Biomedical subjects

Louise Pilote

Publications and source records attributed to Louise Pilote.

At least 37 records · Page 2Linked to original sources

PubMed2005

Outcomes and cost of coronary artery bypass graft surgery in the United States and Canada.

BACKGROUND: We sought to determine whether there is a difference in in-hospital outcomes and costs for coronary artery bypass graft surgery (CABG) between the United States and Canada. METHODS: We compared the outcomes and costs of treating 12 017 consecutive patients (4698 US and 7319 Canadian patients) undergoing CABG at 5 US and 4 Canadian hospitals. Participating hospitals used the same cost accounting system to provide patient-level clinical, resource utilization, and cost-of-treatment data (excluding physicians' fees). Canadian costs were converted to US dollars using purchasing power parities. RESULTS: Compared with Canadian patients, US patients were older (mean +/- SD age, 68.0 +/- 10.4 vs 63.7 +/- 9.8 years [P<.001]), more likely to be female (27.4% vs 21.8% [P<.001]), and discharged from the hospital sooner (mean +/- SD length of stay, 8.7 +/- 0.1 vs 9.5 +/- 0.1 days [P<.001]). In-hospital costs of treatment were substantially higher in the United States than in Canada (mean +/- SD cost, dollar 20,673 +/- dollar 241 vs dollar 10,373 +/- dollar 123 [P<.001]; median, dollar 16,036 vs dollar 7880). After controlling for demographic and clinical differences, length of stay in Canada was 16.8% longer than in the United States; there was no difference in in-hospital mortality; and the cost in the United States was 82.5% higher than in Canada (P<.001). CONCLUSIONS: The in-hospital cost of CABG in the United States is substantially higher than in Canada. This difference is due to higher direct and overhead costs in US hospitals, is not explained by demographic or clinical differences, and does not lead to superior clinical outcomes.

Aged↗

PubMed2005

Differences in outcomes of patients with congestive heart failure prescribed celecoxib, rofecoxib, or non-steroidal anti-inflammatory drugs: population based study.

OBJECTIVES: To compare the risk of death and recurrent congestive heart failure in elderly patients prescribed celecoxib, rofecoxib, or non-steroidal anti-inflammatory drugs (NSAIDs) and to determine whether there are class differences between celecoxib and rofecoxib. DESIGN: Population based retrospective cohort study. SETTING: Databases of hospital discharge summaries and prescription drug claims in Quebec. PARTICIPANTS: 2256 patients aged 66 or more prescribed celecoxib, rofecoxib, or an NSAID after an index admission for congestive heart failure between April 2000 and March 2002. MAIN OUTCOME MEASURES: Time to all cause death and recurrent congestive heart failure, combined and separately. RESULTS: The risk of death and recurrent congestive heart failure combined was higher in patients prescribed NSAIDs or rofexocib than in those prescribed celecoxib (hazard ratio 1.26, 95% confidence interval 1.00 to 1.57 and 1.27, 1.09 to 1.49, respectively). The findings were similar when the outcomes were assessed separately. In pairwise analysis, the risks of death and recurrent congestive heart failure, combined and separate, were similar between patients prescribed NSAIDs and rofecoxib. CONCLUSIONS: Celecoxib seems safer than rofecoxib and NSAIDs in elderly patients with congestive heart failure. Differences were found among cyclo-oxygenase-2 inhibitors.

Aged↗

PubMed2005

Effectiveness of statins for secondary prevention in elderly patients after acute myocardial infarction: an evaluation of class effect.

