The assessment of vascular risk in men with erectile dysfunction: the role of the cardiologist and general physician.

Erectile dysfunction (ED) and cardiovascular disease (CVD) share risk factors and frequently coexist, with endothelial dysfunction believed to be the pathophysiologic link. ED is common, affecting more than 70% of men with known CVD. In addition, clinical studies have demonstrated that ED in men with no known CVD often precedes a CVD event by 2-5 years. ED severity has been correlated with increasing plaque burden in patients with coronary artery disease. ED is an independent marker of increased CVD risk including all-cause and especially CVD mortality, particularly in men aged 30-60 years. Thus, ED identifies a window of opportunity for CVD risk mitigation. We recommend that a thorough history, physical exam (including visceral adiposity), assessment of ED severity and duration and evaluation including fasting plasma glucose, lipids, resting electrocardiogram, family history, lifestyle factors, serum creatinine (estimated glomerular filtration rate) and albumin:creatinine ratio, and determination of the presence or absence of the metabolic syndrome be performed to characterise cardiovascular risk in all men with ED. Assessment of testosterone levels should also be considered and biomarkers may help to further quantify risk, even though their roles in development of CVD have not been firmly established. Finally, we recommend that a question about ED be included in assessment of CVD risk in all men and be added to CVD risk assessment guidelines.

Temporal trends in incidence and long-term case fatality of stroke among children from 1994 to 2007.

OBJECTIVE: To examine the trends in incidence and long-term case fatality of childhood stroke in New Jersey using a statewide administrative database for the years 1994-2007. METHODS: We assessed demographic and clinical information for children with stroke using the Myocardial Infarction Data Acquisition System (MIDAS) database. We ascertained deaths by matching MIDAS records to New Jersey Death Registration Files at 30 days, 1 year, and 5 years from the index stroke. RESULTS: During the 14-year study period, 715 children were hospitalized for a first time with stroke. Age-adjusted incidence of stroke demonstrated a significant quadratic trend in which the rates decreased from 1994 to a nadir at 1999-2001 and increased thereafter (overall p for trend = 0.06 with quadratic term p = 0.02). Better treatment of sickle cell disease with transfusion therapy after year 1998 (p = 0.007) and improved diagnostic accuracy of MRI (p = 0.009) may partially explain these trends. Thirty-day, 1-year, and 5-year case fatality rates were 12.3%, 15.7%, and 17.5%, respectively. At all time periods, adjusted survival from hemorrhagic stroke was significantly lower than that from ischemic stroke (p = 0.0005). CONCLUSIONS: After an initial decrease, the incidence of pediatric stroke is rising. Children with hemorrhagic stroke had a 2 times higher risk of death than those with ischemic stroke. Whereas approximately 70% of all deaths occurred within the first month of hospitalization, an additional 5.2% of the initial study cohort died over the next 5 years.

Systematically missing confounders in individual participant data meta-analysis of observational cohort studies.

One difficulty in performing meta-analyses of observational cohort studies is that the availability of confounders may vary between cohorts, so that some cohorts provide fully adjusted analyses while others only provide partially adjusted analyses. Commonly, analyses of the association between an exposure and disease either are restricted to cohorts with full confounder information, or use all cohorts but do not fully adjust for confounding. We propose using a bivariate random-effects meta-analysis model to use information from all available cohorts while still adjusting for all the potential confounders. Our method uses both the fully adjusted and the partially adjusted estimated effects in the cohorts with full confounder information, together with an estimate of their within-cohort correlation. The method is applied to estimate the association between fibrinogen level and coronary heart disease incidence using data from 154,012 participants in 31 cohorts

Plasma fibrinogen level and the risk of major cardiovascular diseases and nonvascular mortality: an individual participant meta-analysis.

