Pharmacologic profile of survivors of acute myocardial infarction at United States academic hospitals

Optimal drug therapy for patients with acute myocardial infarction (AMI) is well described in the medical literature. However, data on the actual pharmacologic management of patients surviving AMI at academic hospitals is unavailable. The purpose of this study was to document treatment profiles in 500 patients surviving AMI at 12 academic hospitals in the United States. These profiles were compared with established guidelines and were evaluated for trends. Overall, thrombolytics (streptokinase > or = tissue-type plasminogen activator) were administered in 29% of the patients, with a greater proportion of patients receiving beta-blockers than calcium channel antagonists in the initial 72 hours (61% vs 40%; p < 0.005) and at discharge (51% vs 35%; p < 0.005). Further, women were less likely than men to receive thrombolytic therapy (odds ratio [OR] = 0.61; confidence interval [CI], 0.54 to 0.69) or beta-blocker therapy within the first 72 hours (OR = 0.61; CI, 0.55 to 0.67) or at hospital discharge (OR = 0.53; CI, 0.48 to 0.58). Overall, improvements could still be made in the number of patients who receive thrombolytic and acute and chronic beta-blocker therapies after AMI, particularly in women. Changes in treatment profiles may be a reflection of the publication of large clinical trials.     

Illicit drug use by persons with disabilities: insights from the National Household Survey on Drug Abuse

OBJECTIVES: This study sought to evaluate the association of drug use with disability in a representative sample of the US household population. METHODS: The use of illicit drugs and alcohol reported by respondents in the 1991 National Household Survey on Drug Abuse who identified themselves as "disabled, unable to work" was compared with respondents without disabilities. RESULTS: Among younger adults (18-24 years), persons with disabilities were more likely than those without disabilities to report that they had used heroin (adjusted odds ratio [OR] = 6.89; 95% confidence interval [CI] = 1.35, 35.1) or crack cocaine (OR = 6.38; 95% CI = 1.05, 38.6). Among older adults (35 years and older), persons with disabilities were more likely to report the use of sedatives (OR = 2.46; 95% CI = 1.21, 4.94) or tranquilizers (OR = 2.18: 95% CI = 1.08; 4.42) not medically prescribed. CONCLUSIONS: These results suggest that use of illicit drugs is a potentially serious problem among persons with disabilities and requires both research and clinical attention.     

Therapy of acute myocardial infarct (1994-1996) at non-university hospitals in Switzerland (CHAMI Study)

The CHAMI study (Confederatio Helvetica Acute Myocardial Infarction) recorded the therapies administered for acute myocardial infarction in 520 consecutive patients between October 1994 and February 1996 at 10 non-academic hospitals in Switzerland. The patients in this group consisted of 363 men and 157 women with an average age of 63.2 years. The prescribed medications administered from the day of hospital admission until the day of discharge were recorded. In the acute phase, the patients were given the following therapy: thrombolytic agents 40%, i.v. nitrates 65%, i.v. beta-blockers 22%, aspirin 95%, oral beta-blockers 36%, ACE inhibitors 14%. Impressive was the lower distribution of thrombolytic agents and beta-blockers among the older patients (age > 70) (thrombolytic agents 52.1% vs 28.4%; oral beta-blockers 44.0% vs 29.1%) and in particular among women (thrombolytic agents 26.8% vs 46%; oral beta-blockers 29.3% vs 39.7%) in men. Therapy at hospital discharge consisted, inter alia, of aspirin (73%), beta-blockers (54%), ACE inhibitors (3%), and lipid lowering agents (10%). The hospital mortality was 12.6%. The CHAMI study provided the participating hospitals with a quality control comparison with other participating centers and impressively demonstrated with the example of the lipid lowering agents, that the significance of secondary prophylaxis is assigned too little importance in contrast to acute therapy.     

