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PubMedDate not supplied

Characteristics and lipid distribution of a large, high-risk, hypertensive population: the lipid-lowering component of the Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) consisted of 42,418 participants randomized to one of four antihypertensive treatment groups: chlorthalidone, amlodipine, lisinopril, or doxazosin. A subset of these participants with fasting low-density lipoprotein cholesterol levels 100-189 mg/dL were randomized into a lipid-lowering component: 5170 to receive pravastatin (40 mg daily) and 5185 to receive usual care. This report describes the characteristics and lipid distribution of these participants. There were no important differences between the randomized treatment groups. Women had higher total cholesterol, low-density lipoprotein cholesterol, and high-density lipoprotein cholesterol than men. There was a similar finding for black participants compared with whites, except blacks had lower triglycerides. Diabetics had lower high-density lipoprotein cholesterol and higher triglycerides than nondiabetics, and patients with body mass index <25 kg/m(2) had higher high-density lipoprotein cholesterol but lower low-density lipoprotein cholesterol and triglycerides than patients with higher body mass index. The success of the randomization of this large, diverse population and the differences in the lipid distributions among its subgroups will allow further understanding of optimal lipid-lowering treatment.

Aged↗
PubMed1997

Emergency medical service providers' role in the early heart attack care program: prevention and stratification strategies.

Emergency Medical Services-Early Heart Attack Care (EMS-EHAC) is a community-based program where paramedics increase the consumer's awareness about early chest pain symptom recognition. EMS-EHAC prevention, along with seamless chest pain care (between the paramedic and chest pain emergency department) can be the basis for an outcome-based study to examine the impact of advanced life support EMS. Studies that show the impact of care given by paramedics on the outcome of patient care must be designed to demonstrate the value and the cost benefit of providing advanced life support (ALS). Third party payers are going to examine if there are significant quality differences between ALS and basic life support (BLS) services. If significant benefits of ALS care cannot be demonstrated, the cost differences could potentially place the future of advanced life support paramedic programs in jeopardy. A positive outcome resulting in a lower acute cardiac event, and the realization of the cost benefits from the EMS-EHAC program could be utilized by EMS management to justify or expand advanced life support programs.

Allied Health Personnel↗
PubMed1987

A scoring system to identify men at high risk of a heart attack.

A scoring system for identification of men at high risk of a heart attack within 5 years of screening is presented. The full scoring system includes an electrocardiogram and blood cholesterol measurement and the top fifth of the distribution of this full score yields 59% of the major ischaemic heart disease events occurring in the 5 years after screening. An intermediate scoring system, without an electrocardiogram but retaining blood cholesterol, yields 58% of cases from the top fifth of the score distribution. A basic (GP) score, without electrocardiogram or blood cholesterol measurement, yields 54% of cases and is recommended for use in opportunistic screening in general practice. This high risk strategy would increase public awareness of the size of the problem, help to prevent premature death and provide a useful complement to the population strategies of health education and government policy.

Adult↗
PubMed2001

Impact of community-based education on health care evaluation in patients with acute chest pain syndromes: the Wabasha Heart Attack Team (WHAT) project.

BACKGROUND: Community education programmes focused on raising public awareness of the symptomatology of acute coronary syndromes have had mixed results. OBJECTIVES: The Wabasha Heart Attack Team project, a unique multidisciplinary public education effort in Minnesota, sought to educate area citizens about signs and symptoms of acute myocardial infarction (MI). METHODS: After an intensive 1-month education period, we compared presentations for emergency evaluation of chest pain during the study period with baseline data from the same seasonal period of the preceding year. RESULTS: Visits to the Emergency Room for symptomatic heart disease increased significantly during the study period (56 patients versus 46 patients during the baseline period), as did the percentage of patients presenting with acute MI (18% versus 12%, P < 0.05). Use of emergency medical services for pre-hospital evaluation was significantly increased (41% versus 27%, P < 0.05). CONCLUSION: A community education campaign can significantly increase use of pre-hospital emergency medical service resources and may increase the number of patients presenting with acute chest pain symptoms, including MI.

Aged↗
PubMed1984

Social networks and support during the crisis of heart attack.

The type, source, and extent of support received by the families of heart attack victims were investigated in this study to shed light on the nature of families' informal support systems. The author concludes that grown-up children and friends and neighbors were families' greatest source of emotional support but that professional intervention is needed to mobilize and supplement informal networks.

