Search PubMed⌕ Search

Biomedical subjects

J M Gore

Publications and source records attributed to J M Gore.

At least 55 records · Page 3Linked to original sources
PubMed1998

Early assessment and in-hospital management of patients with acute myocardial infarction at increased risk for adverse outcomes: a nationwide perspective of current clinical practice. The National Registry of Myocardial Infarction (NRMI-2) Participants.

BACKGROUND: Therapeutic decision making in critically ill patients requires both prompt and comprehensive analysis of available information. Data derived from randomized clinical trials provide a powerful tool for risk assessment in the setting of acute myocardial infarction (MI); however, timely and appropriate use of existing therapies and resources are the key determinants of outcome among high-risk patients. METHODS: Demographic, procedural, and outcome data from patients with MI were collected at 1073 U.S. hospitals collaborating in the National Registry of MI (NRMI 2). Patients were classified on hospital arrival as either "low risk" or "high risk" according to a modified Thrombolysis in Myocardial Infarction II Risk Scale based on predetermined demographic, electrocardiographic, and clinical features. RESULTS: Among the 170,143 patients enrolled, 115,222 (67.5%) were classified as low risk and 55,521 (32.5%) as high risk for in-hospital death, recurrent ischemia, recurrent MI, congestive heart failure, and stroke. Using a composite unsatisfactory outcome measure, in-hospital adverse events were had by a greater proportion of patients initially classified as high risk compared with those classified as low risk. By multivariate analysis, age >70 years, prior MI, Killip class >1, anterior site of infarction, and the combination of hypotension and tachycardia were independent predictions of poor outcome in patients with or without ST-segment elevation on the presenting electrocardiogram. High-risk patients with ST-segment elevation were treated with thrombolytics (47.5%) or alternative forms of reperfusion therapy (9.3%) within 62 minutes and 226 minutes of hospital arrival, respectively. High-risk patients offered reperfusion therapy were also more likely to receive aspirin, beta-blockers (intravenous, oral) and angiotensin-converting enzyme inhibitors within 24 hours of infarction (all p < 0.0001), survive their event (8.4% versus 21.4% p < 0.0001), and leave the hospital sooner than those not reperfused. CONCLUSIONS: This large registry experience included more than 150,000 nonselected patients with MI and suggests that high-risk patients can be identified on initial hospital presentation. The current use of reperfusion and adjunctive therapies among high-risk patients is suboptimal and may directly influence outcome. Randomized trials designed to test the impact of specific management strategies on outcome according to initial risk classification are warranted.

Angioplasty, Balloon, Coronary↗
PubMed1998

Clinical experience with primary percutaneous transluminal coronary angioplasty compared with alteplase (recombinant tissue-type plasminogen activator) in patients with acute myocardial infarction: a report from the Second National Registry of Myocardial Infarction (NRMI-2).

OBJECTIVES: We sought to compare outcomes after primary percutaneous transluminal coronary angioplasty (PTCA) or thrombolytic therapy for acute myocardial infarction (MI). BACKGROUND: Primary PTCA and thrombolytic therapy are alternative means of achieving reperfusion in patients with acute MI. The Second National Registry of Myocardial Infarction (NRMI-2) offers an opportunity to study the clinical experience with these modalities in a large patient group. METHODS: Data from NRMI-2 were reviewed. RESULTS: From June 1, 1994 through October 31, 1995, 4,939 nontransfer patients underwent primary PTCA within 12 h of symptom onset, and 24,705 patients received alteplase (recombinant tissue-type plasminogen activator [rt-PA]). When lytic-ineligible patients and patients presenting in cardiogenic shock were excluded, baseline characteristics were similar. The median time from presentation to initiation of rt-PA in the thrombolytic group was 42 min; the median time to first balloon inflation in the primary PTCA group was 111 min (p < 0.0001). In-hospital mortality was higher in patients in shock after rt-PA than after PTCA (52% vs. 32%, p < 0.0001). In-hospital mortality was the same in lytic-eligible patients not in shock: 5.4% after rt-PA and 5.2% after PTCA. The stroke rate was higher after lytic therapy (1.6% vs. 0.7% after PTCA, p < 0.0001), but the combined end point of death and nonfatal stroke was not significantly different between the two groups (6.2% after rt-PA and 5.6% after PTCA). There was no difference in the rate of reinfarction (2.9% after rt-PA and 2.5% after PTCA). CONCLUSIONS: These findings suggest that in lytic-eligible patients not in shock, PTCA and rt-PA are comparable alternative methods of reperfusion when analyzed in terms of in-hospital mortality, mortality plus nonfatal stroke and reinfarction.