Prospective study of calcium channel blocker use, cardiovascular disease, and total mortality among hypertensive women: the Nurses' Health Study

BACKGROUND: In several observational studies, patients prescribed calcium channel blockers had higher risks of cardiovascular diseases and mortality than those prescribed other antihypertensive medications. We explored these associations in the Nurses' Health Study. METHODS AND RESULTS: A total of 14 617 women who reported hypertension and regular use of diuretics, beta-blockers, calcium channel blockers, ACE inhibitors, or a combination in 1988 were included in the analyses. Cardiovascular events and deaths were ascertained through May 1, 1994. We documented 234 cases of myocardial infarction. Calcium channel blocker monodrug users had an age-adjusted relative risk (RR) of myocardial infarction of 2.36 (95% CI, 1.43 to 3.91) compared with those prescribed thiazide diuretics. Women prescribed calcium channel blockers had a higher prevalence of ischemic heart disease. After adjustment for these and other coronary risk factors, the RR was 1.64 (95% CI, 0.97 to 2.77). Comparing the use of any calcium channel blocker (monodrug and multidrug users) with that of any other antihypertensive agent, the adjusted RR was 1.42 (95% CI, 1.01 to 2.01). An association between calcium channel blocker use and myocardial infarction was apparent among women who had ever smoked cigarettes (covariate-adjusted RR, 1.81; 95% CI, 1.20 to 2.72) but not among never-smokers (RR, 0.94; 95% CI, 0.48 to 1.84). CONCLUSIONS: In analyses adjusted only for age, we found a significant elevation in RR of total myocardial infarction among women who used calcium channel blockers compared with those who did not. After adjustment for comorbidity and other covariates, the RR was reduced. Whether the remaining observed elevated risk is real, or a result of residual confounding by indication, or chance, or a combination of the above cannot be evaluated with certainty on the basis of these observational data.     

Postinfarction use of beta-blockers in elderly patients

beta-Adrenoceptor antagonists (beta-blockers) reduce mortality and recurrent myocardial infarction (MI) in older patients after both Q-wave MI and non-Q-wave MI. The effects of beta-blockers are to: (i) reduce complex ventricular arrhythmias, including ventricular tachycardia; (ii) increase the ventricular fibrillation threshold; (iii) reduce myocardial ischaemia; (iv) decrease sympathetic tone; (v) markedly attenuate the circadian variation of complex ventricular arrhythmias: (vi) abolish the circadian variation of myocardial ischaemia; and (vii) abolish the circadian variation of sudden cardiac death or MI. beta-Blockers reduce mortality in patients with MI and complex ventricular arrhythmias. In addition, they are excellent antianginal agents. Older persons with hypertension who have had an MI should be treated initially with a beta-blocker. beta-Blockers reduce mortality in patients with: (i) diabetes mellitus who have had an MI; (ii) MI and congestive heart failure with an abnormal or normal left ventricular ejection fraction; and (iii) MI and an asymptomatic abnormal left ventricular ejection fraction. Severe congestive heart failure, severe peripheral arterial disease with threatening gangrene, greater than first degree atrioventricular block, hypotension, bradycardia, lung disease with bronchospasm, and bronchial asthma are contraindications to treatment with beta-blockers.     

Do "America's Best Hospitals" perform better for acute myocardial infarction?

BACKGROUND: "America's Best Hospitals," an influential list published annually by U.S. News and World Report, assesses the quality of hospitals. It is not known whether patients admitted to hospitals ranked at the top in cardiology have lower short-term mortality from acute myocardial infarction than those admitted to other hospitals or whether differences in mortality are explained by differential use of recommended therapies. METHODS: Using data from the Cooperative Cardiovascular Project on 149,177 elderly Medicare beneficiaries with acute myocardial infarction in 1994 or 1995, we examined the care and outcomes of patients admitted to three types of hospitals: those ranked high in cardiology (top-ranked hospitals); hospitals not in the top rank that had on-site facilities for cardiac catheterization, coronary angioplasty, and bypass surgery (similarly equipped hospitals); and the remaining hospitals (non-similarly equipped hospitals). We compared 30-day mortality; the rates of use of aspirin, beta-blockers, and reperfusion; and the relation of differences in rates of therapy to short-term mortality. RESULTS: Admission to a top-ranked hospital was associated with lower adjusted 30-day mortality (odds ratio, 0.87; 95 percent confidence interval, 0.76 to 1.00; P=0.05 for top-ranked hospitals vs. the others). Among patients without contraindications to therapy, top-ranked hospitals had significantly higher rates of use of aspirin (96.2 percent, as compared with 88.6 percent for similarly equipped hospitals and 83.4 percent for non-similarly equipped hospitals; P<0.01) and beta-blockers (75.0 percent vs. 61.8 percent and 58.7 percent, P<0.01), but lower rates of reperfusion therapy (61.0 percent vs. 70.7 percent and 65.6 percent, P=0.03). The survival advantage associated with admission to top-ranked hospitals was less strong after we adjusted for factors including the use of aspirin and beta-blockers (odds ratio, 0.94; 95 percent confidence interval, 0.82 to 1.08; P=0.38). CONCLUSIONS: Admission to a hospital ranked high on the list of "America's Best Hospitals" was associated with lower 30-day mortality among elderly patients with acute myocardial infarction. A substantial portion of the survival advantage may be associated with these hospitals' higher rates of use of aspirin and beta-blocker therapy.     