BACKGROUND: Clinical trials have shown the benefits of statins after acute myocardial infarction (AMI). However, it is unclear whether different statins exert a similar effect in reducing the incidence of recurrent AMI and death when used in clinical practice. METHODS: We conducted a retrospective cohort study (1997-2002) to compare 5 statins using data from medical administrative databases in 3 provinces (Quebec, Ontario and British Columbia). We included patients aged 65 years and over who were discharged alive after their first AMI-related hospital stay and who began statin treatment within 90 days after discharge. The primary end point was the combined outcome of recurrent AMI or death from any cause. The secondary end point was death from any cause. Adjusted hazard ratios (HRs) for each statin compared with atorvastatin as the reference drug were estimated using Cox proportional hazards regression analysis. RESULTS: A total of 18,637 patients were prescribed atorvastatin (n = 6420), pravastatin (n = 4480), simvastatin (n = 5518), lovastatin (n = 1736) or fluvastatin (n = 483). Users of different statins showed similar baseline characteristics and patterns of statin use. The adjusted HRs (and 95% confidence intervals) for the combined outcome of AMI or death showed that each statin had similar effects when compared with atorvastatin: pravastatin 1.00 (0.90-1.11), simvastatin 1.01 (0.91-1.12), lovastatin 1.09 (0.95-1.24) and fluvastatin 1.01 (0.80-1.27). The results did not change when death alone was the end point, nor did they change after adjustment for initial daily dose or after censoring of patients who switched or stopped the initial statin treatment. INTERPRETATION: Our results suggest that, under current usage, statins are equally effective for secondary prevention in elderly patients after AMI.

Aged↗

PubMed2005

Effect of gender on treatment, resource utilization, and outcomes in congestive heart failure in Quebec, Canada.

This study assessed whether a gender gap exists in therapy, procedure use, and outcomes in patients who have a new diagnosis of congestive heart failure (CHF) at the population level. The Quebec hospital discharge database was linked with the physician and drug claims databases to identify a cohort of patients who had a diagnosis of CHF (code 428 in the International Classification of Diseases, Ninth Revision) between January 1998 and December 2002. There were 16,017 men and 16,622 women. Women who had CHF were older (78 +/- 11 vs 73 +/- 11 years, p <0.001), had more hypertension (41% vs 28%, p <0.001) and hyperlipidemia (18% vs 14%, p <0.001) but less frequent myocardial infarction (19% vs 25%, p <0.001). Women were less likely to see a cardiologist (30% vs 34%, p <0.001) and required a longer hospital stay (12.0 +/- 14.8 vs 10.6 +/- 13.3 days, p <0.001). During the first year after a first CHF hospitalization, women were less like to have an assessment of left ventricular function (61% vs 65%, p <0.001), diagnostic cardiac catheterization (11% vs 15%, p <0.001), and revascularization procedure (4% vs 6%, p <0.001). Women were less likely to be prescribed an angiotensin-converting enzyme inhibitor (60% vs 66%) and more likely to be prescribed a beta blocker (38% vs 34%). Women and men had similar yearly numbers of rehospitalizations for CHF (1.4 +/- 1.0 vs 1.5 +/- 1.0) and emergency room visits (1.7 +/- 1.2 vs 1.8 +/- 1.3). The adjusted risk of death was minimally higher in men than in women (hazard ratio 1.06, 95% confidence interval 1.03 to 1.1, p <0.01). Thus, despite less frequent cardiologist assessment, fewer cardiac-related procedures, and less frequent use of standard medical therapy, clinical outcomes in women and men who had CHF were similar.

Aged↗

PubMed2005

Bleeding complications associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients following acute myocardial infarction.

BACKGROUND: Combinations of aspirin with thienopyridine derivatives (clopidogrel bisulfate or ticlopidine hydrochloride) and/or warfarin sodium are increasingly being used in various cardiac conditions. However, little is known about the bleeding risks associated with these combinations, particularly in elderly individuals at the population level. This study estimates the bleeding risks associated with combinations of aspirin, thienopyridine derivatives, and warfarin in elderly patients. METHODS: We conducted a population-based observational cohort study using linked administrative databases. A total of 21,443 elderly survivors of acute myocardial infarction between 1996 and 2000 were studied. Patients were divided into 5 groups according to drug exposure: aspirin alone, warfarin alone, aspirin plus a thienopyridine derivative (antiplatelet combination), aspirin plus warfarin (anticoagulant combination), and aspirin plus warfarin plus a thienopyridine derivative (3-drug combination). Hospitalizations for bleeding events were examined. RESULTS: Hospitalizations for bleeding were observed in 1428 patients (7%). Compared with rates of patients receiving aspirin alone (0.03 per patient-year), rates of bleeding were higher among patients receiving the antiplatelet combination (0.07 per patient-year), the anticoagulant combination (0.08 per patient-year), and the 3-drug combination (0.09 per patient-year). Compared with aspirin alone, the adjusted odds ratios (95% confidence intervals) for bleeding were 1.65 (1.02-2.73) for patients receiving the antiplatelet combination and 1.92 (1.28-2.87) for patients receiving the anticoagulant combination. Only 1 of 141 patients in the 3-drug combination group had a bleeding event. CONCLUSION: In practice, antiplatelet and anticoagulant combinations lead to modest increases in bleeding risk in elderly patients, but the overall risk is small.