Aged↗
PubMed1998

Seasonal distribution of acute myocardial infarction in the second National Registry of Myocardial Infarction.

OBJECTIVES: This observational study sought to determine whether cases of acute myocardial infarction (AMI) reported to the second National Registry of Myocardial Infarction (NRMI-2) varied by season. BACKGROUND: The existence of circadian variation in the onset of AMI is well established. Examination of this periodicity has led to new insights into pathophysiologic triggers of atherosclerotic plaque rupture. Although a seasonal pattern for mortality from AMI has been previously noted, it remains unclear whether the occurrence of AMI also displays a seasonal rhythmicity. Documentation of such a pattern may foster investigation of new pathophysiologic determinants of plaque rupture and intracoronary thrombosis. METHODS: We analyzed the number of cases of AMI reported to NRMI-2 by season during the period July 1, 1994 to July 31, 1996. Data were normalized so that seasonal occurrence of AMI was reported according to a standard 90-day length. RESULTS: A total of 259,891 cases of AMI were analyzed during the study period. Approximately 53% more cases were reported in winter than during the summer. The same seasonal pattern (decreasing occurrence of reported cases from winter to fall to spring to summer) was seen in men and women, in different age groups and in 9 of 10 geographic areas. In-hospital case fatality rates for AMI also followed a seasonal pattern, with a peak of 9% in winter. CONCLUSION: The present results suggest that there is a seasonal pattern in the occurrence of AMIs reported to NRMI-2 that is characterized by a marked peak of cases in the winter months and a nadir in the summer months. This pattern was seen in all subgroups analyzed as well as in different geographic areas. These findings suggest that the chronobiology of seasonal variation in AMI may be affected by variables independent of climate.

Aged↗
PubMed1998

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.

Adult↗
PubMed1998

Sex differences in symptom presentation associated with acute myocardial infarction: a population-based perspective.

OBJECTIVES: To describe sex differences in symptom presentation after acute myocardial infarction (AMI) while controlling for differences in age and other potentially confounding factors. BACKGROUND: Although several studies have examined sex differences in diagnosis, management, and survival after AMI, limited data exist about possible sex differences in symptom presentation in the setting of AMI. METHODS: Community-based study of patients hospitalized with confirmed AMI in all 16 metropolitan Worcester, Mass., hospitals (1990 census population = 437,000). Men (n = 810) and women (n = 550) hospitalized with validated AMI in 1986 and 1988 comprised the study sample. RESULTS: After simultaneously controlling for age, medical history, and AMI characteristics through regression modeling, men were significantly less likely to complain of neck pain (adjusted odds ratio (OR) = 0.52; 95% CI: 0.35, 0.78), back pain (OR = 0.38; 95% CI: 0.26, 0.56), jaw pain (OR = 0.50; 95% CI: 0.31, 0.81), and nausea (O.R. = 0.58; 95% CI: 0.45, 0.75) than women. Conversely, men were significantly more likely to report diaphoresis (OR = 1.27; 95% CI: 1.00, 1.61) than women. There were no statistically significant sex differences in complaints of chest pain though men were more likely to complain of this symptom. CONCLUSIONS: The results of this population-based observational study suggest differences in symptom presentation in men and women hospitalized with AMI. These findings have implications for public and health care provider education concerning recognition of sex differences in AMI-related symptoms and health care seeking behaviors.