Influence of payor on use of invasive cardiac procedures and patient outcome after myocardial infarction in the United States. Participants in the National Registry of Myocardial Infarction

OBJECTIVES: We sought to determine the influence of payor status on the use and appropriateness of cardiac procedures. BACKGROUND: The use of invasive procedures affects the cost of cardiovascular care and may be influenced by payor status. METHODS: We compared treatment and outcomes of myocardial infarction among four payor groups: fee for service (FFS), health maintenance organization (HMO), Medicaid and uninsured. Multivariate comparison was performed on the use of invasive cardiac procedures, length of hospital stay and in-hospital mortality in 17,600 patients <65 years old enrolled in the National Registry of Myocardial Infarction from June 1994 to October 1995. To determine the appropriateness of coronary angiography, we compared its use in patients at low and high risk for cardiac events. RESULTS: Angiography was performed in 86% of FFS, 80% of HMO, 61% of Medicaid and 75% of uninsured patients. FFS patients were more likely to undergo angiography than HMO (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.13 to 1.42), Medicaid (OR 2.43, 95% CI 2.11 to 2.81) and uninsured patients (OR 1.99, 95% CI 1.76 to 2.25). Similar patterns for the use of coronary revascularization were found. Among those at low risk, FFS patients were as likely to undergo angiography as HMO patients but more likely than Medicaid and uninsured patients. For those at high risk, FFS patients were more likely to undergo angiography than patients in other payor groups. Adjusted mean length of stay (7.3 days) was similar among all payor groups, but adjusted mortality was higher in the Medicaid group (Medicaid vs. FFS: OR 1.55, 95% CI 1.19 to 2.01). CONCLUSIONS: Payor status is associated with the use and appropriateness of invasive cardiac procedures but not length of hospital stay after myocardial infarction. The higher in-hospital mortality in the Medicaid cohort merits further study.     

Pulsed-field gel electrophoresis is more efficient than ribotyping and random amplified polymorphic DNA analysis in discrimination of Pasteurella haemolytica strains

OBJECTIVE: Factors such as size of hyphema, intraocular pressure, initial visual acuity, and use of steroids or antifibrinolytic drugs may be associated with the likelihood of rebleeding in traumatic hyphema. The association of the visual outcome with secondary hemorrhage has been questioned. DESIGN: Randomized, placebo-controlled, clinical trial. PARTICIPANTS: Two hundred and thirty-eight patients who had hyphema develop after blunt trauma. INTERVENTION: Eighty patients received oral tranexamic acid, 80 patients received placebo, and 78 patients received oral prednisolone. MAIN OUTCOME MEASURES: Secondary hemorrhage and vision at the time of discharge from the hospital were measured. RESULTS: Rebleeding occurred in 43 (18%) of the patients and was prevented significantly by oral tranexamic acid compared with the placebo (odds ratios [OR] = 0.39; 95% confidence interval [CI], 0.17, 0.89). Occurrence of secondary hemorrhage had weak associations with initial high intraocular pressure (OR = 2.7; 95% CI, 0.99, 7.3) and initial visual acuity of 6/60 or less (OR = 1.8; 95% CI, 0.9, 3.7). Secondary hemorrhage had no statistical association with age, gender, oral prednisolone, size of hyphema, and retinal damage. Visual acuity of 6/60 or less at the time of discharge was significantly associated with rebleeding (OR = 10.5; 95% CI, 3.7, 29.2), initial visual acuity of 6/60 or less (OR = 9.9; 95% CI, 2.8, 38.0), retinal damage (OR = 14.6; 95% CI, 3.8, 55.8), and male gender (OR = 6.5; 95% CI, 1.4, 31.9). Final visual acuity had no significant statistical association with age, use of oral prednisolone or tranexamic acid, and size of hyphema. CONCLUSIONS: High intraocular pressure and low vision at the time of first examination may be associated with increased chance of rebleeding. Retinal damage, secondary hemorrhage, male gender, and initial poor vision are associated with a worse visual outcome in patients with traumatic hyphema.     

