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Purpose: The aim of this statement is to summarize data on stroke risk factors that are unique to and more common in women than men and to expand on the data provided in prior stroke guidelines and cardiovascular prevention guidelines for women. This guideline focuses on the risk factors unique to women, such as reproductive factors, and those that are more common in women, including migraine with aura, obesity, metabolic syndrome, and atrial fibrillation., Methods: Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through May 15, 2013. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee., Results: We provide current evidence, research gaps, and recommendations on risk of stroke related to preeclampsia, oral contraceptives, menopause, and hormone replacement, as well as those risk factors more common in women, such as obesity/metabolic syndrome, atrial fibrillation, and migraine with aura., Conclusions: To more accurately reflect the risk of stroke in women across the lifespan, as well as the clear gaps in current risk scores, we believe a female-specific stroke risk score is warranted.

Background: Although prospective studies, systematic reviews, and meta-analyses have documented an association between depression and increased morbidity and mortality in a variety of cardiac populations, depression has not yet achieved formal recognition as a risk factor for poor prognosis in patients with acute coronary syndrome by the American Heart Association and other health organizations. The purpose of this scientific statement is to review available evidence and recommend whether depression should be elevated to the status of a risk factor for patients with acute coronary syndrome., Methods and Results: Writing group members were approved by the American Heart Association's Scientific Statement and Manuscript Oversight Committees. A systematic literature review on depression and adverse medical outcomes after acute coronary syndrome was conducted that included all-cause mortality, cardiac mortality, and composite outcomes for mortality and nonfatal events. The review assessed the strength, consistency, independence, and generalizability of the published studies. A total of 53 individual studies (32 reported on associations with all-cause mortality, 12 on cardiac mortality, and 22 on composite outcomes) and 4 meta-analyses met inclusion criteria. There was heterogeneity across studies in terms of the demographic composition of study samples, definition and measurement of depression, length of follow-up, and covariates included in the multivariable models. Despite limitations in some individual studies, our review identified generally consistent associations between depression and adverse outcomes., Conclusions: Despite the heterogeneity of published studies included in this review, the preponderance of evidence supports the recommendation that the American Heart Association should elevate depression to the status of a risk factor for adverse medical outcomes in patients with acute coronary syndrome.

Background: Older women experience higher complication rates and mortality after percutaneous coronary intervention (PCI) than men, but there is limited evidence about sex-based differences in outcomes among younger patients. We compared rates of complications and inhospital mortality by sex for younger and older PCI patients., Methods: A total of 1,079,751 hospital admissions for PCI were identified in the CathPCI Registry(®) from 2005 to 2008. Complication rates (general, bleeding, bleeding with transfusion, and vascular) and inhospital mortality after PCI were compared by sex and age (<55 and ≥55 years). Analyses were adjusted for demographic and clinical factors and stratified by PCI type (elective, urgent, or emergency)., Results: Overall, 6% of patients experienced complications, and 1% died inhospital. Unadjusted complication rates were higher for women compared with men in both age groups. In risk-adjusted analyses, younger women (odds ratio 1.24, 95% CI 1.16-1.33) and older women (1.27, 1.09-1.47) were more likely to experience any complication than similarly aged men. The increased risk persisted across complication categories and PCI type. Within age groups, risk-adjusted mortality was marginally higher for young women (1.19, 1.00-1.41), but not for older women (1.03, 0.97-1.10). In analyses stratified by PCI type, young women had twice the mortality risk after an elective procedure as young men (2.04, 1.15-3.61)., Conclusions: Women, regardless of age, experience more complications after PCI than men; young women are at increased mortality risk after an elective PCI. Identifying strategies to reduce adverse outcomes, particularly for women younger than 55 years, is important., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Using a sample of 2925 stroke-free participants drawn from a national population-based study, we examined cross-sectional associations of obstructive sleep apnea (OSA) risk with cognition and quality of life and whether these vary with age, while controlling for demographics and comorbidities. Included participants from the REasons for Geographic And Racial Differences in Stroke (REGARDS) study were aged 47-93 years. OSA risk was categorized as high or low based on responses to the Berlin Sleep Questionnaire. Cognitive function was assessed with standardized fluency and recall measures. Depressive symptoms were assessed with the four-item Center for Epidemiologic Studies Depression Scale. Health-related quality of life (HRQoL) was assessed with the Medical Outcomes Study Short Form-12 (SF-12). Multivariate analyses of covariance (mancova) statistics were applied separately to the cognitive and quality of life dependent variables while accounting for potential confounders (demographics, comorbidities). In fully adjusted models, those at high risk for OSA had significantly lower cognitive scores (Wilks' lambda = 0.996, F3,2786  = 3.31, P < 0.05) and lower quality of life [depressive symptoms and HRQoL] (Wilks' lambda = 0.989, F3,2786  = 10.02, P < 0.0001). However, some of the associations were age-dependent. Differences in cognition and quality of life between those at high and low obstructive sleep apnea risk were most pronounced during middle age, with attenuated effects after age 70 years., (© 2013 European Sleep Research Society.)

Background and Purpose: Stroke mortality has been declining since the early 20th century. The reasons for this are not completely understood, although the decline is welcome. As a result of recent striking and more accelerated decreases in stroke mortality, stroke has fallen from the third to the fourth leading cause of death in the United States. This has prompted a detailed assessment of the factors associated with the change in stroke risk and mortality. This statement considers the evidence for factors that have contributed to the decline and how they can be used in the design of future interventions for this major public health burden., Methods: Writing group members were nominated by the committee chair and co-chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiological studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize evidence and to indicate gaps in current knowledge. All members of the writing group had the opportunity to comment on this document and approved the final version. The document underwent extensive American Heart Association internal peer review, Stroke Council leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee., Results: The decline in stroke mortality over the past decades represents a major improvement in population health and is observed for both sexes and for all racial/ethnic and age groups. In addition to the overall impact on fewer lives lost to stroke, the major decline in stroke mortality seen among people <65 years of age represents a reduction in years of potential life lost. The decline in mortality results from reduced incidence of stroke and lower case-fatality rates. These significant improvements in stroke outcomes are concurrent with cardiovascular risk factor control interventions. Although it is difficult to calculate specific attributable risk estimates, efforts in hypertension control initiated in the 1970s appear to have had the most substantial influence on the accelerated decline in stroke mortality. Although implemented later, diabetes mellitus and dyslipidemia control and smoking cessation programs, particularly in combination with treatment of hypertension, also appear to have contributed to the decline in stroke mortality. The potential effects of telemedicine and stroke systems of care appear to be strong but have not been in place long enough to indicate their influence on the decline. Other factors had probable effects, but additional studies are needed to determine their contributions., Conclusions: The decline in stroke mortality is real and represents a major public health and clinical medicine success story. The repositioning of stroke from third to fourth leading cause of death is the result of true mortality decline and not an increase in mortality from chronic lung disease, which is now the third leading cause of death in the United States. There is strong evidence that the decline can be attributed to a combination of interventions and programs based on scientific findings and implemented with the purpose of reducing stroke risks, the most likely being improved control of hypertension. Thus, research studies and the application of their findings in developing intervention programs have improved the health of the population. The continued application of aggressive evidence-based public health programs and clinical interventions is expected to result in further declines in stroke mortality.

