Racial Disparities in Acute Coronary Syndrome Management Within a Universal Healthcare Context: Insights From the AMI-OPTIMA Trial.

BACKGROUND: Although prior studies have demonstrated racial disparities regarding acute coronary syndrome (ACS) care within private or mixed healthcare systems, few researchers have explored such disparities within universal healthcare systems. We aimed to evaluate the quality and outcomes of in-hospital ACS management for White patients vs patients of colour, within a universal healthcare context. METHODS: We performed a post hoc analysis of the Acute Myocardial Infarction - Knowledge Translation to Optimize Adherence to Evidence-Based Therapy study, a cluster-randomized trial evaluating a knowledge-translation intervention at 24 hospitals in Quebec, Canada (years: 2009 and 2012). The primary endpoint was coronary catheterization. The secondary endpoints included in-hospital mortality, percutaneous and surgical coronary revascularization, major bleeding, total stroke, and discharge prescription of evidence-based medical therapy. RESULTS: Of 3444 included patients, 2738 were White, and 706 were people of colour. The mean age was 68.2 years (33.3% women) among White patients and 69.5 years (36.0% women) among patients of colour. Patients of colour were less likely to undergo in-hospital coronary catheterization than were White patients (74.5% vs 80.3%, P = 0.001). This difference was attenuated after adjusting for patient-level characteristics (odds ratio 0.89; 95% confidence interval 0.73-1.09), and it was eliminated after adjusting for hospital-level characteristics (odds ratio 1.04; 95% confidence interval 0.73-1.49). CONCLUSIONS: Racial disparity in coronary catheterization for ACS persists within a universal healthcare context. Patients' comorbidities and hospital-level factors may be partially responsible for this inequality. Future research on cardiovascular healthcare in patients with diverse racial/ethnic backgrounds in universal healthcare systems is needed to remediate racial inequality in ACS management.

CONTEXTE: Bien que des études antérieures aient démontré l'existence de disparités raciales dans la prise en charge du syndrome coronarien aigu (SCA) au sein de systèmes de santé privés ou mixtes, peu de chercheurs ont étudié ces disparités au sein de systèmes universels de soins de santé. Nous avons cherché à évaluer la qualité et les résultats de la prise en charge du SCA à l'hôpital pour les patients blancs par rapport aux patients de couleur, dans un contexte de soins de santé universels. MÉTHODOLOGIE: Nous avons effectué une analyse a posteriori de l'étude AMI-OPTIMA, un essai sur échantillon en grappes aléatoire évaluant une intervention d'application des connaissances dans 24 hôpitaux du Québec, au Canada (années : 2009 et 2012). Le paramètre d'évaluation principal était le cathétérisme coronaire. Les paramètres d'évaluation secondaires comprenaient la mortalité à l'hôpital, la revascularisation coronaire percutanée et chirurgicale, l'hémorragie majeure, l'accident vasculaire cérébral et la prescription au congé d'un traitement médical fondé sur des données probantes. RÉSULTATS: Sur les 3444 patients étudiés, 2738 étaient blancs et 706 étaient des personnes de couleur. L'âge moyen était de 68,2 ans (33,3 % de femmes) chez les patients blancs, et de 69,5 ans (36,0 % de femmes) chez les patients de couleur. Les patients de couleur étaient moins susceptibles de subir un cathétérisme coronaire à l'hôpital que les patients blancs (74,5 % contre 80,3 %, p = 0,001). Cette différence a été atténuée après ajustement pour tenir compte des caractéristiques des patients (rapport de cotes : 0,89; intervalle de confiance [IC] à 95 % : 0,73-1,09), et éliminée après ajustement pour tenir compte des caractéristiques des hôpitaux (rapport de cotes : 1,04; IC à 95 % : 0,73-1,49). CONCLUSIONS: La disparité raciale en ce qui a trait au cathétérisme coronaire pour un SCA persiste dans un contexte de soins de santé universels. Les comorbidités des patients et des facteurs liés à l'hôpital peuvent être partiellement responsables de cette inégalité. De plus amples recherches sur les soins cardiovasculaires chez les patients de diverses origines raciales ou ethniques dans les systèmes universels de soins de santé sont nécessaires pour remédier aux inégalités raciales dans la prise en charge du SCA.