Impact of age on the severity, course, and complications of alcohol withdrawal

BACKGROUND: Early identification of alcohol-dependent patients at increased risk for severe or complicated alcohol withdrawal would improve triage and treatment. However, the role of age in predicting alcohol withdrawal outcomes has not been well studied. OBJECTIVE: To assess the impact of age on the severity, course, and complications of alcohol withdrawal. METHODS: We performed a retrospective cohort study of 284 inpatients admitted for alcohol withdrawal between September 1992 and August 1994. Outcomes included alcohol withdrawal severity measured by the revised Clinical Institute Withdrawal Assessment for Alcohol scale, quantity and duration of benzodiazepine therapy, and complications during withdrawal. RESULTS: Initial and maximal withdrawal severity scores, amount of benzodiazepine administered, and duration of benzodiazepine treatment for elevated withdrawal severity scores did not change significantly with age. However, patients aged 60 years and older had increased risk for delirium (adjusted odds ratio [OR], 4.7; 95% confidence interval [CI], 1.5-15.0; P = .008), falls (OR, 3.1; 95% CI, 0.9-11.2; P = .08), and transient dependency in 2 or more activities of daily living (OR, 5.8; 95% CI, 2.9-11.7; P < .001). As age increased, there were significant increases in length of stay (P < .001) and frequency of discharge to an extended care facility (P < .001). CONCLUSIONS: Although alcohol withdrawal severity scores and benzodiazepine requirements were similar across age groups, patients aged 60 years and older were at increased risk for cognitive and functional impairment during withdrawal. These findings support recommendations that older patients with alcohol withdrawal are best treated in closely supervised settings.     

Hormone replacement therapy as a risk factor for epithelial ovarian cancer: results of a case-control study

OBJECTIVE: To evaluate the role of hormone replacement therapy (HRT) as a risk factor for the development of epithelial ovarian cancer. METHODS: A case-control study was performed that used 491 patients with epithelial ovarian cancer frequency matched for age at diagnosis (+/-5 years) with a control population of 741 patients with malignancies of nonestrogen-dependent tissues. The odds ratio (OR) for the development of epithelial ovarian cancer was estimated using logistic regression analysis with adjustment for age at diagnosis, parity, oral contraceptive use, smoking history, family history of epithelial ovarian cancer, age at menarche, menopausal status, income, and education. RESULTS: One hundred of 491 patients (20.4%) in the study population had ever used HRT, and 160 of 741 patients (21.6%) in the control population had ever used HRT (OR 0.85; 95% confidence interval [CI] 0.62, 1.2). A significant association between HRT and specific histologic subtypes of epithelial ovarian cancer was not demonstrable for serous cystadenocarcinoma (OR 1.2, 95% CI 0.8, 1.7), Clear cell carcinoma (OR 1.1, 95% CI 0.4, 3.4), or endometrioid carcinoma (OR 0.4; 95% CI 0.2, 1.2). A significant association between duration of use of HRT and the risk of developing epithelial ovarian cancer was not demonstrable for under 5 years (OR 0.8; 95% CI 0.5, 1.2), 5-9 years (OR 0.6; 95% CI 0.3, 1.1), or 10 or more years (OR 0.6; 95% CI 0.3, 1.4). CONCLUSION: A significant association between the use of HRT and the risk of developing epithelial ovarian cancer, even with prolonged exposure, is not demonstrable.     

