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Many studies document disparities between Blacks and Whites in the treatment of acute myocardial infarction on controlling for patient demographic factors and comorbid conditions. Other studies provide evidence of disparities between Hispanics and Whites in cardiac care. Such disparities may be explained by differences in the hospitals where minority and nonminority patients obtain treatment and by differences in the traits of physicians who treat minority and nonminority patients. We used 1997-2005 Florida hospital inpatient discharge data to estimate models of cardiac catheterization, percutaneous transluminal coronary angioplasty, and coronary artery bypass grafting in Medicare fee-for-service patients 65 years and older. Controlling for hospital fixed effects does not explain Black–White disparities in cardiac treatment but largely explains Hispanic–White disparities. Controlling for physician fixed effects accounts for some extent of the racial disparities in treatment and entirely explains the ethnic disparities in treatment.

AbstractAir pollution remains a major threat to cardiovascular health and most acute myocardial infarction (AMI) deaths occur at home. However, currently established knowledge on the deleterious effect of air pollution on AMI has been limited to routinely monitored air pollutants and overlooked the place of death. In this study, we examined the association between short-term residential exposure to China's routinely monitored and unmonitored air pollutants and the risk of AMI deaths at home. A time-stratified case-crossover analysis was undertaken to associate short-term residential exposure to air pollution with 0.1 million AMI deaths at home in Jiangsu Province (China) during 2016–2019. Individual-level residential exposure to five unmonitored and monitored air pollutants including PM1 (particulate matter with an aerodynamic diameter ≤ 1 μm) and PM2.5 (particulate matter with an aerodynamic diameter ≤ 2.5 μm), SO2 (sulfur dioxide), NO2 (nitrogen dioxide), and O3 (ozone) was estimated from satellite remote sensing and machine learning technique. We found that exposure to five air pollutants, even below the recently released stricter air quality standards of the World Health Organization (WHO), was all associated with increased odds of AMI deaths at home. The odds of AMI deaths increased by 20% (95% confidence interval: 8 to 33%), 22% (12 to 33%), 14% (2 to 27%), 13% (3 to 25%), and 7% (3 to 12%) for an interquartile range increase in PM1, PM2.5, SO2, NO2, and O3, respectively. A greater magnitude of association between NO2 or O3 and AMI deaths was observed in females and in the warm season. The greatest association between PM1 and AMI deaths was found in individuals aged ≤ 64 years. This study for the first time suggests that residential exposure to routinely monitored and unmonitored air pollutants, even below the newest WHO air quality standards, is still associated with higher odds of AMI deaths at home. Future studies are warranted to understand the biological mechanisms behind the triggering of AMI deaths by air pollution exposure, to develop intervention strategies to reduce AMI deaths triggered by air pollution exposure, and to evaluate the cost-effectiveness, accessibility, and sustainability of these intervention strategies.
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Dept. of Public Health/諛뺤궗 ; Ischemic stroke, hemorrhagic stroke, and acute myocardial infarction (AMI) are diseases that occur during the so-called golden hour. These diseases need timely treatment and quick response to reduce mortality. Although the government has made efforts to improve survival, 30-day in-hospital mortality rates due to stroke and AMI are high. This study aimed to identify and compare factors that affect 7-day, 30-day, and in-hospital mortality in patients who had a stroke and have AMI who are admitted via the emergency department. This study used the Korean National Health Insurance claims data from 2002 to 2013. The study sample included 7,693 patients who had an ischemic stroke, 2,828 patients who had a hemorrhagic stroke, and 4,916 patients with AMI who were admitted via the emergency departments of a superior general hospital and general hospital, did not transfer to another hospital or come from another hospital, and were aged �돟20 years. This study was analyzed by using Cox�셲 proportional hazards frailty model. 500 (6.5%) patients were dead of 7,693 patients with ischemic stroke, 569 (20.1%) patients were dead of 2,828 patients with hemorrhagic stroke, and 399 (8.1%) patients were dead of 4,916 patients with AMI. The analysis of the association between patient characteristics and mortality, clinical factors were associated with 7-day mortality such as age, sex, hypertension, and diabetes in all three diseases. Non-clinical factors such as individual household income and health insurance type were associated with 30-day mortality and in-hospital mortality. In the analysis of the association between treatment characteristics and mortality, performing PCI was associated with reducing adjusted hazard ratio (aHR) for 7-day, 30-day and in-hospital mortality (aHR,0.40; 95% CI,0.29-0.54; aHR, 0.35; 95% CI, 0.23-0.55; aHR, 0.43; 95% CI, 0.27-0.67, respectively) among AMI patients. In patients with AMI and ischemic stroke, the adjusted hazard ratio of patient who utilized intensive care unit service was high for 7-day, 30-day and in-hospital mortality comparing to those who did not utilize intensive care unit service. There was a weekend effect in AMI and ischemic stroke. In patients with hemorrhagic stroke, the risk of mortality for patients who received surgical interventions such as trephination and craniotomy was high than those who received medical interventions such as administration of mannitol and intravenous antihypertensive agents to control intracranial pressure (eg., for 30-day mortality; aHR, 2.42; 95% CI, 1.36-4.32 for patients who received mannitol; aHR, 3.30; 95% CI, 1.80-6.04 for patients who received trephination; aHR, 5.27; 95% CI, 2.49-11.17 for patients who received craniotomy). In the analysis of the association between hospital characteristics and mortality, characteristic of funding source and number of patients per one nurse was associated with reducing risk of mortality for 7-day, 30-day and in-hospital mortality in patients with ischemic stroke. In all three diseases, greater volume was associated with reducing the risk of mortality, and greater transferred rated was associated with increasing the risk of mortality in patients with hemorrhagic stroke. These findings suggest that focus should be on preventing hypertension in stroke and preventing diabetes in AMI. Health-care providers should make efforts to provide consistent care like that provided on weekdays. Especially health policy makers and health-care providers should seek ways to obtain personal resources that can provide highly technical interventions such as percutaneous coronary intervention (PCI). At the same time, ways that can reflect the real hospital context have been developed to improve the quality of hospital care. �꽌濡�: �떖�뇤�삁愿�吏덊솚�� �쟾泥댁궗留앹쓽 �궗遺꾩쓽 �씪�쓣 �옄移섑븯�뒗 吏덊솚�쑝濡쒖꽌, �뼢�썑 �븳援��쓽 怨좊졊�솕瑜� 媛먯븞�븷 �븣, 吏덈퀝遺��떞�� �뜑�슧 而ㅼ쭏 寃껋쑝濡� �삁�긽�맂�떎. �뇤議몄쨷怨� 湲됱꽦�떖洹쇨꼍�깋利앹쑝濡� �씤�븳 �궗留앹쓣 以꾩씠怨좎옄, �젙遺��� �쓽猷뚭린愿��쓽 �걡�엫�뾾�뒗 �끂�젰�쓣 �빐�솕�쓬�뿉�룄 遺덇뎄�븯怨�, �뿬�쟾�엳 蹂묒썝 �궡 �궗留앸쪧�씠 �넂�떎. �뿰援щぉ�쟻: Algebra Effectiveness Model瑜� �쟻�슜�븯�뿬 �뇤議몄쨷怨� �떖洹쇨꼍�깋利� �솚�옄�뿉�꽌 �솚�옄�슂�씤,. ; open