Aged↗
PubMed1998

Thrombolysis-related intracranial hemorrhage: a radiographic analysis of 244 cases from the GUSTO-1 trial with clinical correlation. Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries.

BACKGROUND AND PURPOSE: Intracranial hemorrhage (ICH) is a serious complication of thrombolytic therapy. We systematically reviewed the radiographic features of 244 cases of symptomatic ICH complicating thrombolysis for acute myocardial infarction in the Global Utilization of Streptokinase and Tissue Plasminogen Activator for Occluded Coronary Arteries (GUSTO-1) trial, correlated these observations with clinical data, and speculated on hemorrhage pathogenesis. METHODS: CT scans from 244 patients suffering symptomatic ICH were systematically reviewed for selected radiographic features, including ICH type, location, hematoma characteristics, mass effect features, hydrocephalus, and preexisting lesions. Hematoma volume was estimated by computer-assisted volumetric analysis. Data from this analysis were correlated with clinical data including hypertension, anticoagulation, age, thrombolytic regimen, and ICH timing. RESULTS: Most hemorrhages were large (median [25th, 75th percentile] volume, 72 mL [39, 118]), solitary (66%), lobar (77%), confluent (80%), and intraparenchymal (82%) with a blood/fluid level (82%) and little edema (median [25th, 75th percentile] volume, 9 mL [5, 16]). Hydrocephalus (P<.001), any one mass effect feature (P<.001), intraventricular hemorrhage (P=.022), mottled hematoma appearance (P=.050), and hematoma blood/fluid level (P<.001) were associated with higher hemorrhage volume in the radiographic analysis, as were older age (P=.005), treatment with combined streptokinase and tissue plasminogen activator (P=.034), and hemorrhage onset 8 to 13 hours after treatment (P=.008) in the clinical analysis. Subdural hemorrhage was a high-volume subgroup whose risk increased with antecedent trauma (P=.026) or syncope (P=.006). Deep intraparenchymal hemorrhage was associated with hypertension (P=.016), and multifocal ICH occurred significantly earlier after treatment (P=.002). CONCLUSIONS: Although the majority of postthrombolytic ICH are large, solitary, and supratentorial, the spectrum is diverse. Features of mass effect reflected the large volumes, and hematoma characteristics of mottling and blood/fluid levels were frequent. Thrombolysis-related coagulopathy and age appear to be the most important identifiable factors in the genesis of postthrombolytic ICH, but the hemorrhage subtype seen may reflect an interaction with other factors such as hypertension, ICH timing, antecedent head trauma, and syncope.

Cerebral Hemorrhage↗
PubMed1997

Incidence and predictors of bleeding after contemporary thrombolytic therapy for myocardial infarction. The Global Utilization of Streptokinase and Tissue Plasminogen activator for Occluded coronary arteries (GUSTO) I Investigators.

BACKGROUND: Although the benefit of thrombolytic therapy in reducing mortality in acute myocardial infarction is well established, the types of bleeding and risk factors for bleeding are less well described in large trials. METHODS AND RESULTS: We analyzed the baseline characteristics, outcomes, and incidence of bleeding by location, severity, and treatment assignment among 41,021 patients in the GUSTO-I trial of thrombolysis for acute myocardial infarction. Of the 40,903 patients for whom there were complete data, 1.2% suffered severe bleeding and 11.4% experienced moderate hemorrhage at a variety of sites. The most common sources of bleeding were procedure related. The thrombolytic regimen was strongly related to the incidence of bleeding; comparatively more bleeding was seen with the therapies of streptokinase plus intravenous heparin and the streptokinase and tissue plasminogen activator plus intravenous heparin combination. In multivariate analysis, the four most powerful independent predictors of hemorrhage were older age, lighter body weight, female sex, and African ancestry; they remained the most important predictors of bleeding when multivariate analysis was performed on patients who did not undergo invasive procedures. The presence of serious hemorrhage was associated with other undesirable outcomes (recurrent events, left ventricular dysfunction, arrhythmia, or stroke). CONCLUSIONS: Important predictors of bleeding in this population are increased age, lighter weight, female sex, African ancestry, and experiencing invasive procedures. Other nonhemorrhagic adverse clinical outcomes were associated with moderate and severe bleeding, which was in turn associated with increased length of hospital stay and mortality at 30 days.