Placebo-controlled evaluation of Ritalin side effects

OBJECTIVE: To address the frequency of side effects of Ritalin therapy in children with attention deficit hyperactivity disorder (ADHD) using the Barkeley Side Effects Questionnaire (BSEQ) in a clinical setting. DESIGN: Randomized double-blind placebo-controlled cross-over trial. SETTING: A large rural tertiary care clinic. PATIENTS: 234 consecutive children aged 5 through 15 years who met the Diagnostic and Statistical Manual of Mental Disorders (3rd ed, revised) criteria for ADHD were enrolled. Of these children, 206 had sufficient side effects data for analysis. INTERVENTIONS: 0.3 mg/kg per dose and 0.5 mg/kg per dose Ritalin compared to placebo in separate 2-week trials. Each treatment was given three times a day for 7 consecutive days. MEASUREMENTS AND MAIN RESULTS: Parents, blinded to the treatment assignment, assessed side effects via the BSEQ at baseline and at the end of each of the 4 treatment weeks. Univariate odds ratios (OR) were used to describe the magnitude of differences in observed side effects between Ritalin and placebo weeks of the trial for each of the items on the BSEQ. The frequency of the following side effects significantly increased with Ritalin therapy: insomnia (OR = 3.13, 95% confidence interval [CI] = (1.80,5.42)), appetite disturbance (OR = 19.00, 95% CI = (9.18,39.31)), stomachache (OR = 7.00, 95% CI = (3.29, 14.89)), headache (OR = 5.29, 95% CI = (2.51,11.15)), and dizziness (OR = 7.50, 95% CI = (1.93,29.13)). The frequency of the following side effects significantly decreased with Ritalin therapy: staring and daydreaming (OR = 0.47, 95% CI = (0.27,0.84)), irritability (OR = 0.33, 95% CI = (0.18,0.61)), anxiety (OR = 0.42, 95% CI = (0.23,0.76)), and nailbiting (OR = 0.19, 95% CI = (0.07, 0.53)). The incidence rates of the remaining BSEQ items did not differ significantly between the Ritalin and placebo weeks of the trial. CONCLUSION: The BSEQ proved to be clinically effective in tracking Ritalin side effects and should be incorporated into the routine evaluation and monitoring of ADHD patients for whom stimulants are prescribed.     

Multivariate analysis of risk factors for infection due to penicillin-resistant and multidrug-resistant Streptococcus pneumoniae: a multicenter study

Pneumococcal disease was studied prospectively to determine the risk factors associated with resistance to penicillin and other antibiotics. One hundred twelve clinically significant pneumococcal isolates were recovered from 95 patients. Approximately one-half (49.47%) of the cases were due to penicillin-resistant strains. Multivariate analysis showed that previous use of beta-lactam antibiotics (odds ratio [OR], 2.81; 95% confidence interval [CI], 0.95-8.27), alcoholism (OR, 5.22; 95% CI, 1.43-19.01), and noninvasive disease (OR, 4.53; 95% CI, 1.54-13.34) were associated with penicillin resistance, whereas intravenous drug use (OR, 0.14; 95% CI, 0.03-0.74) was not. Statistical analyses of the variables associated with resistance to multiple antibiotics detected age of younger than 5 years (OR, 16.79; 95% CI, 1.60-176.34) or of 65 years or older (OR, 4.33; 95% CI, 1.42-13.21) and previous use of beta-lactam antibiotics by patients with noninvasive disease (OR, 7.92; 95% CI, 1.84-34.06) as parameters associated with increased risk. We conclude that multivariate analysis provides clues for empirical therapy for pneumococcal infection.     

ACE inhibitor use is associated with hospitalization for severe hypoglycemia in patients with diabetes. DARTS/MEMO Collaboration. Diabetes Audit and Research in Tayside, Scotland. Medicines Monitoring Unit