Background and Purpose: The Centers for Medicare and Medicaid Services proposes to use 30-day hospital readmissions after ischemic stroke as part of the Hospital Inpatient Quality Reporting Program for payment determination beginning in 2016. The proportion of poststroke readmissions that is potentially preventable is unknown., Methods: Thirty-day readmissions for all Medicare fee-for-service beneficiaries aged≥65 years discharged alive with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision, Clinical Modification 433, 434, 436) between December 2005 and November 2006 were analyzed. Preventable readmissions were identified based on 14 Prevention Quality Indicators developed for use with administrative data by the US Agency for Healthcare Research and Quality. National, hospital-level, and regional preventable readmission rates were estimated. Random-effects logistic regression was also used to determine patient-level factors associated with preventable readmissions., Results: Among 307 887 ischemic stroke discharges, 44 379 (14.4%) were readmitted within 30 days; 5322 (1.7% of all discharges) were the result of a preventable cause (eg, pneumonia), and 39 057 (12.7%) were for other reasons (eg, cancer). In multivariate analysis, older age and cardiovascular-related comorbid conditions were strong predictors of preventable readmissions. Preventable readmission rates were highest in the Southeast, Mid-Atlantic, and US territories and lowest in the Mountain and Pacific regions., Conclusions: On the basis of Agency for Healthcare Research and Quality Prevention Quality Indicators, we found that a small proportion of readmissions after ischemic stroke were classified as preventable. Although other causes of readmissions not reflected in the Agency for Healthcare Research and Quality measures could also be avoidable, hospital-level programs intended to reduce all-cause readmissions and costs should target high-risk patients.

Background and Purpose: Stroke is a leading cause of disability, cognitive impairment, and death in the United States and accounts for 1.7% of national health expenditures. Because the population is aging and the risk of stroke more than doubles for each successive decade after the age of 55 years, these costs are anticipated to rise dramatically. The objective of this report was to project future annual costs of care for stroke from 2012 to 2030 and discuss potential cost reduction strategies., Methods and Results: The American Heart Association/American Stroke Association developed methodology to project the future costs of stroke-related care. Estimates excluded costs associated with other cardiovascular diseases (hypertension, coronary heart disease, and congestive heart failure). By 2030, 3.88% of the US population>18 years of age is projected to have had a stroke. Between 2012 and 2030, real (2010$) total direct annual stroke-related medical costs are expected to increase from $71.55 billion to $183.13 billion. Real indirect annual costs (attributable to lost productivity) are projected to rise from $33.65 billion to $56.54 billion over the same period. Overall, total annual costs of stroke are projected to increase to $240.67 billion by 2030, an increase of 129%., Conclusions: These projections suggest that the annual costs of stroke will increase substantially over the next 2 decades. Greater emphasis on implementing effective preventive, acute care, and rehabilitative services will have both medical and societal benefits.

Background: Modification of traditional cardiac risk factors is an important goal for patients after an acute myocardial infarction (AMI). Risk factor prevalence and secondary prevention efforts at discharge are well characterized among older patients; however, research is limited for younger and minority AMI populations, particularly among women., Methods: Among 2369 AMI patients enrolled in a 19-center prospective study, we compared the prevalence and cumulative number of five cardiac risk factors (hypertension, hypercholesterolemia, current smoking, diabetes, obesity) by age, sex, and race. We also compared secondary prevention strategies at discharge for these risk factors, including prescription of antihypertensive or lipid-lowering medications and counseling on preventive behaviors (smoking cessation, diabetes management, diet/weight management)., Results: Approximately 93% of patients had ≥1 risk factor, 72% had ≥2 factors, and 40% had ≥3 factors. The prevalence of multiple risk factors was markedly higher for blacks than for whites within each age-sex group; black women had the greatest risk factor burden of any subgroup (60% of older black women and 54% of younger black women had ≥3 risk factors). Secondary prevention efforts for smoking cessation were less common for black compared with white patients, and younger black patients were less often prescribed antihypertensive and lipid-lowering medications compared with younger white patients., Conclusions: Multiple cardiac risk factors are highly prevalent in AMI patients, particularly among black women. Secondary prevention efforts, however, are less common for blacks compared to whites, especially among younger patients. Our findings highlight the need for improved risk factor modification efforts in these high-risk subgroups.

Background and Purpose: A systematic review found an association between the July start of internships and residencies and higher mortality rates for hospitalized patients, but data related to stroke are limited. We assessed seasonal variations in 30-day risk-adjusted mortality rates (RAMRs) after ischemic stroke by hospital teaching status., Methods: The analysis included all fee-for-service Medicare beneficiaries aged ≥ 65 years with a primary discharge diagnosis of ischemic stroke (International Classification of Diseases, 9th revision, codes 433, 434, and 436) from 1999 to 2006. Hierarchical linear regression models calculated RAMRs, adjusting for patient demographics and comorbidities. Annual data were combined and reconstructed for time series analyses; RAMRs were calculated for each month. Structural models compared monthly seasonal patterns stratified by hospital teaching status., Results: Of 2 824 694 ischemic stroke discharges, 51.7% were from teaching hospitals. There were seasonal patterns within each calendar year, with the highest 30-day RAMR in the winter and the lowest in the summer, but with a smaller peak in July. Thirty-day RAMRs decreased from 1999 to 2006, as did seasonal variations within each calendar year. Seasonal patterns were similar for teaching and nonteaching hospitals., Conclusions: The 30-day RAMR decreased overall, but seasonal patterns were present, with the highest RAMR in January and a smaller peak in July. Because patterns were similar for teaching and nonteaching hospitals, the July peak cannot be explained by the introduction of new trainees in the beginning of the academic year. The reasons for these seasonal patterns warrant further investigation.

Background: Previous studies show that black patients undergo carotid endarterectomy (CEA) less frequently than white patients. Diagnostic imaging is necessary to determine whether a patient is a candidate for the operation. We determined whether there were differences in the use of diagnostic carotid imaging and the frequency of CEA between elderly black and white ischemic stroke patients., Methods: Medicare fee-for-service beneficiaries with discharge diagnoses of ischemic stroke (International Classification of Diseases, 9th revision codes 433, 434, and 436) were randomly selected for inclusion in the National Stroke Project 1998-1999, 2000-2001. Receipt of at least one type of carotid imaging study was compared for black and white patients. Binomial logistic regression models were used to evaluate the associations between race and receipt of carotid imaging and CEA with adjustment for demographics, degree of carotid artery stenosis, and other clinical covariates., Results: Among 19,639 stroke patients (1974 black, 17,655 white), 69.6% received at least 1 diagnostic carotid imaging test (blacks 68.4%; whites 69.7%; P = .233). After risk adjustment, blacks were less likely to receive carotid imaging (adjusted odds ratio [OR] 0.87; 95% confidence interval [CI] 0.78-0.97). There was no relationship between race and the receipt of CEA after adjustment for degree of carotid stenosis and other covariates (adjusted OR 1.14; 95% CI 0.66-1.96)., Conclusions: Black ischemic stroke patients were less likely to receive diagnostic carotid imaging than white patients, although the difference was small and only significant after risk adjustment. There was no difference in the proportion having CEA after adjustment for degree of carotid artery stenosis and other clinical factors., (Copyright © 2012 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Objective: To examine changes in social support during early recovery after acute myocardial infarction (AMI) and determine whether these changes influence outcomes within the first year., Methods: Among 1951 AMI patients enrolled in a 19-center prospective study, we examined changes in social support between baseline (index hospitalization) and 1 month post-AMI to longitudinally assess their association with health status and depressive symptoms within the first year. We further examined whether 1-month support predicted outcomes independent of baseline support. Hierarchical repeated-measures regression evaluated associations, adjusting for site, baseline outcome level, baseline depressive symptoms, sociodemographic characteristics, and clinical factors., Results: During the first month of recovery, 5.6% of patients had persistently low support, 6.4% had worsened support, 8.1% had improved support, and 80.0% had persistently high support. In risk-adjusted analyses, patients with worsened support (vs. persistently high) had greater risk of angina (relative risk=1.46), lower disease-specific quality of life (β=7.44), lower general mental functioning (β=4.82), and more depressive symptoms (β=1.94) (all p≤.01). Conversely, patients with improved support (vs. persistently low) had better outcomes, including higher disease-specific quality of life (β=6.78), higher general mental functioning (β=4.09), and fewer depressive symptoms (β=1.48) (all p≤.002). In separate analyses, low support at 1 month was significantly associated with poorer outcomes, independent of baseline support level (all p≤.002)., Conclusion: Changes in social support during early AMI recovery were not uncommon and were important for predicting outcomes. Intervening on low support during early recovery may provide a means of improving outcomes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Emotional support and depression may influence adherence to risk factor management instructions after acute myocardial infarction (AMI), but their role requires further investigation., Purpose: To examine the longitudinal association between perceived emotional support and risk factor management adherence and assess depressive symptoms as a moderator of this association., Methods: Among 2,202 AMI patients, we assessed adherence to risk factor management instructions over the first recovery year. Modified Poisson mixed-effects regression evaluated associations, with adjustment for demographic and clinical factors., Results: Patients with low baseline support had greater risk of poor adherence over the first year than patients with high baseline support (relative risk [RR] = 1.20, 95% confidence interval [CI] = 1.02-1.43). In stratified analyses, low support remained a significant predictor of poor adherence for non-depressed (RR = 1.41, 95% CI = 1.23-1.61) but not depressed (RR = 1.01, 95% CI = 0.78-1.30) patients (p for interaction < 0.001)., Conclusions: Low emotional support is associated with poor risk factor management adherence after AMI. This relationship is moderated by depression, with a significant relationship observed only among non-depressed patients.