Age Factors↗

PubMed2005

Pharmacological treatment of congestive heart failure in Canada: a description of care in five provinces.

INTRODUCTION: Congestive heart failure (CHF) is responsible for significant morbidity, mortality and health resource consumption. There have been major advances in the treatment of this condition over the past two decades, yet little information is currently available regarding the current status of CHF management in Canada. OBJECTIVE: To describe the pharmacological management of patients hospitalized with CHF in five provinces: Alberta, British Columbia, Nova Scotia, Ontario and Quebec. DESIGN AND METHODS: Administrative data sources were used to identify all consecutive patients hospitalized with a principal diagnosis of CHF and discharged alive in the provinces of Alberta, British Columbia, Quebec and Ontario. Rates of use of prespecified medications at 30 days after hospital discharge were obtained for patients 65 years of age and older by linkage of their hospital records with drug benefit plans in these provinces. For Nova Scotia, the disease-specific registry of the Improving Cardiovascular Outcomes in Nova Scotia (ICONS) study was used to obtain discharge medications of individuals consecutively hospitalized with a diagnosis of CHF. Where available, data were acquired from 1997 to 2002. RESULTS: Data were obtained for a total of 115,037 patients in the five provinces over the five-year period. Overall, 54.9% of patients received an angiotensin-converting enzyme inhibitor at or 30 days after hospital discharge, with minimal change in prescription rates over the five-year period. Beta-blocker prescription rates increased steadily during the study, more than doubling from 15.0% in 1997/1998 to 32.0% in 2001/2002. Spironolactone use increased dramatically, with only 2.2% of patients receiving this medication in 1997/1998 compared with 18.7% in 2001/2002. The rates of digoxin prescription decreased each year, while the use of angiotensin receptor blockers increased slightly throughout the observation period. CONCLUSIONS: While the use of evidence-based treatment for CHF in Canada is increasing and is currently at levels similar to those reported in other developed countries, there is still the potential in every province for further improvement.

Adrenergic beta-Antagonists↗

PubMed2005

Comparison of nested case-control and survival analysis methodologies for analysis of time-dependent exposure.

BACKGROUND: Epidemiological studies of exposures that vary with time require an additional level of methodological complexity to account for the time-dependence of exposure. This study compares a nested case-control approach for the study of time-dependent exposure with cohort analysis using Cox regression including time-dependent covariates. METHODS: A cohort of 1340 subjects with four fixed and seven time-dependent covariates was used for this study. Nested case-control analyses were repeated 100 times for each of 4, 8, 16, 32, and 64 controls per case, and point estimates were compared to those obtained using Cox regression on the full cohort. Computational efficiencies were evaluated by comparing central processing unit times required for analysis of the cohort at sizes 1, 2, 4, 8, 16, and 32 times its initial size. RESULTS: Nested case-control analyses yielded results that were similar to results of Cox regression on the full cohort. Cox regression was found to be 125 times slower than the nested case-control approach (using four controls per case). CONCLUSIONS: The nested case-control approach is a useful alternative for cohort analysis when studying time-dependent exposures. Its superior computational efficiency may be particularly useful when studying rare outcomes in databases, where the ability to analyze larger sample sizes can improve the power of the study.