CONTEXT: Plasma fibrinogen levels may be associated with the risk of coronary heart disease (CHD) and stroke. OBJECTIVE: To assess the relationships of fibrinogen levels with risk of major vascular and with risk of nonvascular outcomes based on individual participant data. DATA SOURCES: Relevant studies were identified by computer-assisted searches, hand searches of reference lists, and personal communication with relevant investigators. STUDY SELECTION: All identified prospective studies were included with information available on baseline fibrinogen levels and details of subsequent major vascular morbidity and/or cause-specific mortality during at least 1 year of follow-up. Studies were excluded if they recruited participants on the basis of having had a previous history of cardiovascular disease; participants with known preexisting CHD or stroke were excluded. DATA EXTRACTION: Individual records were provided on each of 154,211 participants in 31 prospective studies. During 1.38 million person-years of follow-up, there were 6944 first nonfatal myocardial infarctions or stroke events and 13,210 deaths. Cause-specific mortality was generally available. Analyses involved proportional hazards modeling with adjustment for confounding by known cardiovascular risk factors and for regression dilution bias. DATA SYNTHESIS: Within each age group considered (40-59, 60-69, and > or =70 years), there was an approximately log-linear association with usual fibrinogen level for the risk of any CHD, any stroke, other vascular (eg, non-CHD, nonstroke) mortality, and nonvascular mortality. There was no evidence of a threshold within the range of usual fibrinogen level studied at any age. The age- and sex- adjusted hazard ratio per 1-g/L increase in usual fibrinogen level for CHD was 2.42 (95% confidence interval [CI], 2.24-2.60); stroke, 2.06 (95% CI, 1.83-2.33); other vascular mortality, 2.76 (95% CI, 2.28-3.35); and nonvascular mortality, 2.03 (95% CI, 1.90-2.18). The hazard ratios for CHD and stroke were reduced to about 1.8 after further adjustment for measured values of several established vascular risk factors. In a subset of 7011 participants with available C-reactive protein values, the findings for CHD were essentially unchanged following additional adjustment for C-reactive protein. The associations of fibrinogen level with CHD or stroke did not differ substantially according to sex, smoking, blood pressure, blood lipid levels, or several features of study design. CONCLUSIONS: In this large individual participant meta-analysis, moderately strong associations were found between usual plasma fibrinogen level and the risks of CHD, stroke, other vascular mortality, and nonvascular mortality in a wide range of circumstances in healthy middle-aged adults. Assessment of any causal relevance of elevated fibrinogen levels to disease requires additional research.

Time trends in the occurrence and outcome of acute myocardial infarction and coronary heart disease death between 1986 and 1996 (a New Jersey statewide study).

Most reports of the decrease in age-adjusted coronary heart disease (CHD) are based on databases with upper age cut-offs that exclude approximately half of the events. We report changes in rates of acute myocardial infarction (AMI) and of out-of-hospital coronary death between 1986 and 1996 among New Jersey residents > or =15 years old. Data on patients discharged with the diagnosis of AMI from nonfederal acute care hospitals in the state (n = 270,091) and all records in the New Jersey death registration files with CHD (n = 172,175) listed as the cause of death from 1986 to 1996 (total study n = 442,266) were analyzed. The rate of hospitalized AMI cases in the state remained essentially unchanged during these 11 years, whereas in-hospital and 30-day case fatality among all age groups and both sexes declined. Age-adjusted CHD rates showed a decrease in fatal events, a smaller decrease in total events, and a slight increase in nonfatal events. The proportion of fatal CHD events occurring out-of-hospital decreased especially among men. The median age at occurrence of events increased by 1 year. Despite a decrease in CHD mortality, the rate of nonfatal events increased, especially among persons > or =75 years old. Thus, the decrease in age-adjusted CHD mortality is not all due to treatment and true prevention of CHD, but the disease simply occurs at an older age.

The pharmacokinetics and pharmacodynamics of irbesartan in heart failure.

Alterations in the pharmacokinetic parameters of a number of medications have been observed in patients with heart failure. Because the angiotensin II receptor antagonist irbesartan has beneficial effects in patients with heart failure, the pharmacokinetics and pharmacodynamics of irbesartan in 10 patients with New York Heart Association (NYHA) class II or III heart failure compared with 10 control subjects matched with respect to race, age, weight, and sex were studied. In a crossover study, participants were randomized to receive open-label irbesartan 75 mg as either an oral capsule or an intravenous (i.v.) infusion in the first treatment period. After a 7- to 10-day washout period, participants were crossed over to the other treatment arm. Single-dose noncompartmental pharmacokinetic parameters, angiotensin II levels, and plasma renin activity (PRA) of irbesartan were determined for each participant. Following oral and i.v. administration, the pharmacokinetics of irbesartan in patients with heart failure was not significantly different from those of matched controls, indicating that there is little influence of potential changes in organ/tissue perfusion and gut edema on the absorption, distribution, and elimination of irbesartan. After dosing with irbesartan, mean increases in angiotensin II and PRA concentrations were higher in patients with heart failure than in the matched controls, but there was more interpatient variability in the patients with heart failure. Given the variability of the data, no definitive conclusions can be made with regard to these pharmacodynamic parameters. The results of this study indicate that the pharmacokinetics of irbesartan following oral and i.v. administration is not altered in patients with heart failure. Therefore, this indicates that no dosage adjustment is needed when prescribing irbesartan in heart failure patients.