Background: Somatic depressive symptoms and certain biomarkers are each associated with worse acute myocardial infarction (AMI) prognosis, but the relationship between depressive symptom domains and inflammatory, neurohormonal, and coagulation markers is unknown., Methods: We examined the relationship between depressive symptoms and 1-month biomarker levels (high-sensitivity C-reactive protein [hs-CRP], N-terminal pro-brain natriuretic peptide [NT-proBNP], white blood cell [WBC], platelet counts) in 1265 AMI patients. Depressive symptoms (9-item Patient Health Questionnaire) were assessed during index hospitalization and categorized as somatic or cognitive. Using median regression models, the upper quartile of somatic and cognitive depression scores and each biomarker were compared with the lower three quartiles, adjusting for site, demographics, and clinical characteristics., Results: Although hs-CRP values were higher in patients with somatic symptoms, this association was attenuated after adjustment (B(per SD increase) = .02, 95% confidence interval: .00; .05, p = .07). WBC count was independently associated with somatic depressive symptoms (B(per SD increase) = .28, 95% confidence interval: .12; .44, p < .001). Cognitive depressive symptoms were not associated with hs-CRP or WBC count. Neither dimension was associated with NT-proBNP or platelet levels. For each biomarker, the depression dimensions explained <1% of their variation., Conclusions: Neither somatic nor cognitive depressive symptoms were meaningfully associated with hs-CRP, NT-proBNP, WBC, or platelet counts 1 month after AMI, suggesting that the association between depression and long-term outcomes may be unrelated to these biomarkers. Future research should explore other biomarkers to better illuminate pathways by which depression adversely impacts AMI prognosis., (Copyright © 2012 Society of Biological Psychiatry. Published by Elsevier Inc. All rights reserved.)

Background and Purpose: Ischemic stroke patients treated at Joint Commission Primary Stroke Center (JC-PSC)-certified hospitals have better outcomes. Data reflecting the impact of JC-PSC status on outcomes after hemorrhagic stroke are limited. We determined whether 30-day mortality and readmission rates after hemorrhagic stroke differed for patients treated at JC-PSC-certified versus noncertified hospitals., Methods: The study included all fee-for-service Medicare beneficiaries aged 65 years or older with a primary discharge diagnosis of subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH) in 2006. Covariate-adjusted logistic and Cox proportional hazards regression assessed the effect of care at a JC-PSC-certified hospital on 30-day mortality and readmission., Results: There were 2305 SAH and 8708 ICH discharges from JC-PSC-certified hospitals and 3892 SAH and 22 564 ICH discharges from noncertified hospitals. Unadjusted in-hospital mortality (SAH: 27.5% versus 33.2%, P<0.0001; ICH: 27.9% versus 29.6%, P=0.003) and 30-day mortality (SAH: 35.1% versus 44.0%, P<0.0001; ICH: 39.8% versus 42.4%, P<0.0001) were lower in JC-PSC hospitals, but 30-day readmission rates were similar (SAH: 17.0% versus 17.0%, P=0.97; ICH: 16.0% versus 15.5%, P=0.29). Risk-adjusted 30-day mortality was 34% lower (odds ratio, 0.66; 95% confidence interval, 0.58-0.76) after SAH and 14% lower (odds ratio, 0.86; 95% confidence interval, 0.80-0.92) after ICH for patients discharged from JC-PSC-certified hospitals. There was no difference in 30-day risk-adjusted readmission rates for SAH or ICH based on JC-PSC status., Conclusions: Patients treated at JC-PSC-certified hospitals had lower risk-adjusted mortality rates for both SAH and ICH but similar 30-day readmission rates as compared with noncertified hospitals.

Background: The use of antithrombotic medications after ischemic stroke is recommended for deep vein thrombosis prophylaxis and secondary stroke prevention. We assessed the rate of receipt of these therapies among eligible ischemic stroke patients age ≥65 years and determined the effects of age and other patient characteristics on treatment., Methods and Results: The analysis included Medicare fee-for-service beneficiaries discharged with ischemic stroke (ICD 433.x1, 434.x1, 436) randomly selected for inclusion in the Medicare Health Care Quality Improvement Program's National Stroke Project 1998 to 1999, 2000 to 2001. Patients discharged from nonacute facilities, transferred, or terminally ill were excluded. Receipt of in-hospital pharmacological deep vein thrombosis prophylaxis, antiplatelet medication, anticoagulants for atrial fibrillation, and antithrombotic medications at discharge were assessed in eligible patients, stratified by age (65 to 74, 75 to 84, and 85+ years). Descriptive models identified characteristics associated with treatment. Among 31 554 patients, 14.9% of those eligible received pharmacological deep vein thrombosis prophylaxis, 83.9% antiplatelet drugs, 82.8% anticoagulants for atrial fibrillation, and 74.2% were discharged on an antithrombotic medication. Rates of treatment decreased with age and were lowest for patients ages 85 years or older. Admission from a skilled nursing facility and functional dependence were associated with lower treatment rates., Conclusions: There was substantial underutilization of antithrombotic therapies among elderly ischemic stroke patients, particularly among the very elderly, those admitted from skilled nursing facilities, and patients with functional dependence. The reasons for low use of antithrombotic therapies, including the apparent underutilization of deep vein thrombosis prophylaxis in otherwise eligible patients, require further investigation.