Aged↗

PubMed2005

Cardiac medical therapy in patients after undergoing coronary artery bypass graft surgery: a review of randomized controlled trials.

The purpose of this paper is to review the randomized controlled trial (RCT) data investigating cardiac medical therapy for patients after coronary artery bypass grafting (CABG). We identified RCTs with > or =100 enrolled patients that examined the impact of cardiac medical therapy on outcomes > or =1 year after CABG. The MEDLINE database was searched for trials conducted between 1966 and 2004 on the following medications: aspirin, antilipid agents, beta-blockers, calcium channel blockers (CCBs), nitrates, and angiotensin-converting enzyme (ACE) inhibitors. Both aspirin and antilipid agents were found to reduce the progression of atherosclerosis and the occurrence of graft occlusion. Cardiovascular events were decreased with antilipid agents. In small trials, beta-blockers and CCBs failed to decrease the incidence of cardiovascular events. No RCTs examined nitrates, and one small RCT documented a reduction in cardiovascular events among patients treated with ACE inhibitors. We conclude that few RCTs have examined the efficacy of cardiac medical therapy in post-CABG patients. Based on current RCT evidence, aspirin and antilipid agents should be used routinely after CABG. However, current data do not support the use of beta-blockers, CCBs, and nitrates, and more evidence is needed regarding the use of ACE inhibitors.

Adrenergic beta-Antagonists↗

PubMed2005

Hospital readmissions following abdominal aortic aneurysm repair.

In-hospital outcomes associated with abdominal aortic aneurysm (AAA) repair are well described. However, little is known about post-discharge readmission rates, lengths of stay, associated mortality, and costs. We examined 206 consecutive patients who underwent AAA repair at two American hospitals between 1998 and 2000. Index hospitalization and 6-month readmission data were extracted from a resource and cost accounting system used by both hospitals. Among the 206 patients, 183 survived until discharge (mortality rate 11.2%). Among the surviving patients, 38 (21.0%) were readmitted within 6 months. Half of the readmissions occurred within two weeks of discharge, with patients presenting with a diverse array of complications. Nonelective repair and diabetes mellitus were independent predictors of hospital readmission (OR = 2.83, 95% CI = 1.25-6.40, p = 0.01; OR = 6.60, 95% CI = 1.02-42.4, p = 0.047, respectively). For each readmission, the mean length of stay was 10.7 +/- 2.5 days and the mean cost was dollar 13,397 +/- 3,381. The cumulative number of hospital days during the 6 months post-discharge was 17.7 +/- 3.5 days for each readmitted patient and the mean per-patient total cost was dollar 23,262 +/- 5,478. The mortality rate among readmitted patients was 13.2%. Overall, readmissions following AAA repair accounted for a cost >50% over and above the cost of the readmitted patients' index hospitalization. Hospital readmissions are common during the 6 months following AAA repair. Patients who are readmitted experience long lengths of stay and high mortality rates, and their care incurs high costs.

Aged↗

PubMed2005

Invasive versus noninvasive management of ST-elevation acute myocardial infarction: a review of clinical trials and observational studies.

BACKGROUND: Despite decades of research, it is still unclear whether patients with uncomplicated ST-segment elevation acute myocardial infarction (AMI) should be managed with an invasive or a noninvasive approach after successful thrombolysis. METHODS: We reviewed randomized trials in which patients were randomized to a strategy of routine cardiac catheterization after thrombolysis (invasive) or a strategy whereby patients received cardiac catheterization only if they demonstrated reversible ischemia by noninvasive testing (noninvasive). We also reviewed observational studies that compared outcomes for patients who were admitted to hospitals with and without availability of cardiac catheterization facilities or in different geographic regions. RESULTS: Evidence to date suggests that invasive approach does not result in mortality or reinfarction benefits for patients with uncomplicated ST-segment elevation AMI. However, all except one of the trials performed are dated in view of recent treatment advances, and long-term outcomes for the recent trial have not been published. Several observational studies suggest that the invasive approach may improve "softer" outcomes such as quality of life and functional status. CONCLUSION: In conclusion, there is currently no evidence to support widespread use of the invasive approach among patients with uncomplicated ST-segment elevation AMI. However, trials with long-term follow-up should be repeated in the current clinical context and should include both hard and softer outcome measures.