Age Factors↗
PubMed1997

Use of lipid-lowering medication in patients with acute myocardial infarction (Worcester Heart Attack Study).

As part of a population-based longitudinal study, we examined the use of lipid-lowering medication in 3,824 patients hospitalized with acute myocardial infarction in the Worcester, Massachusetts metropolitan area between 1986 and 1993. The rate of utilization of lipid-lowering medication either before (1.8%) or during hospitalization (1.9%) for acute myocardial infarction was low.

Coronary Disease↗
PubMed1997

Age-related trends (1986-1993) in the use of thrombolytic agents in patients with acute myocardial infarction. The Worcester Heart Attack Study.

OBJECTIVE: To examine age-related differences and temporal trends in the use of thrombolytic therapy in a community-wide study of patients hospitalized with acute myocardial infarction (AMI) between 1986 and 1993. METHODS: All hospitals in the Worcester, Mass, metropolitan area (1990 census population, 4370000) were included. A total of 3824 patients with validated AMI categorized according to age comprised the study sample: younger than 55 years (n = 577), 55 to 64 years (n = 758), 65 to 74 years (n = 1143), and 75 years or older (n = 1346). RESULTS: Use of thrombolytic therapy increased during the period under study in all patients hospitalized with AMI (9% in 1986; 26% in 1993). In 1986, the majority of treated patients received streptokinase; while increases over time in the use of tissue-type plasminogen activator were noted, streptokinase remained the thrombolytic agent of choice in 1993. Marked age-related trends in the use of thrombolytic therapy were observed, with the most striking increases in the use of thrombolytic therapy over time seen in those aged 65 years or older. Between 1986 and 1993 the relative increases in the use of thrombolytic therapy were observed in the following age groups: younger than 55 years (106%), 55 to 64 years (85%), 65 to 74 years (694%), and 75 years or older (571%). Despite these encouraging trends in the use of thrombolytic therapy in older patients, after controlling for a variety of potential confounding variables elderly patients were significantly less likely to receive thrombolytic therapy during hospitalization for AMI. Compared with patients aged 75 years or older, patients younger than 55 years were 6.4 times (95% confidence interval [CI], 4.8-8.5), patients aged 55 to 64 years were 4.9 times (95% CI, 3.8-6.4), and patients aged 65 to 74 years were 3.0 times (95% CI, 2.3-3.9) significantly more likely to receive thrombolytic therapy. These differences were in part related to the proportion of patients with myocardial infarction satisfying eligibility criteria for the receipt of thrombolytic therapy; patients aged 75 years or older were significantly less likely to meet these criteria (19%) than were those younger than 55 years (49%), those aged 55 to 64 years (38%), and those aged 65 to 74 years (28%). CONCLUSIONS: The present results show that while there have been substantial increases over time in the use of thrombolytic therapy in patients with AMI, most particularly in older individuals, the elderly remain appreciably less likely to receive these agents during hospitalization for AMI. These differences may be due to the smaller percentage of elderly patients satisfying criteria for the use of these agents compared with younger patients with coronary heart disease, as well as to a reluctance by physicians to use these agents in older patients. Continued monitoring of these trends remains important for examining changes in physicians' practice patterns regarding the use of thrombolytic therapy in this vulnerable population.