Background: Among individuals with ischemic heart disease, young women with an acute myocardial infarction (AMI) represent an extreme phenotype associated with an excess mortality risk. Although women younger than 55 years of age account for less than 5% of hospitalized AMI events, almost 16 000 deaths are reported annually in this group, making heart disease a leading killer of young women. Despite a higher risk of mortality compared with similarly aged men, young women have been the subject of few studies., Methods and Results: Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients (VIRGO) is a large, observational study of the presentation, treatment, and outcomes of young women and men with AMI. VIRGO will enroll 2000 women, 18 to 55 years of age, with AMI and a comparison cohort of 1000 men with AMI from more than 100 participating hospitals. The aims of the study are to determine sex differences in the distribution and prognostic importance of biological, demographic, clinical, and psychosocial risk factors; to determine whether there are sex differences in the quality of care received by young AMI patients; and to determine how these factors contribute to sex differences in outcomes (including mortality, hospitalization, and health status). Blood serum and DNA for consenting participants will be stored for future studies., Conclusions: VIRGO will seek to identify novel and prognostic factors that contribute to outcomes in this young AMI population. Results from the study will be used to develop clinically useful risk-stratification models for young AMI patients, explain sex differences in outcomes, and identify targets for intervention.

Context: Whether decreases in the length of stay during the past decade for patients with heart failure (HF) may be associated with changes in outcomes is unknown., Objective: To describe the temporal changes in length of stay, discharge disposition, and short-term outcomes among older patients hospitalized for HF., Design, Setting, and Participants: An observational study of 6,955,461 Medicare fee-for-service hospitalizations for HF between 1993 and 2006, with a 30-day follow-up., Main Outcome Measures: Length of hospital stay, in-patient and 30-day mortality, and 30-day readmission rates., Results: Between 1993 and 2006, mean length of stay decreased from 8.81 days (95% confidence interval [CI], 8.79-8.83 days) to 6.33 days (95% CI, 6.32-6.34 days). In-hospital mortality decreased from 8.5% (95% CI, 8.4%-8.6%) in 1993 to 4.3% (95% CI, 4.2%-4.4%) in 2006, whereas 30-day mortality decreased from 12.8% (95% CI, 12.8%-12.9%) to 10.7% (95% CI, 10.7%-10.8%). Discharges to home or under home care service decreased from 74.0% to 66.9% and discharges to skilled nursing facilities increased from 13.0% to 19.9%. Thirty-day readmission rates increased from 17.2% (95% CI, 17.1%-17.3%) to 20.1% (95% CI, 20.0%-20.2%; all P < .001). Consistent with the unadjusted analyses, the 2005-2006 risk-adjusted 30-day mortality risk ratio was 0.92 (95% CI, 0.91-0.93) compared with 1993-1994, and the 30-day readmission risk ratio was 1.11 (95% CI, 1.10-1.11)., Conclusion: For patients admitted with HF during the past 14 years, reductions in length of stay and in-hospital mortality, less marked reductions in 30-day mortality, and changes in discharge disposition accompanied by increases in 30-day readmission rates were observed.

Background: The association between hospital volume and the death rate for patients who are hospitalized for acute myocardial infarction, heart failure, or pneumonia remains unclear. It is also not known whether a volume threshold for such an association exists., Methods: We conducted cross-sectional analyses of data from Medicare administrative claims for all fee-for-service beneficiaries who were hospitalized between 2004 and 2006 in acute care hospitals in the United States for acute myocardial infarction, heart failure, or pneumonia. Using hierarchical logistic-regression models for each condition, we estimated the change in the odds of death within 30 days associated with an increase of 100 patients in the annual hospital volume. Analyses were adjusted for patients' risk factors and hospital characteristics. Bootstrapping procedures were used to estimate 95% confidence intervals to identify the condition-specific volume thresholds above which an increased volume was not associated with reduced mortality., Results: There were 734,972 hospitalizations for acute myocardial infarction in 4128 hospitals, 1,324,287 for heart failure in 4679 hospitals, and 1,418,252 for pneumonia in 4673 hospitals. An increased hospital volume was associated with reduced 30-day mortality for all conditions (P<0.001 for all comparisons). For each condition, the association between volume and outcome was attenuated as the hospital's volume increased. For acute myocardial infarction, once the annual volume reached 610 patients (95% confidence interval [CI], 539 to 679), an increase in the hospital volume by 100 patients was no longer significantly associated with reduced odds of death. The volume threshold was 500 patients (95% CI, 433 to 566) for heart failure and 210 patients (95% CI, 142 to 284) for pneumonia., Conclusions: Admission to higher-volume hospitals was associated with a reduction in mortality for acute myocardial infarction, heart failure, and pneumonia, although there was a volume threshold above which an increased condition-specific hospital volume was no longer significantly associated with reduced mortality., (2010 Massachusetts Medical Society)

Background: Prior studies have associated low social support (SS) with increased rehospitalization and mortality after acute myocardial infarction. However, relatively little is known about whether similar patterns exist for other outcomes, such as health status and depressive symptoms, and whether these patterns vary by sex., Methods and Results: Using data from 2411 English- or Spanish-speaking patients with acute myocardial infarction enrolled in a 19-center prospective study, we examined the association of SS (low, moderate, high) with health status (angina, disease-specific quality of life, general physical and mental functioning) and depressive symptoms over the first year of recovery. Overall and sex-stratified associations were evaluated using mixed-effects Poisson and linear regression, adjusting for site, baseline health status, baseline depressive symptoms, and demographic and clinical factors. Patients with the lowest SS (relative to those with the highest) had increased risk of angina (relative risk, 1.27; 95% confidence interval [CI], 1.10, 1.48); lower disease-specific quality of life (mean difference [beta]=-3.33; 95% CI, -5.25, -1.41), lower mental functioning (beta=-1.72; 95% CI, -2.65, -0.79), and more depressive symptoms (beta=0.94; 95% CI, 0.51, 1.38). A nonsignificant trend toward lower physical functioning (beta=-0.87; 95% CI, -1.95, 0.20) was observed. In sex-stratified analyses, the relationship between SS and outcomes was stronger for women than for men, with a significant SS-by-sex interaction for disease-specific quality of life, physical functioning, and depressive symptoms (all P<0.02)., Conclusions: Lower SS is associated with worse health status and more depressive symptoms over the first year of acute myocardial infarction recovery, particularly for women.

Background and Purpose: Of the 795,000 strokes occurring in the USA each year, over 20% are recurrent events. Little is known about how the rates of recurrent stroke in the country have changed over time. Our objective was to determine national trends in 1-year recurrent ischemic stroke rates by US county among the elderly from 1994 to 2002., Methods: One-year recurrent stroke rates following incident ischemic stroke (ICD-9 433, 434, 436) among all fee-for-service Medicare beneficiaries were determined by US county for 1994-1996, 1997-1999, and 2000-2002. Bayesian spatiotemporal Poisson modeling was used to determine county-specific trends in recurrent stroke rates over time with risk adjustment for demographics, medical history and comorbid conditions., Results: The analysis included more than 2.5 million beneficiaries (56% women; mean age: 78 years; 87% white; n = 957,933 for 1994-1996; n = 838,330 for 1996-1999; n = 895,916 for 2000-2002) aggregated to all 3,118 US counties. After adjustment for changing patient demographics and comorbidities, there was a 4.5% decrease in recurrent stroke rates from 1994-1996 (13.2%) to 2000-2002 (12.6%; p for trend <0.0001). The geographic and temporal patterns were not uniform; the recurrent stroke rates decreased within sections of the Southeast (the 'stroke belt'), but increased in counties in the middle and western sections of the USA., Conclusions: The overall recurrent ischemic stroke rates declined by almost 5% from 1994 to 2002, but temporal patterns varied markedly by region. Additional research is needed to identify the reasons for this geographic disparity., (Copyright © 2010 S. Karger AG, Basel.)