Adaptation, Psychological↗
PubMedDate not supplied

Long-term survival differences among low-anxious, high-anxious and repressive copers enrolled in the Montreal heart attack readjustment trial.

OBJECTIVE: This study reports 5-year outcomes from the Montreal Heart Attack Readjustment Trial, a randomized, controlled trial of monthly telephone monitoring of psychological distress and home nursing visits in a sample of 1376 patients. It focuses on differences in long-term program impact associated with patients' sex and baseline anxiety/repressor coping styles. The potential mediating roles of medications, medical care utilization, and changes in negative emotions over the program are also explored. METHODS: Three subgroups were defined using median splits on the State Anxiety Inventory and Marlowe-Crowne Scale administered at baseline: truly low anxious, repressors, and high anxious. Quebec medicare data were used to track survival through 5 years. RESULTS: The trend toward worse prognosis in women in the treatment group and no evidence of treatment impact in men that were seen during the program year were maintained during the follow-up. Analysis of results in terms of coping styles showed a significant long-term survival benefit of treatment in highly anxious men, for whom reductions in somatic symptoms of depression mediated program impact. However, the program was also associated with significantly worse survival in repressors of both sexes. By the end of the program, repressors in the treatment group were more likely to be prescribed benzodiazepines and to have visited emergency rooms without being readmitted than those in the control group, suggesting that the program may have increased distress in repressors. CONCLUSIONS: Patients' coping style is important in determining outcomes of psychosocial treatments and should be taken into account when tailoring interventions.

Adaptation, Psychological↗
PubMed1999

ED slashes treatment time for heart attack drugs.

A New Jersey hospital cut its time for thrombolytic treatment for heart attack patients from 61 minutes to less than 25 minutes. Improvements included a one-page time-to-treatment assessment tool and a five-minute protocol for walk-in patients. Emergency department leaders suggest focusing on clinical processes to get medical staff buy-in.

Benchmarking↗
PubMed2004

Do-not-resuscitate orders in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study.

BACKGROUND: Coronary heart disease is the leading cause of death in Americans. Despite increased interest in end-of-life care, data regarding the use of do-not-resuscitate (DNR) orders in acutely ill cardiac patients remain extremely limited. The objectives of this study were to describe use of DNR orders, treatment approaches, and hospital outcomes in patients with acute myocardial infarction. METHODS: The study sample consisted of 4621 residents hospitalized with acute myocardial infarction at all metropolitan Worcester, Mass, area hospitals in five 1-year periods from 1991 to 1999. RESULTS: Significant increases in the use of DNR orders were observed during the study decade (from 16% in 1991 to 25% in 1999). The elderly, women, and patients with previous diabetes mellitus or stroke were more likely to have DNR orders. Patients with DNR orders were significantly less likely to be treated with effective cardiac medications, even if the DNR order occurred late in the hospital stay. Less than 1% of patients were noted to have DNR orders before hospital admission. Patients with DNR orders were significantly more likely to die during hospitalization than patients without DNR orders (44% vs 5%). CONCLUSIONS: The results of this community-wide study suggest increased use of DNR orders in patients hospitalized with acute myocardial infarction during the past decade. Use of certain cardiac therapies and hospital outcomes are different between patients with and without DNR orders. Further efforts are needed to characterize the use of DNR orders in patients with acute coronary disease.

Aged↗
PubMed1986

Giving up smoking and the risk of heart attacks. A report from The British Regional Heart Study.

In a prospective study of 7735 middle-aged men, both current and ex-cigarette-smokers had a risk of a major IHD event, within an average 6.2 years of screening, more than twice that in men who had never smoked cigarettes; men who had given up smoking more than 20 years ago still had an increased risk. This excess risk among ex-smokers is only to a small extent explained by their higher blood pressure, serum total cholesterol, and body-mass index. An increased prevalence of IHD in men who had recently given up smoking also made a small contribution to excess risk. In both current and former cigarette smokers, the number of years a man had smoked cigarettes ("smoking-years") was the clearest indicator of IHD risk due to cigarettes. The major benefit of giving up smoking may lie in halting the accumulation of smoking years.

Adult↗
PubMed2005

Failure of current public educational campaigns to impact on the initial response of patients with possible heart attack.

