CONTEXT: A high homocysteine level has been identified as an independent modifiable risk factor for coronary heart disease (CHD) events and death. Since January 1998, the US Food and Drug Administration has required that all enriched grain products contain 140 microg of folic acid per 100 g, a level considered to decrease homocysteine levels. OBJECTIVES: To examine the potential effect of grain fortification with folic acid on CHD events and to estimate the cost-effectiveness of additional vitamin supplementation (folic acid and cyanocobalamin) for CHD prevention. DESIGN AND SETTING: Cost-effectiveness analysis using the Coronary Heart Disease Policy Model, a validated, state-transition model of CHD events in adults aged 35 through 84 years. Data from the third National Health and Nutrition Examination Survey (NHANES III) were used to estimate age- and sex-specific differences in homocysteine levels. INTERVENTION: Hypothetical comparison between a diet that includes enriched grain products projected to increase folic acid intake by 100 microg/d with the same diet without folic acid fortification; and a comparison between vitamin therapy that consists of 1 mg of folic acid and 0.5 mg of cyanocobalamin and the diet that includes grains fortified with folic acid. MAIN OUTCOME MEASURES: Incidence of myocardial infarction and death from CHD, quality-adjusted life-years (QALYs) saved, and medical costs. RESULTS: Grain fortification with folic acid was predicted to decrease CHD events by 8% in women and 13% in men, with comparable reductions in CHD mortality. The model projected that, compared with grain fortification alone, treating all patients with known CHD with folic acid and cyanocobalamin over a 10-year period would result in 310 000 fewer deaths and lower costs. Over the same 10-year period, providing vitamin supplementation in addition to grain fortification to all men aged 45 years or older without known CHD was projected to save more than 300 000 QALYs, to save more than US $2 billion, and to be the preferred strategy. For women without CHD, the preferred vitamin supplementation strategy would be to treat all women older than 55 years, a strategy projected to save more than 140 000 QALYs over 10 years. CONCLUSIONS: Folic acid and cyanocobalamin supplementation may be cost-effective among many population subgroups and could have a major epidemiologic benefit for primary and secondary prevention of CHD if ongoing clinical trials confirm that homocysteine-lowering therapy decreases CHD event rates.

Adult↗

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Patients with acute chest pain who leave emergency departments against medical advice: prevalence, clinical characteristics, and natural history.

The study group identified 107 patients who left against advice from the emergency departments of three university and four community hospitals after presenting for evaluation of acute chest pain. In comparison with other emergency department patients with acute chest pain, patients who left against advice had findings that suggested they were at higher risk for myocardial infarction than patients for whom admission was not recommended but at lower risk than patients who consented to be admitted. Specific follow-up plans were made at the time of evaluation for 45 patients (42%). Survival data were obtained at 48-72 hours for 104 patients (97%) and at one month for 101 patients (94%). Fourteen patients (12%) were hospitalized within three days of their original emergency department visits, and three patients had documented acute myocardial infarctions. The only death within one month was that of a patient who died suddenly out-of-hospital later on the day of his emergency department visit. The authors conclude that patients who left against medical advice had presentations and prognoses that were in between those of patients for whom admission was not recommended and those of patients who consented to be admitted.

Adult↗

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Long-term survival after transient loss of consciousness.

To determine the factors that influenced the long-term outcome of 198 patients who presented to the emergency ward with transient loss of consciousness, the authors followed them for a median of 83 months. Forty-one patients (21%) died, including nine patients who had out-of-hospital sudden cardiac arrest. Compared with age- and sex-adjusted mortality rates for the United States, long-term mortality was not increased among patients with benign causes of syncope. Multivariate analysis revealed that the long-term mortality rate was significantly increased in patients with a prior history of coronary or cerbrovascular disease (RR = 6.7), those who had cancer (RR = 7.3), and those who had drug or metabolic (RR = 5.9), central nervous system (RR = 5.7) or cardiac (RR = 9.2) causes of transient loss of consiousness. Among patients who experience transient losses of consciousness, the cause of the episode is significantly correlated with mortality for at least the next seven years.

Actuarial Analysis↗

PubMedDate not supplied

Noninvasive tests for diagnosing the presence and extent of coronary artery disease: exercise electrocardiography, thallium scintigraphy, and radionuclide ventriculography.

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Angina Pectoris↗