Age Factors↗
PubMed1997

Hemorrhagic events during therapy with recombinant tissue plasminogen activator, heparin, and aspirin for unstable angina (Thrombolysis in Myocardial Ischemia, phase IIIB trial).

This study assesses the effects of invasive procedures, hemostatic and clinical variables, and doses of recombinant tissue plasminogen activator (t-PA) on hemorrhagic events in the thrombolysis in myocardial ischemia (TIMI), phase 1B clinical trial (n = 1,425). Patients seen within 24 hours of the onset of ischemic chest pain at rest were randomized using a 2 x 2 factorial design for comparison of: (1) t-PA versus placebo as initial therapy, and (2) an early invasive (coronary arteriography with percutaneous angioplasty, if feasible) versus an early conservative strategy (coronary arteriography followed by revascularization if initial medical therapy failed). All patients received conventional medication for acute ischemic syndromes, including heparin, aspirin, beta blockers, nitrates, and calcium antagonists. The total dose of t-PA or placebo was 0.8 mg/kg, up to a maximum dose of 80 mg. In patients treated with t-PA, major and minor hemorrhagic events were more common than among those assigned to placebo (p < 0.001). Patients assigned to the invasive strategy arm had a higher hemorrhagic event rate than the noninvasive strategy, although the difference was not significant (p = 0.026). Patients > 75 years of age had higher intracranial hemorrhage rates than those < 75 years of age (6.7% vs 0.2%, respectively, p = 0.01). Major hemorrhagic events were more common in patients with higher heparin levels (p < 0.001), higher peak D-dimer levels (p = 0.007), and lower nadir fibrinogen levels (p = 0.005). Thus, increased morbidity due to hemorrhagic complications is associated with the use of t-PA, increased age, and selected hemostatic measures. Comparison to TIMI II demonstrates a significant association between the dose of t-PA and hemorrhagic complications.

Aged↗
PubMed1997

Ischemic cerebral infarction after rt-PA and heparin therapy for acute myocardial infarction. The TIMI-II pilot and randomized clinical trial combined experience.

BACKGROUND AND PURPOSE: Ischemic cerebral infarction (CI) is a serious complication of acute myocardial infarction (MI). Little information exists on CI after thrombolytic therapy for MI. METHODS: Of 3924 MI patients treated with recombinant tissue plasminogen activator (rt-PA) and heparin, 29 (0.7%) developed CI after treatment. All CI patients had detailed neurological evaluations, and 27 (93%) had CT scans centrally reviewed. RESULTS: Age range was 40 to 74 years (mean, 60 years); 25 patients (86%) were men, and 22 (76%) were white. The electrocardiographic location of MI was anterior in 22 (76%) and nonanterior in 7 (24%). Five CIs occurred within 6 hours, 4 between 6 to 24 hours, 8 during the remainder of the first week, 10 during the second week, and 2 others distributed over the 4 weeks after study entry. Six of 29 CIs did not involve the cerebral cortex; 9 patients (31%) had multiple CIs. Of 28 CIs thought to be embolic in origin, 17 showed strong evidence for at least one cardiac abnormality (mural clot, wall-motion abnormality, aneurysm, or atrial fibrillation) known to be associated more specifically with embolism than MI. Eight of 27 CIs (30%) with CT scans had hemorrhagic transformation of varying degrees; 5 were symptomatic. CONCLUSIONS: The time of occurrence and sites of CI after rt-PA and heparin therapy for acute MI are similar to those reported during the prethrombolytic era.

Adult↗
PubMed1996

Age and outcome with contemporary thrombolytic therapy. Results from the GUSTO-I trial. Global Utilization of Streptokinase and TPA for Occluded coronary arteries trial.