AIMS: The National Heart Foundation of Australia recognizes that the risk of lethal arrhythmias is greater very early after the onset of myocardial infarction and that the more promptly flow can be restored in the infarct-related artery the greater will be the benefits for survival and preservation of heart function. The Heart Foundation has therefore conducted several public media campaigns to encourage patients to seek help more promptly and evaluated their impact. METHODS: Since 1996, we have conducted four surveys of delays preceding admission of patients to coronary care units throughout Australia to assess the impact of the Heart Foundation's media campaigns. Data were collected on 1665 patients who presented to 73 hospitals; information on patient delay was available for 1178 of them. RESULTS: There were no significant differences in patient delay (median 1.5-2.0 h) in the four surveys from 1996 to 2002, nor when patients were categorized by age, sex, presenting diagnosis or history of previous myocardial infarction or coronary revascularization by percutaneous or surgical techniques. CONCLUSION: New approaches are needed to reduce patient-related delay after the onset of symptoms suggesting possible myocardial infarction.

Aged↗
PubMed1998

Educational Strategies to Prevent Prehospital Delay in Patients at High Risk for Acute Myocardial Infarction: A Report by the National Heart Attack Alert Program.

An estimated 13 million people in the United States have coronary heart disease (CHD), peripheral vascular disease, or cerebrovascular disease. The risk for subsequent myocardial infarction (MI) and death in these patients is fivefold to sevenfold higher than for the general population. Many effective therapies are now available for patients with unstable angina, acute myocardial infarction (AMI), potentially fatal arrhythmias, and cardiogenic shock if they seek and receive care expeditiously. However, delays in accessing and receiving care are a continuing problem, threatening the effectiveness of available treatments. Patients with previously diagnosed CHD, including a previous MI, have the same or greater delay times as those without prior MI or CHD. Because of the high-risk status of these patients, combined with the problem of delay in seeking care, this Working Group of the National Heart Attack Alert Program Coordinating Committee advises physicians and other healthcare providers of their important role in reducing treatment delay in these patients. The Working Group recommends that primary care clinicians in the office and in inpatient settings provide these patients and their family members or significant others with contingency counseling about actions to take in response to symptoms of an AMI. The counseling should address the emotional aspects (e.g., fear and denial) that patients and those around them may experience, as well as barriers that may be associated with the healthcare delivery system. Assistance from other healthcare providers (e.g., nurses) should be solicited to initiate, reinforce, and supplement the counseling. A Patient Advisory Form is offered as an aid to providers in counseling their high-risk patients about these issues. Other materials and aids should be considered as well. Physicians' offices and clinics should devise a system to triage patients rapidly when they call or walk in seeking advice for possible AMI symptoms. Further research is needed to learn more about effective counseling strategies; symptom manifestation in high-risk groups, including the elderly, women, and minorities; and healthcare delivery systems that enhance access to timely care for patients with prior CHD or other clinical atherosclerotic disease.

Journal Article↗
PubMed2000

National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia.

The National Heart Attack Alert Program (NHAAP), which is coordinated by the National Heart, Lung, and Blood Institute (NHLBI), promotes the early detection and optimal treatment of patients with acute myocardial infarction and other acute coronary ischemic syndromes. The NHAAP, having observed the development and growth of chest pain centers in emergency departments with special interest, created a task force to evaluate such centers and make recommendations pertaining to the management of patients with acute cardiac ischemia. This position paper offers recommendations to assist emergency physicians in EDs, including those with chest pain centers, in providing comprehensive care for patients with acute cardiac ischemia.

Chest Pain↗
PubMed2004

Hemodynamic observations on a yogic breathing technique claimed to help eliminate and prevent heart attacks: a pilot study.

OBJECTIVE: This pilot study investigated the hemodynamics of a yogic breathing technique claimed "to help eliminate and prevent heart attacks due to abnormal electrical events to the heart," and to generally "enhance performance of the central nervous system (CNS) and to help eliminate the effects of traumatic shock and stress to the CNS." DESIGN: Parameters for (4) subjects were recorded during a preexercise resting period, a 31-minute exercise period, and a postexercise resting period. SETTINGS/LOCATION: Parameters for subjects were recorded in a laboratory at the University of California, San Diego. SUBJECTS: Parameters for 3 males (ages 44, 45, 67) and 1 female (age 41) were recorded. One (1) subject (male age 45) had extensive training in this technique. INTERVENTIONS: This yogic technique is a 1 breath per minute (BPM) respiratory exercise with slow inspiration for 20 seconds, breath retention for 20 seconds, and slow expiration for 20 seconds, for 31 consecutive minutes. OUTCOME MEASURES: Fourteen beat-to-beat parameters were measured noninvasively and calculated for body surface area to yield: stroke index (SI), heart rate (HR), cardiac index, end diastolic index, peak flow, ejection fraction, thoracic fluid index, index of contractility, ejection ratio, systolic time ratio, acceleration index, and systolic, diastolic, and mean arterial pressures (MAPs). Left stroke work index (LSWI) and stroke systemic vascular resistance index (SSVRI) were calculated. RESULTS: We report on SI, HR, MAP, LSWI, and SSVRI and how they can help to describe hemodynamicstate changes. This technique induces dramatic shifts in all hemodynamic variables during the 1 BPM exercise and can produce unique changes in the postexercise resting period after long-term practice that appears to have a unique effect on the brain stem cardiorespiratory center regulating the Mayer wave (0.1-0.01 Hz) patterns of the cardiovascular system. CONCLUSIONS: Preclinical studies are warranted to examine the possible long-term effects of this technique that appear to reset a cardiorespiratory brain-stem pacemaker. We postulate that this effect may be the basis for the purported yogic health claim.