Background: While geographic disparities in stroke mortality are well documented, there are no data describing geographic variation in recurrent stroke. Accordingly, we evaluated geographic variations in 1-year recurrent ischemic stroke rates in the USA with adjustment for patient characteristics., Methods: One-year recurrent stroke rates for ischemic stroke (International Classification of Diseases, 9th Revision codes 433, 434 and 436) following hospital discharge were calculated by county for all fee-for-service Medicare beneficiaries from 2000 to 2002. The rates were standardized and smoothed using a bayesian conditional autoregressive model that was risk-standardized for patients' age, gender, race/ethnicity, prior hospitalizations, Deyo comorbidity score, acute myocardial infarction, congestive heart failure, diabetes, hypertension, dementia, cancer, chronic obstructive pulmonary disease and obesity., Results: The overall 1-year recurrent stroke rate was 9.4% among 895,916 ischemic stroke patients (mean age: 78 years; 56.6% women; 86.6% White, 9.7% Black and 1.2% Latino/Hispanic). The rates varied by geographic region and were highest in the South and in parts of the West and Midwest. Regional variation was present for all racial/ethnic subgroups and persisted after adjustment for individual patient characteristics., Conclusions: Almost 1 in 10 hospitalized ischemic stroke patients was readmitted for an ischemic stroke within 1 year. There was heterogeneity in recurrence patterns by geographic region. Further work is needed to understand the reasons for this regional variability., (Copyright 2010 S. Karger AG, Basel.)

Background: Relatively little is known about trends in the utilization or outcomes of carotid endarterectomy (CEA) in the very elderly. We determined trends in the rates of CEA and perioperative (in-hospital and 30-day) and long-term (1-, 2-, 3-, 4- and 5-year) mortality in a US national sample of patients >or=80 years of age., Methods: All fee-for-service Medicare patients (80-89 and >or=90 years of age) who had a CEA [ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification): 38.12] from 1993 to 1999 were identified using the Centers for Medicare and Medicaid Services Inpatient Standard Analytic Files. Demographic characteristics and comorbid conditions were determined using ICD-9-CM diagnostic codes within the year prior to the index hospitalization for CEA., Results: A total of 140,376 CEA were performed in patients aged 80-89 years and 6,446 in those aged >or=90 years during this 7-year period. The annual number of operations increased from 13,115 in 1993 to 21,582 in 1999 for octogenarians, and from 481 in 1993 to 1,257 in 1999 for nonagenarians. Perioperative mortality was 2.2% in octogenarians and 3.3% in nonagenarians. Long-term mortality increased by approximately 10% per year after the operation, and was 43% in octogenarians and 56% in nonagenarians at 5 years. Perioperative mortality rates remained relatively stable over the 7-year period for both age groups although comorbidities increased., Conclusions: The number of CEA performed in the very elderly in the USA increased from 1993 to 1999. Perioperative mortality rates were high compared with trial results, while long-term survivorship was comparable to that of similarly-aged peers in the USA., ((c) 2009 S. Karger AG, Basel.)

Depression is commonly present in patients with coronary heart disease (CHD) and is independently associated with increased cardiovascular morbidity and mortality. Screening tests for depressive symptoms should be applied to identify patients who may require further assessment and treatment. This multispecialty consensus document reviews the evidence linking depression with CHD and provides recommendations for healthcare providers for the assessment, referral, and treatment of depression.

Background: We evaluated whether there were sex-related differences in the administration of intravenous tissue plasminogen activator (IV-tPA) to patients with acute ischemic stroke admitted to US academic medical centers., Methods: Medical records were abstracted for consecutive ischemic stroke patients admitted to 32 academic medical centers from January through June, 2004, as part of the University HealthSystem Consortium Ischemic Stroke Benchmarking Project. Multivariate logistic models were used to test for sex-related differences in the receipt of IV-tPA with adjustment for demographic and clinical factors., Results: The study included 1,234 patients (49% women; mean age 66.6 years; 56% white). IV-tPA was given to 7% (6.5% of women versus 7.5% of men, p = 0.49). Women and men were equally likely to receive IV-tPA in risk-adjusted analyses (OR 1.02, 95% CI 0.64-1.64). Approximately 77% of women and men who did not receive IV-tPA did not meet the 3-hour treatment window or their time of onset was unknown., Conclusions: Women admitted to academic hospitals receive IV-tPA as often as men; however, a substantial percentage of both women and men are not arriving within the 3-hour time window required for diagnostic assessment and administration of intravenous thrombolytic therapy. Additional efforts are needed to improve the rapid identification, evaluation and treatment of stroke patients.

Background and Purpose: Differences in the management of women and men with acute coronary symptoms are well documented, but relatively little is known about practices for patients with ischemic stroke. We sought to determine whether there are sex-associated differences in the utilization of diagnostic tests for ischemic stroke patients treated at academic hospitals in the United States., Methods: Medical records were abstracted for consecutive ischemic stroke patients admitted to 32 US academic medical centers from January through June, 2004, as part of the University HealthSystem Consortium Ischemic Stroke Benchmarking Project. We compared the utilization rates of diagnostic tests including neuroimaging (CT or MRI), electrocardiogram (ECG), ultrasound of the carotid arteries, and echocardiography (transthoracic or transesophageal) for women and men. Multivariate logistic regression was used to test for sex differences with adjustment for potential confounders., Results: The study included 1,256 ischemic stroke patients (611 women; 645 men; mean age 66.6 +/- 14.6 years; 56% white). There were no differences between women and men in the use of neuroimaging (odds ratio, OR = 1.37; 95% confidence interval, CI = 0.58-3.24), ECG (OR = 1.00, 95% CI = 0.70-1.44), carotid artery ultrasound (OR = 0.93, 95% CI = 0.72-1.21) or echocardiography (OR = 0.70, 95% CI = 0.70-1.22). The results were similar after covariate adjustment., Conclusions: Women and men admitted to US academic hospitals receive comparable diagnostic evaluations, even after adjusting for sociodemographic and clinical factors., (Copyright 2009 S. Karger AG, Basel.)

Rural U.S. communities face major challenges in ensuring the availability of high-quality health care. We examined whether hospital-specific, all-cause, thirty-day risk-standardized mortality rates (RSMRs) following acute myocardial infarction, heart failure, and pneumonia varied by hospitals' geographic remoteness. We analyzed 2001-2003 Medicare administrative data, comparing RSMRs among hospitals located in urban, large rural, small rural, or remote small rural regions. We found only small mortality differences across remoteness regions for hospitalizations for the three conditions. We examine the implications of these findings for the millions of Americans who rely upon rural hospitals for their care.

Background: Previous studies have demonstrated the effects of single factors, such as age, sex, and race, with longer delays from symptom onset to hospital presentation in patients with ST-elevation myocardial infarction., Methods: We studied risk factors individually and in combination to determine the cumulative effect on delay times in 482,327 patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction between January 1, 1995, and December 31, 2004. We analyzed patient subgroups with the following risk factors in combination: younger than 70 years vs 70 years and older, race/ethnicity, men vs women, and nondiabetic vs diabetic., Results: The geometric mean for delay time was 114 minutes, with a decreasing trend from 123 minutes in 1995 to 113 minutes in 2004 (P < .001). Nearly half of the patients (45.5%) presented more than 2 hours and 8.7% presented more than 12 hours after the onset of symptoms. Compared with the reference group (those < 70 years, men, white, and did not have diabetes mellitus [DM]), subgroups with longer delay times (P < .01 for all) included those younger than 70 years, men, black, and had DM (+43 minutes); those younger than 70 years, women, black, and had DM (+55 minutes); those 70 years and older, men, black, and had DM (+60 minutes); and those 70 years and older, women, black, and had DM (+63 minutes)., Conclusions: Patient subgroups with a combination of factors (older age, women, Hispanic or black race, and DM) have particularly long delay times that may be 60 minutes longer than subgroups without those characteristics. Improving patient responsiveness in these subgroups represents an important opportunity to improve quality of care and minimize disparities in care.