Impact of an invasive strategy in the elderly hospitalized with acute coronary syndrome with emphasis on the nonagenarians.

BACKGROUND: Published data about nonagenarians with acute coronary syndrome (ACS) were mainly descriptive and limited by small sample sizes and unadjusted outcomes. We aim to describe the characteristics, management, and the impact of an invasive strategy on major adverse events in elderly patients hospitalized with ACS with focus on the nonagerians. METHODS AND RESULTS: We analyzed data collected as part of the AMI-OPTIMA study, a cluster-randomized study of knowledge translation intervention versus usual care on optimal discharge medications in patients admitted with ACS at 24 Canadian hospitals. To determine whether an invasive strategy improved outcomes in the elderly, we used inverse probability weighting to adjust for confounders between patients who underwent invasive versus conservative strategies. Of 4,569 consecutive patients: 2,395 (52%) were <70 years old, 1,031 (23%) were septuagenarians, 941 (21%) were octogenarians, and 202 (4.4%) were nonagenarians. An invasive strategy was associated with reduced in-hospital all-cause mortality in all age groups: 1.1% versus 3.8% in patients <70 years old (P < 0.001), 2.9% versus 7.4% in septuagenarians (P < 0.001), 5.1% versus 14.7% in octogenarians (P < 0.001), and 12.0% versus 25.1% in nonagenarians (P = 0.001). An invasive strategy was also associated with higher thrombolysis in myocardial infarction major bleeds in the nonagenarians (9.0% vs. 2.0%; P = 0.003). CONCLUSIONS: The reduction in in-hospital mortality associated with an invasive strategy in elderly and nonagenarians presented with ACS is generating hypothesis and merits further studies to confirm these benefits and to guide clinicians in the management of these high-risk patients.

Smoking abstinence 1 year after acute coronary syndrome: follow-up from a randomized controlled trial of varenicline in patients admitted to hospital.

BACKGROUND: Patients who continue to smoke after acute coronary syndrome are at increased risk of reinfarction and death. We previously found use of varenicline to increase abstinence 24 weeks after acute coronary syndrome; here we report results through 52 weeks. METHODS: The EVITA trial was a multicentre, double-blind, randomized, placebo-controlled trial of varenicline for smoking cessation in patients admitted to hospital with acute coronary syndrome. Participants were randomly assigned (1:1) to receive varenicline or placebo for 12 weeks, in conjunction with low-intensity counselling. Smoking abstinence was assessed via 7-day recall, with biochemical validation using exhaled carbon monoxide. Participants lost to follow-up or withdrawn were assumed to have returned to smoking. RESULTS: Among the 302 participants, abstinence declined over the course of the trial, with 34.4% abstinent 52 weeks after acute coronary syndrome. Compared with placebo, point estimates suggest use of varenicline increased point-prevalence abstinence (39.9% v. 29.1%, difference 10.7%, 95% confidence interval [CI] 0.01% to 21.44%; number needed to treat 10), continuous abstinence (31.1% v. 21.2%, difference 9.9%, 95% CI -0.01% to 19.8%) and reduction in daily cigarette smoking by 50% or greater (57.8% v. 49.7%, difference 8.1%, 95% CI -3.1% to 19.4%). Varenicline and placebo groups had similar occurrence of serious adverse events (24.5% v. 21.9%, risk difference 2.7%, 95% CI -7.3% to 12.6%) and major adverse cardiovascular events (8.6% v. 9.3%, risk difference -0.7%, 95% CI -7.8% to 6.5%). INTERPRETATION: Varenicline was efficacious for smoking cessation in this high-risk patient population. However, 60% of patients who received treatment with varenicline still returned to smoking. Trial registration: ClinicalTrials.gov, no. NCT00794573.

Recurrent Cardiovascular Events in Survivors of Myocardial Infarction With ST-Segment Elevation (from the AMI-QUEBEC Study).