Adult↗
PubMed2005

Geisinger checklist speeds transfer of heart attack patients.

In cardiology, there is a saying that "time is muscle." The longer it takes to reopen a heart attack patient's blocked artery, the more damage is done to the heart muscle. Cardiologists and emergency department physicians at Geisinger Medical Center are working together to shorten the time that it takes for patients to receive angioplasty, thus saving more heart muscle.

Angioplasty↗
PubMed2002

Validation of Heart Failure Events in the Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) Participants Assigned to Doxazosin and Chlorthalidone.

BACKGROUND: The Antihypertensive and Lipid Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized, double-blind, active-controlled trial designed to compare the rate of coronary heart disease events in high-risk hypertensive participants initially randomized to a diuretic (chlorthalidone) versus each of three alternative antihypertensive drugs: alpha-adrenergic blocker (doxazosin), ACE-inhibitor (lisinopril), and calcium-channel blocker (amlodipine). Combined cardiovascular disease risk was significantly increased in the doxazosin arm compared to the chlorthalidone arm (RR 1.25; 95% CI, 1.17-1.33; P <.001), with a doubling of heart failure (fatal, hospitalized, or non-hospitalized but treated) (RR 2.04; 95% CI, 1.79-2.32; P <.001). Questions about heart failure diagnostic criteria led to steps to validate these events further. METHODS AND RESULTS: Baseline characteristics (age, race, sex, blood pressure) did not differ significantly between treatment groups (P <.05) for participants with heart failure events. Post-event pharmacologic management was similar in both groups and generally conformed to accepted heart failure therapy. Central review of a small sample of cases showed high adherence to ALLHAT heart failure criteria. Of 105 participants with quantitative ejection fraction measurements provided, (67% by echocardiogram, 31% by catheterization), 29/46 (63%) from the chlorthalidone group and 41/59 (70%) from the doxazosin group were at or below 40%. Two-year heart failure case-fatalities (22% and 19% in the doxazosin and chlorthalidone groups, respectively) were as expected and did not differ significantly (RR 0.96; 95% CI, 0.67-1.38; P = 0.83). CONCLUSION: Results of the validation process supported findings of increased heart failure in the ALLHAT doxazosin treatment arm compared to the chlorthalidone treatment arm.

Journal Article↗
PubMed2001

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT): clinical center recruitment experience.

The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) is a randomized clinical outcome trial of antihypertensive and lipid-lowering therapy in a diverse population (including substantial numbers of women and minorities) of 42,419 high-risk hypertensives aged > or = 55 years with a planned mean follow-up of 6 years. In this paper, we describe our experience in the identification, recruitment, and selection of clinical centers for this large simple trial capable of meeting the recruitment goals outlined for ALLHAT, and we highlight factors associated with clinical center performance. Over 135,000 recruitment brochures were mailed to physicians. Requests for information and application packets were received from 9351 (6.8%) interested investigators. A total of 1053 completed applications were received and 909 sites (86%) were eventually approved to join the trial. Of the approved sites, 278 either later declined participation or were never activated, and 8 were closed within a year for lack of enrollment. The final 623 randomizing centers exceeded the trial's recruitment goal to enroll at least 40,000 participants into the trial, although the recruitment period was extended 1.5 years longer than planned. Fewer than a quarter of the sites (22.6%) were recruited from academic medical centers or Department of Veterans Affairs Medical Centers. More than half of the sites (54.7%) were private solo or group practices, which contributed 53% of randomized participants. Community health centers comprised about 8% of the ALLHAT sites and 2.9% were part of health maintenance organizations. More than 22% of the principal investigators reported that they had no previous clinical research experience. In summary, ALLHAT was successful in recruiting a diverse group of clinical centers to achieve its patient recruitment goals.

