comprehensive approach for the assessment of patients' needs and the design of interventions to achieve goals that start with comfort and potentially extend to the experience of transcendence.

Use of emergency medical services in acute myocardial infarction and subsequent quality of care: observations from the National Registry of Myocardial Infarction 2.

BACKGROUND: National practice guidelines strongly recommend activation of the 9-1-1 Emergency Medical Systems (EMS) by patients with symptoms consistent with an acute myocardial infarction (MI). We examined use of the EMS in the United States and ascertained the factors that may influence its use by patients with acute MI. METHODS AND RESULTS: From June 1994 to March 1998, the National Registry of Myocardial Infarction 2 enrolled 772 586 patients hospitalized with MI. We excluded those who transferred in, arrived at the hospital >6 hours from symptom onset, or who were in cardiogenic shock. We compared baseline characteristics and initial management for patients who arrived by ambulance versus self-transport. EMS was used in 53.4% of patients with MI, a proportion that did not vary significantly over the 4-year study period. Nonusers of the EMS were on average younger, male, and at relatively lower risk on presentation. In addition, payer status was significantly associated with EMS use. Use of EMS was independently associated with slightly wider use of acute reperfusion therapies and faster time intervals from door to fibrinolytic therapy (12.1 minutes faster, P<0.001) or to urgent PTCA (31.2 minutes faster, P<0.001). CONCLUSIONS: Only half of patients with MI were transported to the hospital by ambulance, and these patients had greater and significantly faster receipt of initial reperfusion therapies. Wider use of EMS by patients with suspected MI may offer considerable opportunity for improvement in public health.

ST-segment depression on the initial electrocardiogram in acute myocardial infarction-prognostic significance and its effect on short-term mortality: A report from the National Registry of Myocardial Infarction (NRMI-2, 3, 4).

This study analyzed 255,256 patients who had acute myocardial infarction and were enrolled in the National Registry of Myocardial Infarction 2, 3, and 4 (1994 to 2002). The objective was to determine in-hospital mortality rate among patients who had ST-segment depression on the initial electrocardiogram. Patients who had ST-segment depression had an in-hospital mortality rate (15.8%) similar to that of patients who had ST-segment elevation or left bundle branch block (15.5%). After adjusting for observed differences, ST-segment depression was associated with only a slightly lower odds ratio (0.91) of mortality compared with ST-segment elevation or left bundle branch block.

Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program.

BACKGROUND: The use of critical pathways for a variety of clinical conditions has grown rapidly in recent years, particularly pathways for patients with acute coronary syndromes (ACS). However, no systematic review exists regarding the value of critical pathways in this setting. METHODS: The National Heart Attack Alert Program established a Working Group to review the utility of critical pathways on quality of care and outcomes for patients with ACS. A literature search of MEDLINE, cardiology textbooks, and cited references in any article identified was conducted regarding the use of critical pathways for patients with ACS. RESULTS: Several areas for improving the care of patients with ACS through the application of critical pathways were identified: increasing the use of guideline-recommended medications, targeting use of cardiac procedures and other cardiac testing, and reducing the length of stay in hospitals and intensive care units. Initial studies have shown promising results in improving quality of care and reducing costs. No large studies designed to demonstrate an improvement in mortality or morbidity were identified in this literature review. CONCLUSIONS: Critical pathways offer the potential to improve the care of patients with ACS while reducing the cost of care. Their use should improve the process and cost-effectiveness of care, but further research in this field is needed to determine whether these changes in the process of care will translate into improved clinical outcomes.

Untreated hypercholesterolemia in an emergency department chest pain observation unit population.

OBJECTIVES: To describe the prevalence of hypercholesterolemia in a predominantly African American, innercity chest pain observation unit (CPOU) patient population, and to estimate the percentage of patients eligible for cholesterol-lowering therapy as indicated by the 2001 National Cholesterol Education Program guidelines. METHODS: A cross-sectional study design utilizing a convenience sample of patients from a high-volume urban hospital CPOU. Patients with chest pain suspicious of cardiac etiology who had negative initial electrocardiograms and cardiac markers were assigned to the chest pain protocol. Consenting subjects were screened for hypercholesterolemia through capillary blood point-of-care testing with a cutoff of 190 mg/dL. Those who tested positive had four-hour fasting complete lipid profiles performed by the central laboratory. RESULTS: There were 112 patients enrolled in this study (mean age = 51 years; 57% male; and 83% African American). Elevated values on the screening test were obtained on 28 [25%; 95% confidence interval (95% CI) = 16.9 to 33.0] of these patients. These patients were found to have a mean four-hour fasting total cholesterol level of 224 mg/dL, a low-density lipoprotein (LDL) level of 138 mg/dL, a high-density lipoprotein (HDL) level of 52 mg/dL, and a triglyceride level of 168 mg/dL. Of the patients identified through the screening test, 54% proved eligible for cholesterol-lowering medications and 91.7% of these patients reported an interest in initiating therapy. CONCLUSIONS: In this study, approximately 25% of inner-city CPOU patients are possible candidates for cholesterol-lowering interventions. Benefits of initiating therapy during this potential "teachable moment" in a CPOU should be investigated in a subsequent multicenter randomized trial.