Association of increased pulse pressure with the development of heart failure in SHEP. Systolic Hypertension in the Elderly (SHEP) Cooperative Research Group.

The aim of this study was to assess the relationship between pulse pressure (PP) and the occurrence of heart failure (HF) in older persons with isolated systolic hypertension. Data from a prospective, multicenter, randomized, double-blind, placebo-controlled clinical trial were analyzed. A total of 4736 persons aged > or = 60 years with systolic blood pressure (SBP) between 160 and 219 mm Hg and diastolic blood pressure (DBP) < 90 mm Hg who participated in the Systolic Hypertension in the Elderly Program (SHEP) were studied. The main outcome measures were fatal and nonfatal HF. During 4.5 years average follow-up, fatal or nonfatal HF occurred in 160 of 4736 patients. The SBP, PP, and mean arterial pressure (MAP) were strong predictors of the development of HF (P < .0002). Cox proportional hazards regression using time-dependent covariates and controlling for MAP indicated that HF was inversely related to DBP (P = 0.002) and was directly related to pulse pressure (P = 0.002). Data were similar when patients who developed myocardial infarction during follow up were excluded. These data indicate that, in older persons with isolated systolic hypertension, high pulse pressure is associated with increased risk of heart failure independently of MAP and of the occurrence of acute myocardial infarction during follow-up.

Impact of presentation of research results on likelihood of prescribing medications to patients with left ventricular dysfunction.

This study was conducted to evaluate willingness to prescribe medication based on identical data presented in different outcome terms to health professionals of varied discipline, geographic location, and level of training. Cross-sectional survey using a self-administered questionnaire was performed in 400 health professionals (physicians, pharmacists, physicians-in-training, and pharmacy students) in the United States and Europe. Data reflecting a clinical trial were presented in 6 outcome terms: 3 terms describing identical mortality (relative risk reduction, absolute risk reduction, and number of patients needed to be treated to prevent 1 death); and 3 distractors (increased life expectancy, decreased hospitalization rate, and decreased cost). Willingness to prescribe and rank order of medication preference assuming willingness to prescribe were measured. The results of the study showed that willingness to prescribe and first choice preference were significantly greater when study results were presented as relative risk reduction than when identical mortality data were presented as absolute risk reduction or number of patients needed to be treated to avoid 1 death (p <0.001). Increase in life expectancy was the most influential distractor. In conclusion, this study, performed in the era of "evidence-based medicine," demonstrates that the method of reporting research trial results has significant influence on health professionals' willingness to prescribe. The high numerical value of relative risk reduction and the concrete and tangible quality of increased life expectancy exert greater influence on health professionals than other standard outcome terms.

Delay in presentation and evaluation for acute stroke: Stroke Time Registry for Outcomes Knowledge and Epidemiology (S.T.R.O.K.E.).

BACKGROUND AND PURPOSE: Early treatment is a critical determinant of successful intervention in acute stroke. The study was designed to find current patterns of stroke care by determining delays in time from onset of signs or symptoms to arrival at the emergency department and to initial evaluation by physicians and by identifying factors associated with these delays. METHODS: Data were prospectively collected by nurses and physicians from patients, patients' family members, and medical records from 10 hospitals of the Robert Wood Johnson Health System in New Jersey. RESULTS: A total of 553 patients who presented with signs or symptoms of acute stroke were studied. Thirty-two percent of patients arrived at the emergency department within 1.5 hours of stroke onset. Forty-six percent of patients arrived within 3 hours and 61% within 6 hours. Delays in arrival time were significantly associated with sex, race, transportation mode, and history of cardiovascular disease. Patients arriving by ambulance were more likely to present earlier (odds ratio [OR] 3.7 for arrival within 3 hours; OR 4.5 for arrival within 6 hours). Patients arriving by ambulance (OR 2.3 within 15 minutes; OR 1.7 within 30 minutes) and those requiring admission to intensive care units (OR 4.5 within 15 minutes and OR 5.2 within 30 minutes) were examined sooner by physicians. CONCLUSIONS: Despite national efforts to promote prompt stroke evaluation and treatment, significant delays still exist. The lack of improvement throughout the past decade underscores the need for implementation of effective public health programs designed to minimize the time to evaluation and treatment of stroke.

Pharmacodynamics and pharmacokinetics of omapatrilat in heart failure.