Background: We studied the relationship between longer delays from symptom onset to hospital presentation and the use of any reperfusion therapy, door-to-balloon time, and door-to-drug time., Methods: Cohort study of patients with ST-elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from January 1, 1995 to December 31, 2004. Delay in hospital presentation was categorized into 1-hour intervals as < or =1 hour, >1-2 hours, >2-3 hours, etc, up to >11-12 hours. The study analyzed 3 groups: 440,398 patients for the association between delay and use of any reperfusion therapy; 67,207 patients for the association between delay and door-to-balloon time; 183,441 patients for the association between delay and door-to-drug time., Results: In adjusted analyses, patients with longer delays between symptom onset and hospital presentation were less likely to receive any reperfusion therapy, had longer door-to-balloon times, and had longer door-to-needle times (all P <.0001 for linear trend). For patients presenting < or =1 hour, >1-2 hours, >2-3 hours, >9-10 hours, >10-11 hours, and >11-12 hours after symptom onset, the use of any reperfusion therapy were 77%, 77%, 73%, 53%, 50%, and 46%, respectively. Door-to-balloon times were 99, 101, 106, 123, 125, and 123 minutes, respectively, and door-to-drug times were 33, 34, 36, 46, 44, and 47 minutes, respectively., Conclusions: Longer delays from symptom onset to hospital presentation were associated with reduced likelihood of receiving primary reperfusion therapy, and even among those treated, late presenters had significantly longer door-to-balloon and door-to-drug times.

Objective: To assess risk factors associated with care for stroke symptoms., Methods: Using data from the population-based national cohort study (REasons for Geographic And Racial Differences in Stroke) conducted January 25, 2003-February 28, 2007 (N = 23,664), we assessed care-seeking behavior among 3,668 participants who reported a physician diagnosis of stroke/transient ischemic attack (n = 647) or stroke symptoms (n = 3,021) during follow-up. Care seeking was defined as seeking medical attention after stroke symptoms or a physician diagnosis., Results: Overall, 58.5% of participants (2,146/3,668) sought medical care. In multivariable models, higher income was associated with greater likelihood of seeking care (p = 0.02): participants with income of > or = $75,000 had odds 1.43 times (95% confidence interval [CI], 1.02-2.02) greater than those with income of less than $20,000. Diabetes and previous heart disease were associated with increased care seeking: odds ratio (OR) of 1.23 (95% CI, 1.04-1.47) and OR of 1.26 (95% CI, 1.06-1.49), respectively. Participants with previous stroke symptoms but no stroke history were less likely to seek care than those with stroke history or without previous symptoms (OR, 0.80; 95% CI, 0.67-0.96). Past smoking was associated with lower likelihood (OR, 0.71; 95% CI, 0.59-0.85; p = 0.0003) of seeking care relative to nonsmokers., Interpretation: Only approximately half of participants with stroke symptoms sought care. This is despite the encouragement of advocacy groups to seek prompt attention for stroke symptoms. Our results highlight the importance of identifying characteristics associated with care-seeking behavior. Recognizing factors that contribute to delays provides opportunities to enhance education on the importance of seeking care for stroke symptoms.

Background: We examined the prevalence of cardiac and cerebrovascular disease among hospitalized patients with and without multiple sclerosis (MS)., Methods: This study used the Statewide Planning and Research Cooperate System data set of over 15 million hospitalizations in New York City from 1988 through 2002. We identified MS patients 40-84 years of age who were hospitalized for reasons other than MS or related complications. MS patients were matched 1:2 on age, gender, race/ethnicity, and insurance. Outcomes included a principal discharge diagnosis of ischemic heart disease [International Classification of Diseases, Ninth Revision (ICD-9) 410-414], myocardial infarction (ICD-9 410), and ischemic stroke (ICD-9 434, 436). Multivariate logistic regression was used to compare vascular disease outcomes in MS and non-MS patients controlling for demographic and clinical factors., Results: Our study included 9,949 hospitalizations among MS patients and 19,898 hospitalizations for matched non-MS controls. MS patients were less likely to be hospitalized for ischemic heart disease (OR = 0.58, 95% CI = 0.51-0.66) or myocardial infarction (OR = 0.78, 95% CI = 0.64-0.96), but more likely to be hospitalized for ischemic stroke (OR = 1.66, 95% CI = 1.33-2.09) than matched non-MS controls., Conclusion: MS patients have decreased rates of hospital admission for ischemic heart disease and myocardial infarction, but increased rates of hospitalization for ischemic stroke as compared to the general non-MS population., (Copyright 2008 S. Karger AG, Basel.)

Temporal trends in length of stay, discharge disposition, and long-term mortality outcomes were examined in nonagenarians who underwent coronary artery bypass grafting (CABG) from 1993 to 1999. A total of 4,224 fee-for-service Medicare beneficiaries (2,068 women, 2,156 men) aged>or=90 years underwent CABG from 1993 to 1999. The number of procedures increased from 325 in 1993 to 883 in 1999 among all fee-for-service Medicare patients aged>or=65 years. Approximately half of CABG procedures were performed on women each year. The mean length of stay decreased from 18.0+/-10.8 to 13.3+/-8.8 days from 1993 to 1999 but remained longer for women (p<0.001). A greater percentage of women than men were discharged to skilled nursing facilities. The overall crude mortality rates remained relatively stable at 13.5% at 30 days and 59.0% at 5 years. Men and women had comparable short-term mortality outcomes, but men had higher mortality rates for 2- to 5-year outcomes. In conclusion, the number of CABG procedures in nonagenarians is increasing, with a substantial portion attaining survivorship that is equivalent to projected life expectancy.

Safety-net hospitals are experiencing increasing financial strains, possibly affecting their quality of care. We compare quality at safety-net and non-safety-net urban hospitals for Medicare beneficiaries admitted with acute myocardial infarction (AMI). Although safety-net hospitals had modestly higher risk-standardized thirty-day all-cause mortality rates and modestly lower adherence to quality-of-care performance measures than non-safety-net hospitals, there was much heterogeneity among safety-net hospitals and substantial overlap with non-safety-net hospitals. We examine the implications of these findings for the millions of vulnerable Americans who rely on safety-net hospitals for their care.

Background/aims: The results of studies about dietary fish consumption and stroke risk have been conflicting. We sought to examine the relationship between dietary fish and seafood consumption and the risk of stroke or transient ischemic attack (TIA)., Methods: We used data from the National Academy of Sciences-National Research Council Twin Registry, a prospective cohort of white male twins born in the US (1917-1927). Participants were asked about fish and seafood consumption in 1972 and 1985. Self-report or death-certificate report of stroke or TIA was obtained in 1996-1998., Results: Among 5,355 participants, 579 (10.8%) had a stroke or TIA. In unmatched analyses, dietary fish and seafood consumption was not associated with stroke or TIA: 10.4% (91/872) of frequent fish or seafood consumers had a stroke or TIA versus 10.9% (488/4,483) of infrequent consumers, p = 0.70. In an analysis of matched twin pairs, frequent fish or seafood consumption was also not associated with stroke or TIA: hazard ratio 0.89, 95% CI 0.59-1.36., Conclusions: These data, from a prospective cohort of white male twins, do not support an association between dietary fish and seafood consumption and stroke or TIA., (Copyright (c) 2007 S. Karger AG, Basel.)