OBJECTIVES: This study investigated the risk associated with interhospital transfer of patients with acute myocardial infarction (AMI) and clinical outcomes according to the location of the patient' residence. DESIGN: A nationwide longitudinal cohort. SETTING: National Health Insurance Service database of South Korea. PARTICIPANTS: This study included 69 899 patients with AMI who visited an emergency centre from 2013 to 2015, as per the Korea National Health Insurance Service database. PRIMARY OUTCOME MEASURE: The clinical outcome of a patient with AMI was defined as mortality within 7 days, 30 days and 1 year. RESULTS: Clinical outcomes were analysed and compared with respect to the location of the patient's residence and occurrence of interhospital transfer. We concluded that the HR of mortality within 7 days was 1.49 times higher (95% CI 1.18 to 1.87) in rural patients than in urban patients not subjected to interhospital transfer and 1.90 times higher (95% CI 1.13 to 3.19) in transferred rural patients than in non-transferred urban patients. CONCLUSIONS: To reduce health inequality in rural areas, a healthcare policy considering regional characteristics, rather than a central government-led, catch-all approach to healthcare policy, must be formulated. Additionally, a local medical emergency delivery system, based on allocation of roles between different medical facilities in the region, must be established.

OBJECTIVES—To estimate the short term event and cost consequences of achieving two smoking cessation targets for England among a cohort of 35-64 year olds, in terms of the number of hospitalised acute myocardial infarctions (AMIs) and strokes avoided. DESIGN—A spreadsheet model based on previous work and using data for England was constructed to simulate the effects of achieving the target set out in the government's tobacco white paper (target 1). We also examined the consequence of achieving the intensive smoking reduction witnessed in California (target 2). RESULTS—Target 1 would result in 347 AMI and 214 stroke hospitalisations avoided in the year 2000, and by 2010 this would be 6386 AMI and 4964 strokes avoided. Achieving target 2 would result in 739 AMI and 455 stroke hospitalisations avoided in 2000, and 14 554 AMI and 11 304 strokes avoided by 2010. Achieving target 1 would save £524 million (£423 million discounted at a rate of 2.67% for stroke and 2.31% for AMI) and target 2 would save £1.14 billion (£921 million discounted) in terms of National Health Service costs. CONCLUSION—In the short term (11 years), reductions in the prevalence of smoking will produce sizeable reductions in both events and hospital costs. Keywords: smoking cessation modelling cost; acute myocardial infarction; stroke