The characteristics and predictors of long-term recurrent ischemic cardiovascular events (RICEs) after myocardial infarction with ST-segment elevation (STEMI) have not yet been clarified. We aimed to characterize the 10-year incidence, types, and predictors of RICE. We obtained 10-year follow-up of STEMI survivors at 17 Quebec hospitals in Canada (the AMI-QUEBEC Study) in 2003. There were 858 patients; mean age was 60 years and 73% were male. The majority of patients receive reperfusion therapy; 53.3% and 39.2% of patients received primary percutaneous coronary intervention (PCI) and fibrinolytic therapy, respectively. Seventy-five percent of patients underwent in-hospital PCI (elective, rescue, and primary). At 10 years, 42% of patients suffered a RICE, with most RICEs (88%) caused by recurrent cardiac ischemia. The risk of RICE was the highest during the first year (23.5 per patient-year). At 10 years, the all-cause mortality was 19.3%, with 1/3 of deaths being RICE-related. Previous cardiovascular event, heart failure during the index STEMI hospitalization, discharge prescription of calcium blocker increased the risk of RICE by almost twofold. Each point increase in TIMI (Thrombolysis In Myocardial Infarction) score augmented the risk of RICE by 6%, whereas discharge prescription of dual antiplatelets reduced the risk of RICE by 23%. Our findings suggested that survivors of STEMI remain at high long-term risk of RICE despite high rate of reperfusion therapy and in-hospital PCI. Patients with previous cardiovascular event, in-hospital heart failure, and high TIMI score were particularly susceptible to RICE. Future studies are needed to confirm the impacts of calcium blocker and dual antiplatelets on long-term risk of RICE.

Ten-Year Statin Adherence in Survivors of ST-Segment Elevation Myocardial Infarction.

Background          Adherence to statins is often sub-optimal and declines over time. Direct costs incurred by patients are frequently cited as responsible for inadequate statin adherence. To determine whether survivors of ST-segment elevation myocardial infarction (STEMI), who benefit from low or no cost drug dispensation, have optimal long-term adherence to statins, we aimed to evaluate the ten-year adherence to statin of these patients. Methods          The AMI-QUEBEC Study follows a cohort of STEMI survivors hospitalized at 17 hospitals in Quebec, Canada during the year 2003. We obtained their 10-year data on lipid lowering therapy (LLT) consumption. Optimal adherence was defined as the proportion of days covered of ≥80%. We used multivariate logistic regression to determine factors independently associated with optimal adherence to statins. Results          Complete 10-year data on statin dispensation was available for 524 patients. Optimal adherence remained stable over time at 80% and more during the 10-year follow-up period. During the last five years, 12% of patients did not use any LLT. Older age, living in less socially deprived areas, concomitant use of angiotensin-converting-enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB), and admission to hospitals with percutaneous coronary interventions facilities (PCI-hospitals) were associated with improved statin adherence.   Conclusion Future studies are needed to explore the potential factors associated with concomitant use of ACEI/ARB, and admission to PCI-hospitals that may have optimized statin adherence. Socially deprived patients may benefit from more support and encouragement to enhance their long-term statin adherence.

Smokers and Postcessation Weight Gain After Acute Coronary Syndrome.

BACKGROUND: Smoking cessation and weight management are recommended after acute coronary syndrome (ACS); however, little is known about the effects of smoking cessation on weight change after ACS. We aimed to assess the effect of smoking cessation after ACS on weight over a 12-month follow-up period. METHODS AND RESULTS: Data were prospectively collected from the EVITA (Evaluation of Varenicline in Smoking Cessation for Patients Post-Acute Coronary Syndrome) trial. Weight change was compared among 3 groups of patients: those who were completely abstinent (n=70), those who smoked intermittently (n=68), and those who smoked persistently (n=34). Patients' mean baseline weight was 83.9 kg (SD 17.7) with a mean body mass index of 28.5 (SD 5.4). Patients smoked a mean of 37.7 years (SD 17.7) and a mean of 21.0 cigarettes (SD 9.0) per day prior to their ACS. Weight change varied across groups, with abstainers gaining a mean of 4.8 kg (SD 8.6), intermittent smokers gaining a mean of 2.0 kg (SD 8.9) and persistent smokers losing a mean of 0.7 kg (SD 7.4). At 52 weeks, abstainers were more likely to gain weight than persistent smokers (difference in means 5.5 kg; 95% CI 2.3-8.8). This weight gain was not associated with an increase in the use of antihypertensive or antidiabetic medications. CONCLUSIONS: Following an ACS, significant weight is gained by patients who quit smoking. Weight-management interventions among smokers who quit after ACS should be a focus of investigation in future research so that the cardiovascular benefits achieved by smoking cessation are not offset by weight gain in this high-risk population. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00794573.