Background: Although much attention has been given to survival after myocardial infarction (MI), little is known about sex differences in health status (symptoms, function, and quality of life). A particularly critical moment to assess health status following an MI is early after discharge when patients have resumed routine activities and when additional treatments may be offered to those with residual angina or quality of life limitations., Methods: We used multivariable Poisson and linear regression models to examine differences in 30-day health status by sex in a cohort of 2096 MI patients enrolled in a 19-center Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER)., Results: Women (32% of the cohort) were older and less likely to be white, married, or treated with coronary revascularization. They were more likely to have had a non-ST segment elevation MI, diabetes, hypertension, heart failure, chronic lung disease, and worse health status at admission. Risk-adjusted multivariable models suggest women were slightly more likely to have angina (RR 1.06, 95% CI 1.0, 1.14, p = 0.06), worse quality of life (difference in SAQ score = -4.36 points, 95% CI -5.44, -3.27 points, p = <0.001) and poorer physical functioning (difference in SF-12 PCS = -2.55 points, 95%CI = -3.62, -1.48 points, p = <0.001) at 30 days than men., Conclusions: One in four patients experienced angina 1 month after their MI, and women had a slightly greater prevalence than men. The physical function and quality of life of women 30 days after an MI is similar to or worse than that of men.

Purpose: The study's purpose was to determine the prevalence and prognostic importance of acute, severe, noncardiac conditions present at the time of an acute myocardial infarction (AMI)., Methods: We identified consecutive patients with AMI who were discharged from Yale-New Haven Hospital between January 1, 1997, and June 30, 2000. Acute, noncardiac conditions that were present at admission were abstracted from patient records and graded by severity (imminent threat to life; other significant condition that would warrant admission). We examined the prognostic importance of these conditions on hospital mortality in multivariable logistic models. The study included 1145 patients with AMI, of whom 8.5% (n=97) presented with an acute, life-threatening, noncardiac condition at admission and 19.5% (n=223) presented with another significant noncardiac condition., Results: Hospital mortality was 25.8% and 9.0%, respectively, for patients who presented with life-threatening and other significant noncardiac conditions, compared with 4.6% for patients without either of these conditions. In multivariable analysis, life-threatening noncardiac conditions were associated with increased hospital mortality after adjusting for demographic factors, medical history, clinical presentation, cardiac severity, and initial therapy (odds ratio 2.5; 95% confidence interval [CI], 1.2-5.2). No increased hospital mortality risk was found for other significant noncardiac conditions in the risk-adjusted analyses (odds ratio 1.0; 95% CI, 0.5-1.7)., Conclusions: A subgroup of patients with AMI presented with a life-threatening noncardiac condition, which was associated with a marked increase in the risk of death during the hospitalization. Despite the excessive mortality risk associated with concomitant noncardiac conditions, this subset of patients with AMI are poorly described in current literature.

Purpose: Despite dramatic changes in heart failure management during the 1990s, little is known about the national heart failure mortality trends during this time period, particularly among the elderly. The purpose of this study was to determine temporal trends in outcomes of elderly patients with heart failure between 1992 and 1999., Subjects and Methods: We analyzed a national sample of 3,957,520 Medicare beneficiaries aged 65 years or more who were hospitalized with heart failure between 1992 and 1999, assessing temporal trends in 30-day and 1-year all-cause mortality and 30-day and 6-month all-cause hospital readmission. In risk-adjusted analyses, mortality and readmission for each year between 1994 and 1999 were compared with the referent year of 1993., Results: Crude 30-day and 1-year mortality decreased slightly (range for 1992-1999: 11.0%-10.3% and 32.5%-31.7%, respectively), whereas 30-day and 6-month readmission increased (10.2%-13.8% and 35.4%-40.3%, respectively). After risk adjustment, there was no change in 30-day mortality between 1993 and 1999 (eg, for 1999 vs 1993, odds ratio [OR] 1.01, 95% confidence interval [CI], 1.00-1.02). One-year mortality was lower in 1994 compared with 1993 (OR 0.91, 95% CI, 0.90-0.92), but data from subsequent years suggested no continuous improvement after 1994 (1999 vs 1993: OR 0.93, 95% CI, 0.92-0.94). Thirty-day readmission increased (1999 vs 1993: OR 1.09, 95% CI, 1.07-1.10), but there was no change in 6-month readmission (1999 vs 1993: OR 1.00, 95% CI, 0.99-1.01)., Conclusion: We found no substantial improvement in mortality and hospital readmission during the 1990s among elderly patients hospitalized with heart failure. These findings suggest that recent innovations in heart failure management have not yet translated into better outcomes in this population.

Objectives: We estimated the prevalence of renal impairment in heart failure (HF) patients and the magnitude of associated mortality risk using a systematic review of published studies., Background: Renal impairment in HF patients is associated with excess mortality, although precise risk estimates are unclear., Methods: A systematic search of MEDLINE (through May 2005) identified 16 studies characterizing the association between renal impairment and mortality in 80,098 hospitalized and non-hospitalized HF patients. All-cause mortality risks associated with any renal impairment (creatinine >1.0 mg/dl, creatinine clearance [CrCl] or estimated glomerular filtration rate [eGFR] <90 ml/min, or cystatin-C >1.03 mg/dl) and moderate to severe impairment (creatinine > or =1.5, CrCl or eGFR <53, or cystatin-C > or =1.56) were estimated using fixed-effects meta-analysis., Results: A total of 63% of patients had any renal impairment, and 29% had moderate to severe impairment. After follow-up > or =1 year, 38% of patients with any renal impairment and 51% with moderate to severe impairment died versus 24% without impairment. Adjusted all-cause mortality was increased for patients with any impairment (hazard ratio [HR] = 1.56; 95% confidence interval [CI] 1.53 to 1.60, p < 0.001) and moderate to severe impairment (HR = 2.31; 95% CI 2.18 to 2.44, p < 0.001). Mortality worsened incrementally across the range of renal function, with 15% (95% CI 14% to 17%) increased risk for every 0.5 mg/dl increase in creatinine and 7% (95% CI 4% to 10%) increased risk for every 10 ml/min decrease in eGFR., Conclusions: Renal impairment is common among HF patients and confers excess mortality. Renal function should be considered in risk stratification and evaluation of therapeutic strategies for HF patients.

Little is known about the extent to which patients are aware of nationally-recommended cholesterol and lipid subfraction targets. The authors interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their low-density lipoprotein, high-density lipoprotein, and total cholesterol levels as well as corresponding national targets. Only 8%, 8%, and 43% of patients could recall their low-density lipoprotein, high-density lipoprotein, and total cholesterol values, respectively. Only 5%, 2%, and 50% could correctly name targets for these values. Knowledge of cholesterol targets was particularly poor among women, nonwhites, and patients without any college education. Patients with multiple cardiac risk factors and patients with a previous history of cardiovascular disease were no more knowledgeable about their cholesterol targets than those without these conditions. These findings suggest that current cholesterol education efforts appear inadequate, particularly for women, nonwhites, and patients without any college education.

Little is known about patient awareness of nationally recommended blood pressure targets, especially among patients with cardiac disease. To examine this issue, we interviewed 738 patients hospitalized with coronary artery disease to assess their knowledge of their systolic and diastolic blood pressure levels as well as corresponding national targets. We used bivariate and multivariate analyses to determine if any patient demographic or clinical characteristics were associated with blood pressure knowledge. Only 66.1% of patients could recall their own systolic and diastolic blood pressure levels. Only 48.9% of all patients could correctly name targets for these values. Knowledge of target blood pressure levels was particularly poor among patients who were female (odds ratio (OR) 0.69; 95% confidence interval (CI) 0.49-0.98), aged > or =60 years (OR 0.70, CI 0.51-0.97), without any college education (OR 0.48, CI 0.35-0.65), without a documented history of hypertension (OR 0.57, CI 0.39-0.84), and with known diabetes (OR 0.46, CI 0.33-0.66). Patients in the highest risk group, according to Joint National Committee guidelines stratification, were no more knowledgeable about their blood pressure levels and targets than lower risk patients. A significant proportion of patients hospitalized with coronary artery disease do not know their own blood pressure levels or targets. Current blood pressure education efforts appear inadequate, particularly for certain patient subgroups in which hypertension is an important modifiable risk factor.