OBJECTIVE: To evaluate the association between the use of ACE inhibitors and hospital admission for severe hypoglycemia and to explore the effects of potential confounding variables on this relationship. RESEARCH DESIGN AND METHODS: The association between the use of ACE inhibitors and the incidence of hypoglycemia is controversial. A recent study reported that 14% of all hospital admissions for hypoglycemia might be attributable to ACE inhibitors. We performed a nested case-control study, using a cohort of 6,649 diabetic patients taking insulin or oral antidiabetic drugs, on the Diabetes Audit and Research in Tayside, Scotland (DARTS) database. From 1 January 1993 to 30 April 1994, we identified 64 patients who had been admitted to Tayside hospitals with hypoglycemia and selected 440 control patients from the same cohort. RESULTS: Hypoglycemia was associated with the use of ACE inhibitors (odds ratio [OR] 3.2, 95% CI 1.2-8.3, P = 0.023), whereas use of beta-blockers and calcium antagonists was not associated with an increased risk of hospitalization for hypoglycemia with ORs of 0.9 (95% CI 0.3-3.3) and 1.7 (95% CI 0.2-2.1), respectively. There were significant differences between case and control patients in type of diabetes treatment, diabetes duration, place of routine diabetes care, and congestive cardiac failure. These differences did not confound the relationship between ACE inhibitors and hypoglycemia (adjusted OR 4.3, 95% CI 1.2-16.0). CONCLUSIONS: The results show that the association between ACE inhibitor therapy and hospital admission for severe hypoglycemia is not explained by these confounding factors. Although ACE inhibitors have distinct advantages over other antihypertensive drugs in diabetes, the risk of hypoglycemia should be considered.     

Predischarge two-dimensional echocardiographic evaluation of left ventricular thrombosis after acute myocardial infarction in the GISSI-3 study

Left ventricular (LV) thrombosis can be found in patients with acute myocardial infarction (AMI). No wide multicenter trial on AMI has provided information about LV thrombosis until now. The protocol of the GISSI-3 study included the search for the presence of LV thrombosis in patients from 200 coronary care units that did not specifically focus on LV thrombosis. We examined the GISSI-3 database results related to 8,326 patients at low to medium risk for LV thrombi in which a predischarge echocardiogram (9 +/- 5 days) was available. LV thrombosis was found in 427 patients (5.1%): 292 of 2,544 patients (11.5%) with anterior AMI and in 135 of 5,782 patients (2.3%) with AMI in other sites (p <0.0001). The incidence of LV thrombosis was higher in patients with ejection fraction < or = 40% (151 of 1,432 [10.5%] vs 276 of 6,894 [4%]; p <0.0001) both in the total population and in the subgroup with anterior AMI (106 of 597 [17.8%] vs 186 of 1,947 [9.6%]; p <0.0001). Multivariate analysis showed that only the Killip class > I and early intravenous beta-blocker administration were independently associated with higher LV thrombosis risk in the subgroup of patients with anterior AMI (odds ratio 1.75, 95% confidence interval 1.28 to 2.39; odds ratio 1.32, 95% confidence interval 1.02 to 1.72, respectively). In patients with anterior AMI, oral beta-blocker therapy given or not given after early intravenous beta-blocker administration does not influence the occurrence of LV thrombosis. The rate of LV thrombosis was similar in patients treated or not treated with nitrates and lisinopril both in the total population and in patients with anterior and nonanterior AMI. In conclusion, in the GISSI-3 population at low to medium risk for LV thrombi, the highest rate of occurrence of LV thrombosis was found among patients with anterior AMI and an ejection fraction < 40%. Killip class > I and the early intravenous beta-blocker administration were the only variables independently associated with a higher predischarge incidence of LV thrombosis after anterior AMI.     

Antiarrhythmic therapies for the prevention of sudden cardiac death

Despite remarkable advances in cardiovascular therapeutics, sudden cardiac death remains a significant problem. In this review, data from clinical trials and other studies on antiarrhythmic therapies have been evaluated in order to determine effective strategies for the prevention of sudden cardiac death in high risk patients. Overall, routine prophylactic use of class I antiarrhythmic agents in high risk patients, mostly survivors of acute myocardial infarction, is associated with increased risk of death [61 trials, 23,486 patients: odds ratio (OR) 1.13; 95% confidence interval (CI) 1.01 to 1.27, p < 0.05]. Conversely, beta-blockers are associated with highly significant reductions in risk of death in postinfarction patients (56 trials, 53,521 patients: OR 0.81; 95% CI 0.75 to 0.87, p < 0.00001). Overall data from the amiodarone trials on high risk patients, including postinfarction patients, patients with congestive heart failure or survivors of cardiac arrest, suggest that this agent is effective in reducing the risk of death (14 trials, 5713 patients: OR 0.83; 95% CI 0.72 to 0.95, p = 0.01) although further studies are needed to better define which types of patients will potentially benefit most from this agent. No benefits were seen with calcium channel blockers (26 trials, 21,644 patients: OR 1.03; 95% CI 0.94 to 1.13, p = NS). The implantable cardioverter-defibrillator is a promising option for high risk patients, but definition of its role awaits the completion of ongoing clinical trials. Since causes of sudden death are heterogeneous, the clinician should pursue a multifactorial approach to its prevention. Primary and secondary prevention of cardiac ischaemia, through the treatment of cardiovascular risk factors and maximising the use of aspirin, beta-blockers, lipid-lowering drugs, and angiotensin converting enzyme inhibitors after acute myocardial infarction, should lead to a future decrease in the incidence of sudden cardiac death.     