Angioplasty, Balloon, Coronary↗

PubMed2005

Impact of invasive management versus noninvasive management on functional status and quality of life following non-Q-wave myocardial infarction: a randomized clinical trial.

BACKGROUND: Multiple studies have examined whether clinical outcomes are improved by invasive management following non-Q-wave myocardial infarction (NQWMI). However, it remains unclear whether functional status and quality of life are affected by an invasive strategy. METHODS: Following NQWMI, we randomized 88 patients to invasive management vs noninvasive management. The primary end point was functional status assessed at 12 months using maximal endurance exercise treadmill testing measured in metabolic equivalents. Secondary end points included changes in scores between baseline and 12 months on the Duke Activity Status Index, the Seattle Angina Questionnaire, and the Medical Outcomes Study 36-Item Short-Form Survey. RESULTS: Of the 42 patients in the invasive arm, 83% underwent initial angiography. Of the 46 patients in the noninvasive arm, 91% underwent initial stress testing. Inhospital and 12-month revascularization rates were similar in the 2 arms (24% vs 22%, P > or = .99; 31% vs 30%, P > or = .99). Maximal endurance exercise treadmill testing was also similar at 12 months (7.8 vs 6.7 metabolic equivalents, P = .24). Patients in the invasive arm showed improved functional status by mean difference in their Duke Activity Status Index scores (4.3 vs -3.5, P = .04). Improvements in angina-specific quality of life for patients in the invasive arm were demonstrated by the Seattle Angina Questionnaire measures of anginal stability (21.6 vs -5.3, P = .02), anginal frequency (22.9 vs 2.3, P = .02), treatment satisfaction (11.2 vs -10.3, P = .02), and disease perception (24.7% vs 10.9%, P = .07). CONCLUSIONS: Compared with patients undergoing noninvasive management of NQWMI, patients undergoing invasive management have some measures indicative of improved functional status.

Coronary Angiography↗

PubMed2005

Routine versus selective functional testing after percutaneous coronary intervention in patients with diabetes mellitus.

Patients with diabetes mellitus who undergo percutaneous coronary intervention (PCI) have higher rates of restenosis and a poorer prognosis than patients without diabetes. The American College of Cardiology/American Heart Association guidelines on exercise testing suggest that patients with diabetes may benefit from routine post-PCI functional testing (FT). To explore this issue, we examined the functional capacity, quality of life, event rates and procedural outcomes among 61 patients with diabetes enrolled in the Aggressive Diagnosis of Restenosis (ADORE) trial. All patients were randomized to either routine FT or selective FT and were followed for a period of 9 months. Patients with diabetes randomized to routine FT had a higher composite clinical event rate than those randomized to the selective FT strategy. Procedural rates did not differ significantly between the two groups. These results suggest that routine post-PCI FT in patients with diabetes is of little clinical value.

Adolescent↗

PubMed2005

Cost-effectiveness of lipid-lowering treatment according to lipid level.

BACKGROUND: Recent studies suggest that the benefit of lipid-lowering treatment for the primary and secondary prevention of cardiovascular disease (CVD) extends to individuals with average cholesterol levels, to women and to the elderly. However, the proportion of the general population for which treatment is cost-effective has not been evaluated. OBJECTIVES AND METHODS: Using data provided by the Canadian Heart Health Survey, the level of CVD risk was estimated for a random sample of the total population. A cost-effectiveness ratio for simvastatin was then calculated for each individual in the sample. Lastly, the proportion of the total population for which lipid-lowering therapy would be cost-effective for primary and secondary prevention of CVD was estimated according to total cholesterol (TC) levels. RESULTS: Among the surveyed individuals who were 30 to 74 years of age, 2212 had CVD and 12,982 did not. Among those with a TC level higher than 6.2 mmol/L, the proportions of individuals for which lipid-lowering therapy was cost-effective (at a level of less than 50,000 dollars per year of life saved) were 85.6% of men and 28.7% of women for primary prevention, and 99.8% of men and 86.1% of women for secondary prevention. The estimated cost of one year of lipid-lowering treatment for all individuals in the population with a TC level higher than 6.2 mmol/L and for all individuals regardless of TC levels for whom treatment would be cost-effective was $1 billion and 3.9 billion dollars, respectively. CONCLUSIONS: Lipid-lowering treatment for CVD prevention is cost-effective for a high proportion of the population, even for primary prevention. As a result, the cost of population-wide treatment for only one year is high even among individuals with a TC level higher than 6.2 mmol/L. Such costs should be considered in health care policy decisions.