Background: Despite national efforts to improve cholesterol management for patients with coronary artery disease, many patients are not reaching recommended cholesterol target levels. We sought to determine whether a nurse-based educational intervention, designed to educate patients with confirmed coronary artery disease about personal low-density lipoprotein (LDL) cholesterol target levels and encourage partnership with physicians, could increase adherence with National Cholesterol Education Program target levels (LDL cholesterol level < or =100 mg/dL)., Methods: Patients hospitalized with confirmed coronary artery disease were randomized to undergo a nurse-based educational intervention (375 patients) or usual care (381 patients) for a 12-month period after hospitalization. The primary outcome was the proportion of patients at the LDL cholesterol target level 1 year after hospitalization. The secondary outcome was the proportion of patients with accurate knowledge of LDL cholesterol target levels., Results: The groups were similar at baseline in demographic and clinical characteristics, percent at LDL cholesterol target level (43.9% and 41.1%, respectively), and percent with knowledge of LDL cholesterol target levels (both 5%). The proportion of patients at LDL cholesterol target levels at 1 year did not differ between the intervention (70.2%) and usual care group (67.4%, P =.46). At the conclusion of the trial, patient knowledge about LDL cholesterol target level was higher for the intervention group than the usual care group (19.6% and 6.7%, respectively, P =.001), but this was not associated with improved cholesterol management., Conclusions: Our nurse-based educational intervention did not result in a significant increase in the proportion of patients who reached target LDL cholesterol levels 1 year after hospitalization. Although the intervention improved patient knowledge of LDL cholesterol target levels, overall rates of LDL cholesterol knowledge remained low, and it was not associated with improved cholesterol management.

Introduction: Worsening renal function during hospitalization for heart failure, defined as elevation in creatinine during admission, predicts adverse outcomes. Prior studies define worsening renal function using various creatinine elevations, but the relative value of definitions is unknown., Methods and Results: In a prospective cohort of 412 patients hospitalized for heart failure, we compared a spectrum of worsening renal function definitions (absolute creatinine elevations >/=0.1 to >/=0.5 mg/dL and 25% relative elevation from baseline) and associations with 6-month mortality, readmission, and functional decline. Creatinine elevation >/=0.1 mg/dL occurred in 75% of patients, and elevation >/=0.5 mg/dL occurred in 24% of patients. Risk of death rose with higher creatinine elevations (adjusted hazard ratio [HR] = 0.89, 1.19, 1.67, 1.91, and 2.90 for elevations >/=0.1 to >/=0.5 mg/dL). Maximum sensitivity of any definition for predicting mortality was 75% and maximum specificity was 79%. High creatinine elevation was a more important predictor of death than was a single measure of baseline creatinine., Conclusions: Larger creatinine elevations predict highest risk of death, yet even minor changes in renal function are associated with adverse outcomes. The choice of a "best definition" for worsening renal function has implications for the number of patients identified with this risk factor and the magnitude of risk for mortality.

Background: Stroke is an important outcome after acute myocardial infarction. Studies that have examined this relationship have largely excluded older patients, even though half of stroke admissions occur among patients 75 years of age and older., Methods and Results: Among 111 023 medicare patients discharged with a principal diagnosis of acute myocardial infarction during an 8-month period in 1994 to 1995, we identified hospital admissions for ischemic stroke within 6 months of discharge. The rate of admission was 2.5% within 6 months. Independent predictors of ischemic stroke were age greater-than-or-equal 75 years, black race, no aspirin at discharge, frailty, prior stroke, atrial fibrillation, diabetes, hypertension, and history of peripheral vascular disease. To identify individuals at increased risk for stroke, a risk stratification score was constructed from identified factors. The 6-month stroke admission rate for patients with a score of 4 or higher (approximately 20% of the total sample) was approximately 4%., Conclusions: The risk of stroke after myocardial infarction is substantial, with about 1 in 40 patients suffering an ischemic stroke within 6 months of discharge. Simple clinical factors can predict the risk of stroke and, based on these factors, we identified 20% of older patients who have a 1 in 25 chance of being hospitalized for a stroke within 6 months of discharge.

Background and Purpose: We sought to measure the overall rate of usage of tissue-type plasminogen activator (tPA) for ischemic stroke at academic medical centers, and to determine whether ethnicity was associated with usage., Methods: Between June and December 1999, 42 academic medical centers in the United States each identified 30 consecutive ischemic stroke cases. Medical records were reviewed and information on demographics, medical history, and treatment were abstracted. Rates of tPA use were compared for African Americans and whites in univariate analysis and after adjustment for age, gender, stroke severity, and type of medical insurance with multivariable logistic regression., Results: Complete information was available for 1195 ischemic stroke patients; 788 were whites and 285 were African Americans: Overall, 49 patients (4.1%) received tPA. In the subgroup of 189 patients without a documented contraindication to therapy, 39 (20.6%) received tPA. Ten (20%) of those receiving tPA had documented contraindication. African Americans were one fifth as likely to receive tPA as whites (1.1% African Americans versus 5.3%; P=0.001), and the difference persisted after adjustment (OR 0.21, 95% CI 0.06 to 0.68; P=0.01). When comparison was restricted to those without a documented contraindication to tPA, the difference remained significant (OR 0.24, 95% CI 0.06 to 0.93; P=0.04). Medical insurance type was independently associated with tPA treatment. After adjustment for ethnicity and other demographic characteristics, those with Medicaid or no insurance were one ninth as likely to receive tPA as those with private medical insurance (OR 0.11, 95% CI 0.02 to 0.17; P=0.003)., Conclusions: tPA is used infrequently for ischemic stroke at US academic medical centers, even among qualifying candidates. African Americans are significantly less likely to receive tPA for ischemic stroke. Contraindications to treatment do not appear to account for the difference.

Rationale: Although clinical guidelines have become increasingly popular as a means to reduce variation in care, increase efficiency, and improve patient outcomes, little is known about their effectiveness when they are transported outside their original setting, or about the factors that influence their successful translation into clinical practice. This study assessed whether a clinical guideline for low-risk chest pain patients, implemented with a standardized protocol, could be effectively transported to five hospital settings., Methods: In a prospective, interventional trial, a standardized protocol for low-risk chest pain was implemented at each site. A total of 553 consecutively hospitalized low-risk patients with chest pain were enrolled during a 3-month baseline period followed by a standardized 6-month intervention period. During the intervention period, each patient's physician was contacted about eligibility for discharge within the specified 2-day guideline period. Guideline adherence (discharged within 48 hours) and postdischarge patient outcomes were measured. Local guideline champions were interviewed about their implementation experience., Results: Guideline adherence during the intervention period ranged from 61% to 100%, with only two sites achieving significant increases of > or = 10% from the baseline values. Guideline implementation did not affect clinical outcomes or patient satisfaction. Implementation factors such as preexisting hospital environment, implementation team staffing, and the rapid identification and resolution of barriers may influence the successful translation of guidelines into practice., Conclusions: Even with a standardized implementation protocol, consistent results across institutions were not obtained when a clinical guideline for chest pain was implemented beyond its original setting. These findings demonstrate the importance of understanding the local factors that influence guideline implementation.