BACKGROUND: Elderly patients with acute myocardial infarction have much to gain from reperfusion with thrombolytic therapy but are also at increased risk of adverse events. We examined outcomes according to age of patients receiving thrombolysis in an international trial. METHODS AND RESULTS: Patients were randomized to streptokinase plus subcutaneous heparin, streptokinase plus intravenous heparin, accelerated tissue plasminogen activator (TPA) plus intravenous heparin, or streptokinase and TPA plus intravenous heparin. Clinical outcomes at 30 days (death, stroke, and nonfatal, disabling stroke) and 1-year mortality were summarized descriptively for patients aged < 65 (n = 24,708), 65 to 74 (n = 11,201), 75 to 85 (n = 4625), and > 85 years (n = 412) and assessed as continuous functions of age. Older patients had a higher-risk profile with regard to baseline clinical and angiographic characteristics. Mortality at 30 days increased markedly with age (3.0%, 9.5%, 19.6%, and 30.3% in the four groups, respectively), as did stroke, cardiogenic shock, bleeding, and reinfarction. Combined death or disabling stroke occurred less often with accelerated TPA in all but the oldest patients, who showed a weak trend toward a lower incidence with streptokinase plus subcutaneous heparin: odds ratio 1.13; 95% confidence interval 0.6, 2.1. Similarly, accelerated TPA treatment resulted in lower 1-year mortality in all but the oldest patients (47% TPA versus 40.3% streptokinase). CONCLUSIONS: Lower mortality and greater net clinical benefit were seen with accelerated TPA in patients aged < or = 85 years. Because data are limited for patients aged > 85 years, the relative superiority of a given thrombolytic regimen cannot be determined. The interactions of stroke and mortality with newer thrombolytic strategies must be examined explicitly in older patients.

Aged↗
PubMed1996

Early discharge in the thrombolytic era: an analysis of criteria for uncomplicated infarction from the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) trial.

OBJECTIVES: This study sought to readdress the definition of uncomplicated myocardial infarction and to apply clinical criteria for early discharge of such patients in the thrombolytic era. BACKGROUND: Previous studies proposed early hospital discharge at day 7 to 10 after acute myocardial infarction. The potential for earlier discharge of patients with uncomplicated infarction after thrombolysis remains undemonstrated. METHODS: We defined "uncomplicated infarction" a priori as the absence of death, reinfarction, ischemia, stroke, shock, heart failure (Killip class > 1), bypass surgery, balloon pumping, emergency catheterization or cardioversion or defibrillation in the first 4 hospital days. We applied this definition to 41,021 patients in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial. We examined death at 30 days and 1 year and rates of in-hospital reinfarction, heart failure, recurrent ischemia, shock and stroke in the uncomplicated and complicated groups created by application of our definition. We also assessed lengths of hospital and cardiac care unit stay. RESULTS: Application of our clinical criteria yielded 23,497 (57.3%) patients in the uncomplicated group at day 4 with a very low risk of death and in-hospital complications: 30-day mortality 1%, reinfarction 1.7%, heart failure 2.6%, recurrent ischemia 6.7%, shock 0.4% and stroke 0.2%. One-year mortality was 3.6%. The median hospital stay was 9 days (7, 12 [25th, 75th percentiles, respectively]), and the median cardiac care unit stay 3 days (3, 5). CONCLUSIONS: Simple clinical characteristics can identify a very low risk post-myocardial infarction population by hospital day 4. Use of these criteria for early discharge planning could substantially reduce length of stay for patients with uncomplicated acute myocardial infarction.

Aged↗
PubMed1996

Recent age-related trends in the use of thrombolytic therapy in patients who have had acute myocardial infarction. National Registry of Myocardial Infarction.