Mortality benefit of immediate revascularization of acute ST-segment elevation myocardial infarction in patients with contraindications to thrombolytic therapy: a propensity analysis.

CONTEXT: There are no definitive recommendations for the management of acute myocardial infarction (AMI) in patients with ST-segment elevation who have contraindications to thrombolytic therapy. It is not clear whether, and the extent to which, immediate mechanical reperfusion (IMR) reduces in-hospital mortality in this population. OBJECTIVE: To determine whether IMR (defined as percutaneous coronary intervention or coronary artery bypass graft surgery) is associated with a mortality benefit in patients with acute ST-segment elevation AMI who are eligible for IMR but have contraindications to thrombolytic therapy. DESIGN, SETTING, AND PATIENTS: From June 1994 to January 2003, the National Registry of Myocardial Infarction 2, 3, and 4 enrolled 1 799 704 patients with AMI. A total of 19 917 patients with acute ST-segment elevation were eligible for IMR but had thrombolytic contraindications after excluding patients who were transferred in from or out to other facilities, patients who received intracoronary thrombolytics, and those who received no medications within 24 hours of arrival. MAIN OUTCOME MEASURE: In-hospital mortality. RESULTS: Of the 19 917 patients, 4705 patients (23.6%) received IMR and 5173 patients (25.9%) died. In-hospital mortality rates in the IMR and non-IMR treated groups in the unadjusted analysis were 11.1%, representing 521 of 4705 patients, and 30.6%, representing 4652 of 15 212 patients, respectively, for a risk reduction of 63.7% (odds ratio [OR], 0.28; 95% confidence interval [CI], 0.26-0.31). In a further analysis using a propensity matching score to reduce the effects of bias, 3905 patients who received IMR remained at lower risk for in-hospital mortality than 3905 matched patients (10.9% vs 20.1%, respectively, for a risk reduction of 45.8%; OR, 0.48; 95% CI, 0.43-0.55). Following a second logistic model applied to the matched groups to adjust for residual differences, a significant treatment effect persisted (OR, 0.64; 95% CI, 0.56-0.75). CONCLUSIONS: In this population, IMR was associated with a reduced risk of in-hospital mortality after appropriate adjustments. Of those we studied who were eligible for IMR, 15 212 patients (76.4%) did not receive it. These results suggest that using IMR in patients with acute ST-segment elevation AMI and contraindications to thrombolytics should be strongly considered.

When a patient declines curative care: management of a ruptured aortic aneurysm.

The management of major vascular emergencies in the emergency department (ED) involves rapid, aggressive resuscitation followed by emergent definitive surgery. However, for some patients this traditional approach may not be consistent with their goals and values. We explore the appropriate way to determine best treatment practices when patients elect to forego curative care in the ED, while reviewing such a case. We present the case of a 72-year-old patient who presented to the ED with a ruptured abdominal aortic aneurysm, but refused surgery. We discuss the transition of the patient from a curative to a comfort care approach with appropriate direct referral to hospice from the ED. Using principles of autonomy, decision-making capacity, informed consent, prognostication, and goals-of-care, ED clinicians are best able to align their approach with patients' goals and values.

Atherosclerotic risk factors and their association with hospital mortality among patients with first myocardial infarction (from the National Registry of Myocardial Infarction).

Few studies have examined associations between atherosclerotic risk factors and short-term mortality after first myocardial infarction (MI). Histories of 5 traditional atherosclerotic risk factors at presentation (diabetes, hypertension, smoking, dyslipidemia, and family history of premature heart disease) and hospital mortality were examined among 542,008 patients with first MIs in the National Registry of Myocardial Infarction (1994 to 2006). On initial MI presentation, history of hypertension (52.3%) was most common, followed by smoking (31.3%). The least common risk factor was diabetes (22.4%). Crude mortality was highest in patients with MI with diabetes (11.9%) and hypertension (9.8%) and lowest in those with smoking histories (5.4%) and dyslipidemia (4.6%). The inclusion of 5 atherosclerotic risk factors in a stepwise multivariate model contributed little toward predicting hospital mortality over age alone (C-statistic = 0.73 and 0.71, respectively). After extensive multivariate adjustments for clinical and sociodemographic factors, patients with MI with diabetes had higher odds of dying (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.20 to 1.26) than those without diabetes and similarly for hypertension (OR 1.08, 95% CI 1.06 to 1.11). Conversely, family history (OR 0.71, 95% CI 0.69 to 0.73), dyslipidemia (OR 0.62, 95% CI 0.60 to 0.64), and smoking (OR 0.85, 95% CI 0.83 to 0.88) were associated with decreased mortality (C-statistic = 0.82 for the full model). In conclusion, in the setting of acute MI, histories of diabetes and hypertension are associated with higher hospital mortality, but the inclusion of atherosclerotic risk factors in models of hospital mortality does not improve predictive ability beyond other major clinical and sociodemographic characteristics.