Background: Despite prospective randomized control trials showing that beta blockers, aspirin, angiotensin‐converting enzyme (ACE) inhibitors, and lipid‐lowering agents improve survival rates after myocardial infarction (MI), these agents are routinely underutilized. Hypothesis: Our aim was to determine the frequency with which cardiologists at a government, university‐affiliated teaching hospital prescribe aspirin, beta blockers, ACE inhibitors, calcium‐channel blocking agents (CCBs), and lipid‐lowering agents in patients post MI. The patients were followed by their primary care physicians in this hospital after discharge. We evaluated changes in patients' medical management at an average of 24 months after discharge from the acute event. Methods: Clinical data relative to long‐term use of life‐saving drugs in 156 survivors of definite MI (WHO criteria) at a government, university‐affiliated teaching hospital were analyzed over a 24‐month follow‐up period. Results: Over 90% of patients with acute MI were given aspirin and beta blockers at discharge. About 50% of these patients were given ACE inhibitors, only 25% were prescribed CCBs, and 21% were given lipid‐lowering agents. At 24 months of follow‐up, the percentage of patients receiving aspirin, beta blockers, and ACE inhibitors had fallen to 88% (p = 0.0408), 71% (p < 0.0001), and 43% (p = 0.1122), respectively, whereas use of lipid‐lowering agents slightly increased (p = 0.4277). Use of CCBs had also fallen (p = 0.0001). Nonetheless, the use of aspirin, beta blockers, and ACE inhibitors was higher than that in the National Registry of similar patients at discharge (p < 0.0001). Conclusions: Patients at a government, university‐affiliated teaching hospital are likely to receive life‐saving therapy at discharge, in accordance with the American College of Cardiology/American Heart Association (ACC/AHA) guidelines. There is a modest decrease in intake of these life‐saving drugs during the follow‐up period. As documented earlier, cardiologists in a teaching ...

AbstractEpidemiological studies in recent years have identified an association between exposure to air pollutants and acute myocardial infarction (AMI); however, the association between short-term ozone (O3) exposure and AMI hospitalization remains unclear, particularly in developing countries. Therefore, this study collected information on 24,489 AMI patients, including daily air pollutant and meteorological data in Henan, China, between 2016 and 2021. A distributed lagged nonlinear model combined with a Poisson regression model was used to estimate the nonlinear lagged effect of O3 on AMI hospitalizations. We also quantified the effects of O3 on the number of AMI hospitalizations, hospitalization days, and hospitalization costs. The results showed that single- and dual-pollution models of O3 at lag0, lag1, and lag (01–07) were risk factors for AMI hospitalizations, with the most significant effect at lag03 (RR = 1.132, 95% CI:1.083–1.182). Further studies showed that males, younger people (15–64 years), warm seasons, and long sunshine duration were more susceptible to O3. Hospitalizations attributable to O3 during the study period accounted for 11.66% of the total hospitalizations, corresponding to 2856 patients, 33,492 hospital days, and 90 million RMB. Maintaining O3 at 10–130 µg/m3 can prevent hundreds of AMI hospitalizations and save millions of RMB per year in Henan, China. In conclusion, we found that short-term exposure to O3 was significantly associated with an increased risk of hospitalization for AMI in Henan, China, and that further reductions in ambient O3 levels may have substantial health and economic benefits for patients and local healthcare facilities.
Graphical Abstract

Background: Although current guidelines recommend that primary percutaneous intervention (PCI) should be performed for ST-elevation myocardial infarction (STEMI), accessibility to this important health care service for severe heart emergency among floating population in Guangzhou remains largely unstudied and poorly understood. This retrospective study explored the variations in the odds of receiving primary PCI for STEMI patients among floating population and residential population in Guangzhou. Methods: Study data were collected from the First People's Municipal Hospital of Guangzhou to conduct a cross-sectional study of 1,216 patients with STEMI (code 410 of ICD-9) for the period from 2009 to 2014. Data in this study, including demographic and clinical characteristics, invasive treatment and pre-hospital delay time, was retrieved from electronic medical record system developed in 2005 and maintain a comprehensive electronic record of all patients of hospital. Chi-square test was performed to evaluate the differences in demographic characteristics and coexisting condition among STEMI patients between floating population and residential population. Differences in receipt primary PCI, pre-hospital delay time and door-toballoon time between two population groups were evaluated by a binary logistic regression model. To evaluate the performance odds, I adjusted for age, gender, and coexisting conditions. Data of the study was analysed using the SPSS 21 package software. Result: Compare to residential population, STEMI patients in floating population were less likely to receive primary PCI ( 20.5% vs 26.3%, P=0.049). On adjusting for sex, age and coexisting conditions, the odds of receipt primary PCI for STEMI patients in floating population was lower than residential population (floating population, OR=0.63, 95% CI=0.45-0.88; residential population, OR=1.0). More pre-hospital delays of STEMI patients undergoing primary PCI were found in floating population, the odds of delay time >6 hours was higher than residential population ( OR=4.27, 95% CI=1.49-12.24). There was no statistical difference in door-to-balloon time >90 minutes between two population groups (OR=1.61, 95% CI=0.60-4.32). Conclusion: Patients with STEMI in Guangzhou floating population were less likely to receive primary PCI. Policy interventions including government subsidy on severe disease in population, pilot medical insurance schemes, and transferability of insurance payment cross provinces are needed to increase the accessibility to emergency severe health care for STEMI patients in floating population. Additionally, an educational program on early symptoms and rapid response of STEMI should be established to increase the awareness at national level, especially in floating population. ; published_or_final_version ; Public Health ; Master ; Master of Public Health