The purpose of this study was to determine the pharmacodynamics and pharmacokinetics of omapatrilat, administered orally (25 mg) or intravenously (10 mg) in 19 New York Heart Association class II and class III congestive heart failure (CHF) patients versus 17 healthy controls matched for age, race, gender, and weight. The plasma concentrations of atrial natriuretic peptide (ANP) increased by approximately 20% and 30% in CHF and control subjects, respectively, at 4 hours after intravenous or oral omapatrilat administration. Similar elevation in the cyclic guanosine monophosphate concentration (25% to 35%) and ANP urinary excretion (21 ng/24 h to 22 ng/24 h) was seen in all treatment groups after omapatrilat administration. Angiotensin-converting enzyme activity was > 90% inhibited at 4 hours after dosing and remained approximately 60% to 70% inhibited at 24 hours after dosing. The levels of endothelin-1 and endothelin-2 remained unchanged after oral or intravenous administration of omapatrilat. The maximal reduction in seated blood pressure compared with baseline was similarfor CHF and control subjects. Clinical pharmacokinetic parameters were similar in both groups after intravenous dosing, but maximum concentration and area under the concentration-time curve were elevated in CHF patients compared with controls after oral dosing. Omapatrilat was well tolerated; differences in systemic exposure and metabolism between CHF patients and controls did not appear to be clinically significant.

Effective and safe modification of multiple atherosclerotic risk factors in patients with peripheral arterial disease.

BACKGROUND: Patients with peripheral arterial disease (PAD) are at an increased risk of cardiovascular mortality and morbidity and thus are an excellent group in whom to evaluate the feasibility and the effect of an aggressive multifactorial intervention on atherosclerotic vascular disease risk factors. The Arterial Disease Multiple Intervention Trial (ADMIT) was designed to determine the efficacy, safety, and compliance of an multifactorial therapy on selected atherosclerotic disease risk factors in patients with PAD. METHODS: By a 2 x 2 x 2 factorial design, eligible participants (N = 468) were randomly assigned to low-dose warfarin, antioxidant vitamins, and niacin or its corresponding placebo, and followed up for 1 year. All participants were encouraged to use aspirin. Pravastatin was added to the drug regimen for those who needed to reduce LDL cholesterol to recommended levels. RESULTS: Niacin increased HDL cholesterol levels by 30%, with the majority of effect achieved at a dosage of 500 mg twice daily. Warfarin had an anticoagulant effect. The antioxidant vitamins resulted in a significant increase in vitamin E, C, and beta-carotene plasma levels. Overall, compliance was high and few adverse effects were reported. CONCLUSIONS: ADMIT demonstrates that it is both feasible and safe to modify multiple atherosclerotic disease risk factors effectively with intensive combination therapy in patients with PAD.

Effect of niacin on lipid and lipoprotein levels and glycemic control in patients with diabetes and peripheral arterial disease: the ADMIT study: A randomized trial. Arterial Disease Multiple Intervention Trial.

CONTEXT: Although niacin increases low levels of high-density lipoprotein cholesterol (HDL-C), which frequently accompany diabetes, current guidelines do not recommend use of niacin in patients with diabetes because of concerns about adverse effects on glycemic control; however, this is based on limited clinical data. OBJECTIVE: To determine the efficacy and safety of lipid-modifying dosages of niacin in patients with diabetes. DESIGN AND SETTING: Prospective, randomized placebo-controlled clinical trial conducted in 6 clinical centers from August 1993 to December 1995. PARTICIPANTS: A total of 468 participants, including 125 with diabetes, who had diagnosed peripheral arterial disease. INTERVENTIONS: After an active run-in period, participants were randomly assigned to receive niacin (crystalline nicotinic acid), 3000 mg/d or maximum tolerated dosage (n = 64 with diabetes; n = 173 without diabetes), or placebo (n = 61 with diabetes; n = 170 without diabetes) for up to 60 weeks (12-week active run-in and 48-week double-blind). MAIN OUTCOME MEASURES: Plasma lipoprotein, glucose, hemoglobin A(1c) (HbA(1c)), alanine aminotransferase, and uric acid levels; hypoglycemic drug use; compliance; and adverse events, in patients with diabetes vs without who were receiving niacin vs placebo. RESULTS: Niacin use significantly increased HDL-C by 29% and 29% and decreased triglycerides by 23% and 28% and low-density lipoprotein cholesterol (LDL-C) by 8% and 9%, respectively, in participants with and without diabetes (P<.001 for niacin vs placebo for all). Corresponding changes in participants receiving placebo were increases of 0% and 2% in HDL-C and increases of 7% and 0% in triglycerides, and increases of 1% and 1% in LDL-C. Glucose levels were modestly increased by niacin (8.7 and 6.3 mg/dL [0.4 and 0.3 mmol/L]; P =.04 and P<.001) in participants with and without diabetes, respectively. Levels of HbA(1c) were unchanged from baseline to follow-up in participants with diabetes treated with niacin. In participants with diabetes treated with placebo, HbA(1c) decreased by 0.3% (P =.04 for difference). There were no significant differences in niacin discontinuation, niacin dosage, or hypoglycemic therapy in participants with diabetes assigned to niacin vs placebo. CONCLUSIONS: Our study suggests that lipid-modifying dosages of niacin can be safely used in patients with diabetes and that niacin therapy may be considered as an alternative to statin drugs or fibrates for patients with diabetes in whom these agents are not tolerated or fail to sufficiently correct hypertriglyceridemia or low HDL-C levels. JAMA. 2000;284:1263-1270