Antihypertensive Agents↗
PubMed2002

Major outcomes in high-risk hypertensive patients randomized to angiotensin-converting enzyme inhibitor or calcium channel blocker vs diuretic: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT).

CONTEXT: Antihypertensive therapy is well established to reduce hypertension-related morbidity and mortality, but the optimal first-step therapy is unknown. OBJECTIVE: To determine whether treatment with a calcium channel blocker or an angiotensin-converting enzyme inhibitor lowers the incidence of coronary heart disease (CHD) or other cardiovascular disease (CVD) events vs treatment with a diuretic. DESIGN: The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT), a randomized, double-blind, active-controlled clinical trial conducted from February 1994 through March 2002. SETTING AND PARTICIPANTS: A total of 33 357 participants aged 55 years or older with hypertension and at least 1 other CHD risk factor from 623 North American centers. INTERVENTIONS: Participants were randomly assigned to receive chlorthalidone, 12.5 to 25 mg/d (n = 15 255); amlodipine, 2.5 to 10 mg/d (n = 9048); or lisinopril, 10 to 40 mg/d (n = 9054) for planned follow-up of approximately 4 to 8 years. MAIN OUTCOME MEASURES: The primary outcome was combined fatal CHD or nonfatal myocardial infarction, analyzed by intent-to-treat. Secondary outcomes were all-cause mortality, stroke, combined CHD (primary outcome, coronary revascularization, or angina with hospitalization), and combined CVD (combined CHD, stroke, treated angina without hospitalization, heart failure [HF], and peripheral arterial disease). RESULTS: Mean follow-up was 4.9 years. The primary outcome occurred in 2956 participants, with no difference between treatments. Compared with chlorthalidone (6-year rate, 11.5%), the relative risks (RRs) were 0.98 (95% CI, 0.90-1.07) for amlodipine (6-year rate, 11.3%) and 0.99 (95% CI, 0.91-1.08) for lisinopril (6-year rate, 11.4%). Likewise, all-cause mortality did not differ between groups. Five-year systolic blood pressures were significantly higher in the amlodipine (0.8 mm Hg, P =.03) and lisinopril (2 mm Hg, P<.001) groups compared with chlorthalidone, and 5-year diastolic blood pressure was significantly lower with amlodipine (0.8 mm Hg, P<.001). For amlodipine vs chlorthalidone, secondary outcomes were similar except for a higher 6-year rate of HF with amlodipine (10.2% vs 7.7%; RR, 1.38; 95% CI, 1.25-1.52). For lisinopril vs chlorthalidone, lisinopril had higher 6-year rates of combined CVD (33.3% vs 30.9%; RR, 1.10; 95% CI, 1.05-1.16); stroke (6.3% vs 5.6%; RR, 1.15; 95% CI, 1.02-1.30); and HF (8.7% vs 7.7%; RR, 1.19; 95% CI, 1.07-1.31). CONCLUSION: Thiazide-type diuretics are superior in preventing 1 or more major forms of CVD and are less expensive. They should be preferred for first-step antihypertensive therapy.

Aged↗
PubMed2002

Critical pathways for management of patients with acute coronary syndromes: an assessment by the National Heart Attack Alert Program.

BACKGROUND: The use of critical pathways for a variety of clinical conditions has grown rapidly in recent years, particularly pathways for patients with acute coronary syndromes (ACS). However, no systematic review exists regarding the value of critical pathways in this setting. METHODS: The National Heart Attack Alert Program established a Working Group to review the utility of critical pathways on quality of care and outcomes for patients with ACS. A literature search of MEDLINE, cardiology textbooks, and cited references in any article identified was conducted regarding the use of critical pathways for patients with ACS. RESULTS: Several areas for improving the care of patients with ACS through the application of critical pathways were identified: increasing the use of guideline-recommended medications, targeting use of cardiac procedures and other cardiac testing, and reducing the length of stay in hospitals and intensive care units. Initial studies have shown promising results in improving quality of care and reducing costs. No large studies designed to demonstrate an improvement in mortality or morbidity were identified in this literature review. CONCLUSIONS: Critical pathways offer the potential to improve the care of patients with ACS while reducing the cost of care. Their use should improve the process and cost-effectiveness of care, but further research in this field is needed to determine whether these changes in the process of care will translate into improved clinical outcomes.

Acute Disease↗