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We examined the association of hormone therapy (HRT) with hemorrhagic and ischemic stroke among postmenopausal women with acute myocardial infarction (AMI).Hemorrhagic and ischemic strokes are common complications of AMI, and women are at increased risk for hemorrhagic stroke after thrombolytic therapy. This risk may be related to female hormones.Using data from the National Registry of Myocardial Infarction-3, we studied 114,724 women age 55 years or older admitted to the hospital for AMI, of whom 7,353 reported HRT use on admission. We determined rates of in-hospital hemorrhagic and ischemic stroke stratified by HRT use and estimated the independent association of HRT with each stroke type using multivariable logistic regression.The HRT users were younger than non-users, had fewer risk factors for stroke including diabetes and prior stroke, and received more pharmacologic and invasive therapy including cardiac catheterization. A total of 2,152 (1.9%) in-hospital strokes occurred, with 442 (0.4%) hemorrhagic, 1,017 (0.9%) ischemic and 693 (0.6%) unspecified. Among HRT users and non-users, the rates of hemorrhagic stroke (0.40% vs. 0.42%, p = 1.00) and ischemic stroke (0.80% vs. 0.96%, p = 0.11) were similar. Among 13,328 women who received thrombolytic therapy, the rate of hemorrhagic stroke was not significantly different for users and non-users (1.6% vs. 2.1%, p = 0.22). After adjustment for baseline and treatment differences, HRT was not associated with hemorrhagic (odds ratio [OR], 0.88; 95% confidence intervals [CI], 0.58 to 1.35) or ischemic stroke (OR, 0.89; CI, 0.66 to 1.18).Acute myocardial infarction is a high-risk setting for stroke among postmenopausal women, but HRT does not appear to modify that risk. Clinicians should not alter their approach to thrombolytic therapy based on HRT use.

We sought to determine the importance of chest pain on presentation as a predictor of in-hospital treatment and mortality in myocardial infarction (MI) patients with left bundle-branch block (LBBB).Left bundle-branch block patients have a high mortality after MI but are unlikely to receive reperfusion therapy despite evidence from clinical trials demonstrating the efficacy of thrombolytic therapy. Nearly half of MI patients with LBBB present without chest pain.We studied the clinical features, treatment and in-hospital survival of 29,585 patients with LBBB enrolled in the National Registry of MI 2 June 1994 through March 1998). Multivariate logistic regression was used to assess the independent effect of chest pain on reperfusion decisions and in-hospital mortality.Left bundle-branch block patients with chest pain were greater than five-fold more likely to receive reperfusion therapy (13.6% vs. 2.6%) than LBBB patients without chest pain; they were also more likely to receive aspirin, beta-adrenergic blocking agents, heparin and nitrates (all p0.0001). Unadjusted in-hospital mortality was 18% in patients with chest pain and 27% in patients without chest pain. Adjusting for patient characteristics reduced the odds ratio associated with the absence of chest pain from 1.47 (95% confidence interval: 1.41 to 1.54) to 1.21 (95% confidence interval: 1.12 to 1.30). The remainder of the mortality difference was caused by the undertreatment of patients without chest pain, particularly the low utilization of aspirin and beta-blockers.Left bundle-branch block patients with MI who present without chest pain are less likely to receive optimal therapy and are at increased risk of death. Prompt recognition and treatment of this high-risk subgroup should improve survival.

To assess previous missed opportunities for rubella screening and vaccination of women delivering infants with congenital rubella syndrome and to discuss prevention strategies.Descriptive analysis of data collected through interviews and review of medical records.Twenty-one women who delivered infants with congenital rubella syndrome in four Southern California counties from January 1, 1990, through January 8, 1991.Twelve (57%) of the women had a total of 22 known missed opportunities for rubella screening or vaccination. Of the 22 missed opportunities, three (14%) were missed screenings at the time of marriage, two (9%) were missed screenings during previous pregnancies, five (23%) were missed screenings during induced abortions, and 12 (55%) were missed opportunities for vaccination postpartum or after induced abortions. Nine (43%) of the women had no known missed opportunities for rubella screening or vaccination. Of 12 women educated in California, only four (33%) were subject to the 1982 California school rubella immunization requirement.Congenital rubella syndrome could have been prevented in more than half of the infants born to these women if missed opportunities for rubella testing and/or vaccination had not occurred. Because premarital rubella testing and school immunization requirements do not ensure that all women of childbearing age are immune to rubella, physicians and hospitals should establish procedures for postpartum rubella vaccination of susceptible women. Family planning and abortion clinics should implement routine rubella testing and follow-up vaccination of susceptible women.