OBJECTIVE: To examine recent trends in the use of thrombolytic therapy in elderly patients who have had acute myocardial infarction and to determine whether failure to meet time-to-hospital presentation and electrocardiographic criteria might explain age-related differences in the use of thrombolytic therapy. DESIGN: A national registry of patients who have had acute myocardial infarction. SETTING: 1249 U.S. hospitals. PATIENTS: 350,755 patients who had an acute myocardial infarction from 1 July 1990 to 30 September 1994. MEASUREMENTS: Trends in the proportions of patients who received thrombolytic therapy were examined according to age and sex. The association between age and treatment with a thrombolytic agent was determined by crude and multivariable-adjusted analyses. RESULTS: Use of a thrombolytic agent was inversely related to patient age: Almost 51% of patients younger than age 55 years received a thrombolytic agent during hospitalization for acute myocardial infarction; this proportion decreased to 43.6% for patients aged 55 to 64 years, 33.0% for those aged 65 to 74 years, 19.0% for those aged 75 to 84 years, and 7.4% for those aged 85 years or older. However, relative increases in the use of thrombolytic therapy over time were greatest for patients in the oldest age groups. Between 1 July 1990 and 30 June 1991, 16.0% of patients aged 75 to 84 years received a thrombolytic agent compared with 21.4% between 1 June 1993 and 30 September 1994 (a 33.8% relative increase in use). Among persons aged 85 years or older, the proportion of treated patients increased from 5.3% to 9.1% over this same period (a 71.7% relative increase in use). Increases in thrombolytic use were most prominent for older women. After adjustment for sex, diagnosis by initial electrocardiogram, electrocardiogram-based infarction description, time from symptom onset to hospital presentation, and period of the acute myocardial infarction, the odds of receiving a thrombolytic agent were significantly reduced for patients in the older age groups compared with the odds for patients younger than age 55 years (for patients aged 75 to 84 years, the adjusted odds ratio was 0.27 [95% CI, 0.26 to 0.28]; for patients aged 85 years or older, the odds ratio was 0.09 [CI, 0.08 to 0.10]). CONCLUSIONS: Although older patients who have had acute myocardial infarction less commonly receive a thrombolytic agent, use of thrombolytic therapy in this population is expanding. However, substantial differences across age groups persist in the likelihood of receiving treatment, even after adjustment for potentially confounding factors. Age-related differences in thrombolytic use may not be completely explained by the degree to which older patients do not meet conventional eligibility criteria for thrombolytic therapy.

Age Factors↗
PubMed1996

The impact of clinical trials on the use of medications for acute myocardial infarction. Results of a community-based study.

BACKGROUND: The impact of clinical trials on medical practice remains controversial, in part because of weak study designs and nonrepresentative study samples. OBJECTIVE: To assess changes in trends in medication use in the setting of acute myocardial infarction (AMI) before and after publication of two large clinical trials: the Second International Study of Infarct Survival (ISIS-2) trial that supported the use of aspirin after AMI and the Multi-center Diltiazem Postinfarction Trial that reported no overall benefit from the use of calcium antagonists after AMI. METHODS: Study patients consisted of 2114 patients hospitalized with AMI in 16 hospitals in metropolitan Worcester, Mass, during 1986, 1988, and 1990. Data were obtained from medical records. We used multivariable logistic regression models to examine the rate of change in the use of selected medications before and after trial publication, controlling for medical history, characteristics and complications of AMI, medications taken, and procedures performed during hospitalization. The dependent variable was receipt of the specific medication under investigation. RESULTS: Before publication of ISIS-2, 26% of patients with AMI received aspirin while hospitalized compared with 66% after its publication. However, in-hospital aspirin use began to rise before ISIS-2 with an immediate increase in the level of use occurring after trial publication but with no significant change in the rate of increase. Before publication of the Multicenter Diltiazem Postinfarction Trial, 57% of patients with AMI were new recipients of calcium antagonists compared with 51% after trial publication. The decrease in calcium antagonist use began after trial publication (odds ratio, 0.79 per 6-month period; 95% confidence interval, 0.71 to 0.88). CONCLUSIONS: The published results of large trials of cardiovascular therapies have had variable impact on medication use. Efforts to assess the effects of publication of new scientific information on medical care need to consider prior trends in treatment patterns and the varying contexts of medical care. They should consider both direct and indirect routes of influence.

Aged↗