Adult↗

PubMed2005

Ibuprofen may abrogate the benefits of aspirin when used for secondary prevention of myocardial infarction.

OBJECTIVE: To determine whether patients taking aspirin for secondary prevention of myocardial infarction are at increased risk of recurrent disease when they take concomitant ibuprofen. METHODS: In this population based, retrospective cohort study using governmental databases, patients > or = 66 years of age, hospitalized for an index acute myocardial infarction (AMI) between January 1992 and March 1999 and taking ASA throughout the period of followup were identified. The main exposure was the concomitant use of ibuprofen and ASA after the index AMI. The outcome of interest was recurrent AMI. Subjects were followed to one year after the index AMI. RESULTS: A total of 18,503 patients met the study entry criteria. Of these, 372 patients were dispensed a prescription for ibuprofen (exposed) and 14,424 patients were not dispensed a prescription for any nonsteroidal antiinflammatory drug (NSAID) (unexposed). Patients dispensed prescriptions for any NSAID (n = 4079), naproxen (n = 1239), and diclofenac (n = 1474) were analyzed separately. There was a trend to an increase in the rate of recurrent AMI in patients taking ibuprofen and ASA compared to those taking ASA alone as the duration of exposure increased [hazard ratios for ever, > or = 30 days, and > or = 60 days exposed were 1.01 (95% CI 0.58-1.76), 1.13 (95% CI 0.54-2.39), and 1.83 (95% CI 0.76-4.42), respectively]. In contrast, subjects taking prolonged naproxen and ASA had a trend toward a lower rate of recurrent AMI compared to those taking ASA alone. CONCLUSION: The results are consistent with data that suggest that regular, but not intermittent, ibuprofen may abrogate the benefits of aspirin when used for the secondary prevention of AMI. There may be differences in the risk of heart disease with various NSAID.

Aged↗

PubMed2005

Coronary artery bypass graft surgery: do women cost more?

BACKGROUND: Coronary artery bypass graft surgery (CABG) in women has been associated with worse clinical outcomes than CABG in men. However, little is known about the impact of sex on the cost of CABG. OBJECTIVE: To examine the impact of sex on hospital course and the cost of CABG. METHODS: Hospital course and cost were examined among 2880 female and 9137 male patients from four Canadian and five American hospitals. Data were obtained from a resource and cost accounting system used by each of the nine hospitals. RESULTS: Among the 12,017 patients who underwent CABG, 24% (n=2880) were women and 76% (n=9137) were men. Women had a significantly longer length of stay (LOS) than did men (10.3+/-0.2 days and 8.9+/-0.08 days, respectively; P<0.0001) and a significantly higher in-hospital mortality than did men (2.6% and 1.5%, respectively; P<0.0001). The total unadjusted cost was higher for women than for men both in Canada (US$11,200+/-268 and US$10,143+/-139, respectively; P<0.0001) and the United States (US$22,715+/-509 and US$19,906+/-269, respectively; P<0.0001). After adjusting for age and comorbid conditions, female sex was associated with a 10% increase in LOS (P<0.0001), a 97% increase in mortality (P=0.0006) and a 7% increase in overall cost (P<0.0001). CONCLUSION: Compared with men, women undergoing CABG had a modestly increased LOS and a higher mortality. Total in-hospital cost was higher for women in each of the nine hospitals studied. Compared with other clinical variables, female sex is a relatively minor determinant of cost. Nevertheless, because of the expected increase in the number of women undergoing CABG in the future, this increased cost may translate into an important economic burden.