Varenicline for Smoking Cessation in Hospitalized Patients With Acute Coronary Syndrome.

BACKGROUND: Less than one-third of smokers hospitalized with an acute coronary syndrome (ACS) remain abstinent following discharge. We assessed whether varenicline, begun in-hospital, is efficacious for smoking cessation following ACS. METHODS AND RESULTS: We conducted a multi-center, double-blind, randomized, placebo-controlled trial in which smokers hospitalized with an ACS were randomized to varenicline or placebo for 12 weeks. All patients received low-intensity counseling. The primary end point was point-prevalence smoking abstinence assessed at 24 weeks by 7-day recall and biochemical validation using expired carbon monoxide. A total of 302 patients were randomized (mean age 55±9 years; 75% male; 56% ST-segment elevation myocardial infarction; 38% non-ST-segment elevation myocardial infarction; 6% unstable angina). Patients smoked a mean of 21±11 cigarettes/d at the time of hospitalization and had been smoking for a mean of 36±12 years. At 24 weeks, patients randomized to varenicline had significantly higher rates of smoking abstinence and reduction than patients randomized to placebo. Point-prevalence abstinence rates were 47.3% in the varenicline group and 32.5% in the placebo group (P=0.012; number needed to treat=6.8). Continuous abstinence rates were 35.8% and 25.8%, respectively (P=0.081; number needed to treat=10.0), and rates of reduction ≥50% in daily cigarette consumption were 67.4% and 55.6%, respectively (P=0.05; number needed to treat=8.5). Adverse event rates within 30 days of study drug discontinuation were similar between groups (serious adverse events: varenicline 11.9%, placebo 11.3%; major adverse cardiovascular events: varenicline 4.0%, placebo 4.6%). CONCLUSIONS: Varenicline, initiated in-hospital following ACS, is efficacious for smoking cessation. Future studies are needed to establish safety in these patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT00794573.

Canada Acute Coronary Syndrome Risk Score: a new risk score for early prognostication in acute coronary syndromes.

BACKGROUND: Despite the availability of several acute coronary syndrome (ACS) prognostic risk scores, there is no appropriate score for early-risk stratification at the time of the first medical contact with patients with ACS. The primary objective of this study is to develop a simple risk score that can be used for early-risk stratification of patients with ACS. METHODS: We derived the risk score from the Acute Myocardial Infarction in Quebec and Canada ACS-1 registries and validated the risk score in 4 other large data sets of patients with ACS (Canada ACS-2 registry, Canada-GRACE, EFFECT-1, and the FAST-MI registries). The final risk score is named the Canada Acute Coronary Syndrome Risk Score (C-ACS) and ranged from 0 to 4, with 1 point assigned for the presence of each of these variables: age ≥75 years, Killip >1, systolic blood pressure <100 mm Hg, and heart rate >100 beats/min. The primary end points were short-term (inhospital or 30-day) and long-term (1- or 5-year) all-cause mortality. RESULTS: The C-ACS has good predictive values for short- and long-term mortality of patients with ST-segment elevation myocardial infarction and non-ST-segment elevation ACS. The negative predictive value of a C-ACS score ≥1 is excellent at ≥98% (95% CI 0.97-0.99) for short-term mortality and ≥93% (95% CI 0.91-0.96) for long-term mortality. In other words, a C-ACS score of 0 can potentially identify correctly ≥97% short-term survivors and ≥91% long-term survivors. CONCLUSION: The C-ACS risk score permits rapid stratification of patients with ACS. Because this risk score is simple and easy to memorize and calculate, it can be rapidly applied by health care professionals without advanced medical training.

Bupropion for smoking cessation in patients hospitalized with acute myocardial infarction: a randomized, placebo-controlled trial.