Body weight and risk of nonfatal acute myocardial infarction among women: a case-control study from northern Italy

BACKGROUND: The relationship between nonfatal acute myocardial infarction (AMI) and self-reported body weight and body mass index (BMI; Quetelet index, kg/m2) has been investigated. METHODS: A case-control study was conducted between 1983 and 1992 in northern Italy on 432 women with nonfatal AMI and 867 controls in hospital for acute, noncardiovascular, nonneoplastic, nondigestive, non-hormone-related conditions. Odds ratios (OR), with their 95% confidence intervals (CI), were computed by unconditional multiple logistic regression analysis, including terms for age, education, and smoking, plus history of selected diseases. RESULTS: Women with body weight and BMI in the highest quartile had an increased risk of AMI after allowance for age, education, and smoking status (OR 1.5, 95% CI 1.0 to 2.2, and OR 1.7, 95% CI 1.2 to 2.4, respectively). Compared with leaner women, the risk was higher among women with BMI above the median, in association with a history of diabetes (OR 5.2) or hyperlipidemia (OR 6.0). Hypertensive women had similar OR in the two strata of BMI (OR 5.1 and 4.8). The association of BMI with risk of AMI was apparently stronger among women younger than 50 years and among less educated women, but was similar among smokers and never smokers. CONCLUSIONS: The results of this study confirm that AMI among women is related to excess BMI, with a population attributable risk of 17%. The excess risk was substantial among overweight women with history of diabetes or hyperlipidemia, stressing the importance of controlling body weight among these women.     

Differences in risk factors for being either a hepatitis B carrier or anti-hepatitis C+ in a hepatoma-hyperendemic area in rural Taiwan

This is a study of the differences in the risk factors for being either hepatitis B surface antigen positive [HBsAg(+)] or antibody to hepatitis C virus positive [Anti-HCV(+)] in A-Lein, a rural area in southern Taiwan, an area which also has a high hepatoma mortality rate. Three hundred eighty-five patients age > or =40 years participated in hepatoma screening at the A-Lein Community Health Center during 1995. Those who were HBsAg(-) and anti-HCV(-) or had coinfection of HBsAg(+) and anti-HCV(+) were excluded, leaving 293 patients: 109 HBsAg(+) and 184 anti-HCV(+). The anti-HCV(+) patients had a lower socioeconomic status (as defined by level of education and type of occupation) and were older than HBsAg(+) patients (P < 0.05). Those with higher alanine aminotransferase levels (ALT) also had a higher anti-HCV(+) to HBsAg(+) odds ratio (OR), and a dose response relationship was found, P < 0.0001. Anti-HCV(+) patients were more likely than HBsAg(+) patients to have a spouse who shared the infection, OR = 5.11; 95% CI, 2.30-11.28. Anti-HCV(+) patients were more likely than HBsAg(+) patients to have had blood transfusions (OR = 2.66; 95% CI, 1.20-5.89), frequent medical injections (OR = 2.64; 95% CI, 1.62-4.31), or injections by non-licensed medical providers (OR = 1.91; 95% CI, 1.18-3.09). Multiple logistic regression analysis showed that the significant factors for anti-HCV(+) patients vs. HBsAg(+) patients are drinking habit (OR = 3.45; 95% CI, 1.02-11.60), age (OR = 6.33; 95% CI, 2.93-13.68), and frequent medical injections (OR = 2.88; 95% CI, 1.65-5.03). The transmission of hepatitis C in A-Lein is closely related to low socioeconomic status, age, alcohol abuse, spouses being anti-HCV(+), and frequent medical injections, especially from non-licensed medical providers, including both pharmacists and those with no medical licensing whatsoever. These nonlicensed medical providers sometimes reuse needles to save money, which is a likely route of infection.