Canada↗

PubMed2004

Updated risk factor values and the ability of the multivariable risk score to predict coronary heart disease.

Most existing coronary risk assessment methods are based on baseline data only. The authors compared the predictive ability of coronary multivariable risk scores based on updated versus baseline risk factors and investigated the optimal frequency of updating. Data from 16 biennial examinations of 4,962 subjects from the original Framingham Heart Study (1948-1978) were used. The predictive ability of three multivariable risk scores was evaluated through 10-fold cross-validation. The baseline-only multivariable risk score was computed using baseline values of coronary risk factors applied to a Cox model estimated from baseline data. The two other approaches relied on updated risk factors and included them in the models estimated from, respectively, baseline and updated data. All analyses were stratified by sex and age. For 30, 14, and 10 years of follow-up, the predictive ability of the baseline-only multivariable risk score was substantially poorer than that of the models using updated risk factors. Between the two latter models, the one estimated from updated data ensured better prediction than the one estimated from baseline data for 30 years of follow-up among younger subjects only. The results suggest that coronary risk assessment can be improved by utilizing updated risk factors and that the optimal frequency of updating may vary across subpopulations.

Adult↗

PubMed2004

Mortality rates in elderly patients who take different angiotensin-converting enzyme inhibitors after acute myocardial infarction: a class effect?

BACKGROUND: Several randomized, controlled trials show that angiotensin-converting enzyme (ACE) inhibitors improve survival in patients who have had an acute myocardial infarction. However, existing data from trials do not address whether all ACE inhibitors benefit patients similarly. OBJECTIVE: To evaluate whether all ACE inhibitors are associated with similar mortality in patients 65 years of age or older who have had an acute myocardial infarction. DESIGN: Retrospective cohort study that used linked hospital discharge and prescription databases containing information on 18 453 patients 65 years of age or older who were admitted for an acute myocardial infarction between 1 April 1996 and 31 March 2000. SETTING: 109 hospitals in Quebec, Canada. PATIENTS: 7512 patients who filled a prescription for an ACE inhibitor within 30 days of discharge and who continued to receive the same drug for at least 1 year. MEASUREMENTS: The association between the specific drugs and clinical outcomes was measured by using Cox proportional hazards models, with adjustment for demographic, clinical, physician, and hospital variables and dosage categories, represented by time-dependent variables. RESULTS: Enalapril, fosinopril, captopril, quinapril, and lisinopril were associated with higher mortality than was ramipril; the adjusted hazard ratios and 95% CIs were 1.47 (95% CI, 1.14 to 1.89), 1.71 (CI, 1.29 to 2.25), 1.56 (CI, 1.13 to 2.15), 1.58 (CI, 1.10 to 2.82), and 1.28 (CI, 0.98 to 1.67), respectively. The adjusted hazard ratio associated with perindopril was 0.98 (CI, 0.60 to 1.60). LIMITATIONS: The administrative databases did not contain detailed clinical information, and unmeasured factors associated with a patient's risk for death may have influenced physicians' prescription choices. CONCLUSION: Survival benefits in the first year after acute myocardial infarction in patients 65 years of age or older seem to differ according to the specific ACE inhibitor prescribed. Ramipril was associated with lower mortality than most other ACE inhibitors.

Aged↗

PubMed2004

Impact of age on hospital course and cost of coronary artery bypass grafting.

In-hospital outcomes and cost were examined among 2,272 elderly patients (> or =75 years) and 9,745 younger patients (<75 years) who underwent coronary artery bypass graft surgery at 5 United States and 4 Canadian hospitals. Hospital course and cost data were obtained from a resource and cost accounting system used by each of the 9 hospitals. Compared with younger patients, elderly patients had longer hospital stays, increased in-hospital mortality, and increased costs. After controlling for clinical differences, age > or =75 years was associated with an increase in cost of 11%. Given the aging North American population, these results have important implications for health care planning for the next several decades.

Age Factors↗