Management of sexual dysfunction in patients with cardiovascular disease: recommendations of The Princeton Consensus Panel.

Sexual dysfunction is highly prevalent in both sexes and adversely affects patients' quality of life and well being. Given the frequent association between sexual dysfunction and cardiovascular disease, in addition to the potential cardiac risk of sexual activity itself, a consensus panel was convened to develop recommendations for clinical management of sexual dysfunction in patients with cardiovascular disease. Based upon a review of the research and presentations by invited experts, a classification system was developed for stratification of patients into high, low, and intermediate categories of cardiac risk. The large majority of patients are in the low-risk category, which includes patients with (1) controlled hypertension; (2) mild, stable angina; (3) successful coronary revascularization; (4) a history of uncomplicated myocardial infarction (MI); (5) mild valvular disease; and (6) no symptoms and <3 cardiovascular risk factors. These patients can be safely encouraged to initiate or resume sexual activity or to receive treatment for sexual dysfunction. An important exception is the use of sildenafil in patients taking nitrates in any form. Patients in the intermediate-risk category include those with (1) moderate angina; (2) a recent MI (<6 weeks); (3) left ventricular dysfunction and/or class II congestive heart failure; (4) nonsustained low-risk arrhythmias; and (5) >/=3 risk factors for coronary artery disease. These patients should receive further cardiologic evaluation before restratification into the low- or high-risk category. Finally, patients in the high-risk category include those with (1) unstable or refractory angina; (2) uncontrolled hypertension; (3) congestive heart failure (class III or IV); (4) very recent MI (<2 weeks); (5) high-risk arrhythmias; (6) obstructive cardiomyopathies; and (7) moderate-to-severe valvular disease. These patients should be stabilized by specific treatment for their cardiac condition before resuming sexual activity or being treated for sexual dysfunction. A simple algorithm is provided for guiding physicians in the management of sexual dysfunction in patients with varying degrees of cardiac risk.

Management of sexual dysfunction in patients with cardiovascular disease: recommendations of the Princeton Consensus Panel.

Sexual dysfunction is highly prevalent in both sexes and adversely affects patients' quality of life and well being. Given the frequent association between sexual dysfunction and cardiovascular disease, in addition to the potential cardiac risk of sexual activity itself, a consensus panel was convened to develop recommendations for clinical management of sexual dysfunction in patients with cardiovascular disease. Based upon a review of the research and presentations by invited experts, a classification system was developed for stratification of patients into high, low, and intermediate categories of cardiac risk. The large majority of patients are in the low-risk category, which includes patients with (1) controlled hypertension; (2) mild, stable angina; (3) successful coronary revascularization; (4) a history of uncomplicated myocardial infarction (MI); (5) mild valvular disease; and (6) no symptoms and <3 cardiovascular risk factors. These patients can be safely encouraged to initiate or resume sexual activity or to receive treatment for sexual dysfunction. An important exception is the use of sildenafil in patients taking nitrates in any form. Patients in the intermediate-risk category include those with (1) moderate angina; (2) a recent MI (<6 weeks); (3) left ventricular dysfunction and/or class II congestive heart failure; (4) nonsustained low-risk arrhythmias; and (5) >/=3 risk factors for coronary artery disease. These patients should receive further cardiologic evaluation before restratification into the low- or high-risk category. Finally, patients in the high-risk category include those with (1) unstable or refractory angina; (2) uncontrolled hypertension; (3) congestive heart failure (class III or IV); (4) very recent MI (<2 weeks); (5) high-risk arrhythmias; (6) obstructive cardiomyopathies; and (7) moderate-to-severe valvular disease. These patients should be stabilized by specific treatment for their cardiac condition before resuming sexual activity or being treated for sexual dysfunction. A simple algorithm is provided for guiding physicians in the management of sexual dysfunction in patients with varying degrees of cardiac risk.