OBJECTIVES: The purpose of this study was to examine smoking cessation rates among smokers with AMI to determine whether bupropion, started in-hospital, is safe and can improve cessation rates at 1 year. BACKGROUND: Bupropion doubles quit rates in otherwise healthy smokers and patients with stable cardiovascular disease. Although 2 previous trials examined the use of bupropion in patients hospitalized with acute cardiovascular disease, these studies have been inconclusive with respect to its safety and efficacy in patients with acute myocardial infarction (AMI). METHODS: We conducted a multicenter, double-blind, placebo-controlled, randomized trial in smokers hospitalized with AMI. Participants received bupropion or placebo for 9 weeks and were followed for 12 months. Both groups received low-intensity counseling. Point prevalence abstinence was assessed by 7-day recall and biochemical validation of expired carbon monoxide. RESULTS: A total of 392 patients were randomized (mean age 53.9 ± 10.3 years); 83.5% were male; 64.9% had ST-segment elevation myocardial infarction). Patients smoked a mean of 23.2 ± 10.6 cigarettes/day for a mean of 32.9 ± 12.4 years. At 12 months, point prevalence abstinence rates were 37.2% in the bupropion group and 32.0% in the placebo group (p = 0.33; % difference after adjusting for between center differences 3.9%). Continuous abstinence rates were 26.8% and 22.2%, respectively (p = 0.34). Major adverse cardiac event rates were similar (13.0% vs. 11.0%, respectively; p = 0.64). CONCLUSIONS: Two-thirds of patients return to smoking by 12 months after AMI. Bupropion is well tolerated and seems to be safe to use in the immediate post-AMI period. However, bupropion is not effective for smoking cessation in patients post-AMI.

Effectiveness and safety of glycoprotein IIb/IIIa inhibitors in patients with myocardial infarction undergoing primary percutaneous coronary intervention: a meta-analysis of observational studies.

INTRODUCTION: Meta-analyses of randomized controlled trials (RCT) showed that glycoprotein IIb/IIIa inhibitors (GPI) are associated with reduced adverse events following primary percutaneous coronary revascularization (PCI). However, the external validity of RCTs is generally limited due to their restricted inclusion of patients. The objective of this study is to evaluate the effectiveness and safety of GPI, as adjuvant therapy for primary PCI in real-life patients with myocardial infarction with ST segment elevation (STEMI) from the general population. METHODS: We identified all published peer-reviewed observational studies enrolling STEMI patients who underwent primary PCI. We performed random-effect meta-analyses to determine the association of GPI with major adverse events. RESULTS: A total of 11 studies, enrolling 12,253 patients, were retained for this meta-analysis. GPI was associated with approximately 53% reduction in short-term mortality (odds ratio (OR): 0.47, 95% confidence intervals (CI): 0.32-0.68). There was a 62% reduction in long-term mortality associated with GPI (OR: 0.38, 95% CI: 0.30-0.50). GPI was associated with a 62% reduction in 30-day re-infarction (OR: 0.38, 95% CI: 0.24-0.60) and 42% reduction in 30-day repeat PCI (OR: 0.58, 95% CI: 0.36-0.94). A non-significant increase in major bleeding with GPI was observed with an OR of 1.55 (95% CI: 0.92-2.62). CONCLUSIONS: GPI is associated with significant reductions in short-term mortality, re-infarction and repeat PCI, long-term mortality and an inconclusive increase in major bleeding. These results provide evidence for the safety and effectiveness of GPI as adjuvant therapy for primary PCI in real-life STEMI patients.

Safety and effectiveness of enoxaparin following fibrinolytic therapy: Results of the Acute Myocardial Infarction (AMI)-QUEBEC registry.

BACKGROUND: Previous randomized controlled trials and meta-analyses demonstrated the superior efficacy of enoxaparin (ENOX) over unfractionated heparin (UFH) in patients with ST segment elevation myocardial infarction (STEMI). The external validity of randomized controlled trials may be limited by selective inclusion of patients who are younger and healthier than the 'real-life' population. OBJECTIVE: To evaluate the safety and effectiveness of ENOX compared with UFH in unselected STEMI patients. METHODS: The safety and effectiveness of ENOX and UFH were compared in STEMI patients who received fibrinolytic therapy at 17 Quebec hospitals in 2003. RESULTS: A total of 498 STEMI patients received systemic anticoagulation, with ENOX and UFH administered in 114 and 384 patients, respectively. There were no differences in baseline characteristics between the two patient groups. The rates of in-hospital major adverse cardiac or cerebral events were 11.4% in the ENOX group compared with 14.0% in the UFH group (P=0.51). In-hospital death or nonfatal reinfarction occurred in 7.9% of patients who received ENOX compared with 9.9% of patients who received UFH (P=0.52). Major bleeding occurred in 4.4% of patients who received ENOX versus 6.0% in patients who received UFH (P=0.51). INTERPRETATION: There was no significant difference in the rates of in-hospital adverse events in the ENOX group compared with the UFH group, when used in the real-life context. Larger observational studies may further confirm the safety, effectiveness and optimal duration of the administration of ENOX in unselected STEMI patients treated with fibrinolysis.

HISTORIQUE : Des essais aléatoires et contrôlés et des méta-analyses passés ont démontré l'efficacité supérieure de l'enoxaparine (ENOX) par rapport à l'héparine non fractionnée (HNF) chez les patients ayant un infarctus du myocarde avec élévation du segment ST (IMÉST). La validité externe des essais aléatoires et contrôlés peut être limitée par l'inclusion sélective de patients qui sont plus jeunes et en meilleure santé qu'au sein de la « véritable ¼ population. OBJECTIF : Évaluer l'innocuité et l'efficacité de l'ENOX par rapport à l'HNF chez des patients non sélectionnés ayant eu un IMÉST. MÉTHODOLOGIE : Les chercheurs ont comparé l'innocuité et l'efficacité de l'ENOX et de l'HNF chez des patients qui ont subi un IMÉST et ont reçu des fibrinolytiques dans 17 hôpitaux québécois en 2003. RÉSULTATS : Au total, 498 patients ayant subi un IMÉST ont reçu des anticoagulants systémiques, l'ENOX et l'HNF ayant été administrés chez 114 et 384 patients, respectivement. On ne constatait aucune différence à l'égard des caractéristiques de base des deux groupes de patients. Le taux d'événements cardiaques ou cérébraux négatifs majeurs en milieu hospitalier s'élevait à 11,4 % au sein du groupe prenant de l'ENOX, par rapport à 14,0 % dans celui prenant de l'HNF (P=0,51). Un décès en milieu hospitalier ou un infarctus non fatal s'est produit chez 7,9 % des patients qui avaient reçu de l'ENOX par rapport à 9,9 % de ceux qui avaient reçu de l'HNF (P=0,52). Des saignements majeurs se sont produits chez 4,4 % des patients qui avaient reçu de l'ENOX et 6,0 % de ceux qui avaient reçu de l'HNF (P=0,51). INTERPRÉTATION : En milieu réel, on ne remarquait aucune différence significative dans les taux de réactions néfastes en milieu hospitalier au sein du groupe prenant de l'ENOX par rapport à celui prenant de l'HNF. De plus vastes études d'observation pourraient mieux confirmer l'innocuité, l'efficacité et la durée optimale de l'administration d'ENOX chez des patients non sélectionnés ayant eu un IMÉST et étant traités par fibrinolyse.

Routine functional testing after percutaneous coronary intervention: results of the aggressive diagnosis of restenosis in high-risk patients (ADORE II) trial.

BACKGROUND: It is unclear whether routine or selective functional testing is optimal following percutaneous coronary intervention (PCI) in high-risk patients. OBJECTIVES: The aim of this trial was to compare exercise endurance, functional status, and quality of life (QOL) among high-risk patients randomized to either routine or selective functional testing following PCI. METHODS: We randomized 84 patients to either routine or selective functional testing. Patients had one or more of the following: multivessel PCI, diabetes mellitus, left ventricular ejection fraction < 35%, and/or PCI of the proximal left anterior descending artery. Patients in the routine arm (n = 41) underwent maximum endurance exercise treadmill testing (ETT) with nuclear perfusion imaging at 1.5 and 6 months. Patients in the selective arm (n = 43) only underwent functional testing for a clinical indication. All patients underwent a maximum endurance ETT at 9 months. Exercise endurance, functional status, and QOL were assessed at 9 months. RESULTS: Most patients were middle-aged men (58 +/- 10 years old; 87% male) who underwent PCI with stenting (94%). Among routine functional testing patients, 27.0% and 41.9% had a positive functional test at 1.5 and 6 months, respectively. Exercise endurance was improved in the routine vs. selective arm at 9 months (metabolic equivalents: 10.3 +/- 2.6 vs. 8.6 +/- 3.0, P = 0.013). There was no difference in improvement from baseline for the Duke Activity Status Index, the Seattle Angina Questionnaire, or the SF-36. Nine-month cumulative incidences of cardiac procedures and clinical events were not significantly different. CONCLUSIONS: Routine functional testing following PCI in high-risk patients may lead to improved exercise endurance but not improved QOL.