Impact of geographic proximity to cardiac revascularization services on service utilization.

BACKGROUND: In a highly competitive health care environment, even microgeographic differences in availability of tertiary services might affect access to care. OBJECTIVES: To study the impact of (1) geographic distance from patient's residence to cardiac revascularization services and (2) the availability of cardiac revascularization services at the hospital nearest the patient's residence on utilization of these services in a geographically small, densely populated area. METHODS: Historical cohort study of 55,659 New Jersey residents hospitalized between 1992 and 1996 with primary diagnosis of acute myocardial infarction (AMI). MAIN STUDY OUTCOMES: Use of percutaneous transluminal coronary angioplasty (PTCA) or coronary artery bypass graft surgery (CABG) within 90 days of initial hospitalization for AMI and in-hospital mortality. Distance from patient's residence to nearest hospital with cardiac revascularization services (PTCA and CABG) was a straight-line distance in miles, categorized as 0 to <2, 2 to <5, 5 to <10, 10 to <15, 15 to <20, 20 to <25, > or =25 miles. Adjusted odds of PTCA or CABG use at each distance category were compared with odds at > or =25 miles. RESULTS: A strong linear decline in adjusted odds ratios for PTCA use was found with increasing distance of this service from the patient's residence (p <0.05). Adjusted odds of PTCA use were 2.4, 2.1, 1.8, 1.5, 1.3, and 1.0 times higher for each increasing distance category in comparison with > or =25 for patients aged <65 and 3.1, 2.7, 2.2, 1.9, 1.7, and 1.1 for patients aged > or =65. Use of CABG was also higher for patients residing closer to cardiac revascularization services. The availability of these services at the hospital nearest to the patient's residence also increased utilization. In-hospital mortality was not associated with distance from services. CONCLUSION: Even across a relatively small geographic area, shorter distance to services and availability of services at the nearest hospital were strongly related to increased utilization of cardiac revascularization services.

Impact of availability of hospital-based invasive cardiac services on racial differences in the use of these services.

BACKGROUND: Reports indicate that black patients are less likely than white patients to receive invasive cardiac services after hospitalization for acute myocardial infarction (AMI). There is still uncertainty as to why racial differences exist and how they affect patient outcomes. This is the first study to focus on the availability of invasive cardiac services and racial differences in procedure use. Study objectives were to (1) document whether racial differences existed in the use of invasive cardiac procedures, (2) study whether these racial differences were related to availability of hospital-based invasive cardiac services at first admission for AMI, and (3) determine whether there were racial differences in long-term mortality rates. METHODS: A historical cohort study was conducted with discharge records from all acute care hospitals in New Jersey for 1993 linked to death certificate records for 1993 and 1994. There were 13,690 black and white New Jersey residents hospitalized with primary diagnosis of AMI. Use of cardiac catheterization within 90 days, revascularization within 90 days (percutaneous transluminal coronary angioplasty [PTCA] or coronary artery bypass graft surgery [CABG]), and death within 1 year after admission for AMI were the main outcome measures. Patterns for PTCA and CABG as separate outcomes were also studied. Hospital-based cardiac services available were described as no invasive cardiac services, catheterization only, or PTCA/CABG. To account for payer status and comorbidity differences, patients 65 years and older with Medicare coverage were analyzed separately from those younger than 65 years. RESULTS: Black patients aged 65 and older were generally less likely to receive catheterization and revascularization than white patients, regardless of facilities available at first admission. For patients younger than 65 years, the greatest differences between black and white patients in catheterization and PTCA/CABG use within 90 days after AMI occurred when no hospital-based invasive cardiac services were available. However, use of invasive cardiac procedures within 90 days after AMI was substantially increased if the first hospital offered catheterization only or PTCA/CABG services, among all patients, especially among blacks younger than age 65. No significant racial differences or interactions with available services were found in 1-year mortality rates. CONCLUSIONS: Availability of invasive cardiac services at first hospitalization for AMI was associated with increased procedure use for both races. However, use of invasive cardiac procedures was generally lower for black patients than for white patients, regardless of services available. Long-term mortality rates after hospitalization for AMI did not differ between blacks and whites.