Underuse of evidence-based treatment partly explains the worse clinical outcome in diabetic patients with acute coronary syndromes.

BACKGROUND: Diabetes-related differences in treatment and clinical outcome of patients across the entire spectrum of acute coronary syndromes (ACSs) have potential clinical implications but have not been well studied. METHODS: The multicenter, prospective, Canadian ACS Registry enrolled 4578 patients hospitalized for ACS between 1999 and 2001 across 9 provinces in Canada. We compared baseline characteristics, in-hospital and post-discharge treatments, and clinical outcome of diabetic and non-diabetic patients. The impact of diabetes on use of thrombolytic therapy and coronary revascularization; and the independent association between diabetes, treatments, and diabetes-treatment interactions on outcome were examined. RESULTS: Diabetic patients with ACS had more cardiovascular risk factors and higher-risk clinical presentation. They paradoxically received less evidence-based medications in-hospital, at discharge, and at 1-year. Although diabetes independently predicted higher 1-year mortality (OR 1.47, 95% CI 1.15-1.87; P = .002) after adjustment for validated prognosticators, it was also an independent predictor of not receiving thrombolytic therapy (OR 0.72, 95% CI 0.54-0.95; P = .021) and coronary revascularization (OR 0.69, 95% CI 0.59-0.82; P < .001). These underused therapies were all independently associated with reduced 1-year mortality, with no significant diabetes-related treatment-outcome heterogeneity. Importantly, diabetes remained an independent adverse prognosticator even after further adjustment for these differences in treatment. CONCLUSIONS: Evidence-based therapies are underused in the contemporary management of diabetic patients with ACS, which partly explains their worse outcome. Diabetes should be considered a high-risk feature in ACS risk stratification that encourages more intensive treatments. Continued efforts to promote adherence to existing proven therapies and to develop novel treatment strategies targeting diabetes-specific cardiovascular pathophysiology are imperative to improve their adverse prognosis.

Treatment and one-year outcome of patients with renal dysfunction across the broad spectrum of acute coronary syndromes.

BACKGROUND: There are limited data on the treatment and long-term outcome of patients with renal dysfunction across the broad spectrum of acute coronary syndromes (ACS) in Canada. OBJECTIVES: To examine the treatment patterns and outcome of ACS patients with renal dysfunction. METHODS: In the prospective, multicentre, Canadian ACS Registry, 3510 patients hospitalized for ACS (including unstable angina, ST and non-ST elevation myocardial infarction) were categorized into four groups: normal renal function (creatinine clearance [CrCl] 90 mL/min or greater; n=1152), mild renal dysfunction (CrCl 60 mL/min to 89 mL/min; n=1253), moderate renal dysfunction (CrCl 30 mL/min to 59 mL/min; n=944) and severe renal dysfunction (CrCl less than 30 mL/min; n=161). Multivariable logistic regression analysis was performed to examine the independent prognostic value of renal dysfunction, and the association of various therapies with one-year survival. RESULTS: All-cause mortality at one year was 2.8%, 6.4%, 14.5% and 40.9% in patients with normal renal function, and mild, moderate and severe renal dysfunction, respectively (P for trend<0.001). After adjusting for other prognosticators, moderate (OR 1.82, 95% CI 1.08 to 3.08) and severe (OR 6.29, 95% CI 3.37 to 11.77) renal dysfunction remained independent predictors of one-year death. Patients with renal dysfunction were less likely to receive fibrinolytic therapy, to undergo coronary angiography and revascularization in hospital, and to be treated with acetylsalicylic acid, beta-blockers and lipid-lowering therapy at discharge and at one-year follow-up. The association of in-hospital revascularization, and discharge use of acetylsalicylic acid and beta-blockers with better one-year survival was similar among patients with normal and impaired renal function. CONCLUSIONS: Renal dysfunction is prevalent and independently predicts higher mortality in patients with ACS. The current underutilization of effective therapies may contribute to the poor outcome. There remains an important opportunity to improve care in this high-risk population.

Depression and prognosis following hospital admission because of acute myocardial infarction.

BACKGROUND: Whether there is an association between depression at the time of acute myocardial infarction and subsequent risk of cardiac complications and death remains controversial. Most studies of this risk factor have been limited to patients of single institutions, and this might account for the varying results. We prospectively evaluated patients admitted to 5 tertiary care and 5 community hospitals and followed them for 1 year to measure the prevalence and prognostic impact of depressive symptoms after acute myocardial infarction. METHODS: Patients were recruited for the study by trained nurse interviewers who had documented acute myocardial infarction within 2-3 days of admission. The nurses collected information from the medical records and asked study subjects to complete the Beck Depression Inventory questionnaire during their stay in hospital and using a mailed questionnaire 30 days, 6 months and 1 year later. We obtained information on vital status for patients lost to follow-up from a central death registry. RESULTS: Of the 587 study subjects, 550 (94%) completed the Beck Depression Inventory at baseline and 191 (35%) had a score of 10 or more, indicating at least mild depression. Rates of depression did not vary over the follow-up period and were similar among patients admitted to tertiary care or community hospitals. Depressed patients were more likely to undergo catheterization (57% v. 47%, 95% confidence interval [CI] around the difference 0.1%-19.6%) and were more likely to undergo percutaneous coronary intervention (32% v. 24%, 95% CI around the difference 0.1%-16.2%) within 30 days of first admission to hospital. Patients with depression on admission had higher rates of a composite of cardiac complications, including recurrent ischemia, infarction or congestive heart failure during their first stay in hospital or readmission for angina, recurrent acute myocardial infarction, congestive heart failure or arrhythmia (adjusted hazard ratio 1.4, 95% CI 1.05-1.86), compared with patients who were not depressed on admission. After 1 year, death rates were higher among patients who were depressed at admission (30 patients, 16%) compared with nondepressed patients (28 patients, 8%), although the difference was not statistically significant (hazard ratio 1.3, 95% CI 0.59-3.05). INTERPRETATION: Depressive symptoms are common after acute myocardial infarction and are associated with a slight increase in risk of in-hospital catheterization and angiography and readmission because of cardiac complications. Death was infrequent, with no statistically significant difference between the 2 groups.

Quality of life after acute myocardial infarction among patients treated at sites with and without on-site availability of angiography.

BACKGROUND: Previous studies have compared the treatment and outcome of patients with acute myocardial infarction (AMI) admitted at sites with and without availability of angiography. Although mortality rates do not differ, it is unknown if quality of life (QOL) and functional status differ. METHODS: We measured QOL and functional status in patients with AMI treated within Québec at 5 sites with (n = 253) and 5 sites without (n = 334) angiography. RESULTS: At admission, clinical characteristics, complication rates, and baseline measures of QOL and functional status were similar at sites with and without angiography. During hospitalization, patients treated at sites with angiography were more likely to undergo an invasive cardiac procedure than patients admitted at sites without angiography (angiography, 63% vs 26%; percutaneous transluminal coronary angioplasty, 33% vs 13%; and coronary artery bypass graft, 12% vs 5%). At 30 days and 6 months after AMI, QOL was slightly superior at sites with angiography, but by 1 year, most measures of QOL were back to baseline at both types of sites and were similar between the 2 groups. At 6 months, most standard health-related QOL components were similar; only physical and emotional role limitations were higher at sites with angiography. Return to work occurred earlier (at 30 days, 23% vs 12%), and a lower proportion of patients was readmitted for angina (within 1 year after AMI, 12% vs 18%) at sites with angiography. CONCLUSIONS: In the early post-AMI period, the QOL of patients admitted at sites with angiography was higher than that of patients admitted at sites without angiography. However, by 1 year, the QOL and functional status of patients was similar in both groups. Differences in QOL were greatest when differences in treatment were greatest, lending support to a positive albeit small association between an early invasive approach to post-AMI care and improved QOL.