Ventricular fibrillation (VF) during acute myocardial infarction (AMI) is an important contributor to sudden cardiac death. Large animal models are widely used to study AMI-induced arrhythmia, but the mode of AMI induction ranges from thoracotomy and surgical ligation of a coronary vessel (open chest) to minimally invasive techniques, including balloon occlusion (closed chest). How the choice of induction affects arrhythmia development is unclear. The aim of this study was to compare an open-chest and a closed-chest model with regard to hemodynamics, electrophysiology, and arrhythmia development. Forty-two female Danish Landrace pigs (20 open chest, 22 closed chest) were anesthetized, and occlusion of the mid-left anterior descending coronary artery was performed for 60 min. Opening the chest reduced blood pressure and cardiac output (Δ −22 mmHg, Δ −1.5 L/min from baseline, both P < 0.001 intragroup). Heart rate decreased with opening of the chest but increased with balloon placement (P < 0.001). AMI-induced ST elevation was lower in the open-chest group (P < 0.001). Premature ventricular contractions occurred in two distinct phases (0–15 and 15–40 min), the latter of which was delayed in the open-chest group (P = 0.005). VF occurred in 7 out of 20 and 12 out of 22 pigs in the open-chest and closed-chest groups, respectively (P = 0.337), with longer time-to-VF in the open-chest group (23.4 ± 1.2 min in open chest and 17.8 ± 1.4 min in closed chest; P = 0.007). In summary, opening the chest altered hemodynamic parameters and delayed the onset of ventricular arrhythmias. Hence, in the search for mechanisms and novel treatments of AMI-induced arrhythmia, caution should be taken when choosing between or comparing the results from these two models. ; This work was funded by Novo Nordisk Foundation Synergy program (to T. Jespersen and J. Tfelt-Hansen); Hjertecenterts Forskningsudvalg (to S. M. Sattler); and the European Union's Horizon 2020 Research and Innovation Program (ESCAPE-NET) Grant 733381 (to J. ...

ObjectivesThis feasibility study was conducted to inform the design and power evaluation of CODE-MI, a pan-Canadian trial evaluating the impact of using the female-specific 99th-percentile threshold for high-sensitivity cardiac troponin (hs-cTn) on the diagnosis, treatment and outcomes of women presenting to the emergency department with symptoms suggestive for myocardial ischemia.
ApproachCODE-MI is a multi-center, stepped-wedge cluster randomized trial. The cohort and outcomes will be obtained from routinely collected administrative data. Using linked administrative data from 11 hospitals in Ontario from 2014/10 to 2017/09, this feasibility study obtained the following estimates: number of eligible patients, i.e., women presenting to the emergency department with symptoms suggestive of myocardial ischemia and a 24-hour peak hs-cTn value within the female-specific and overall thresholds (i.e. primary cohort); the rate of the 1-year composite outcome of all-cause mortality, re-admission for non-fatal myocardial infarction, incident heart failure, or emergent/urgent coronary revascularization. Study power was evaluated via simulations.
ResultsOverall, 2,073,849 emergency department visits were assessed. Among women, chest pain (with or without cardiac features) and shortness of breath were the most common complaints associated with a diagnosis of acute coronary syndrome. An estimated 7.7% of women with these complaints are eligible for inclusion in the primary cohort. The rate of the 1-year outcome in the primary cohort varied significantly across hospitals with a median rate of 12.2% (95%CI: 7.9%-17.7%). With 30 hospitals, randomized at 5-month intervals in 5 steps, approximately 19,600 women are expected to be included in CODE-MI, resulting in >82% power to detect a 20% decrease in the odds of the primary outcome at a 0.05 significance level.
ConclusionRoutinely collected administrative health data serve as a rich and essential resource for conducting pragmatic trials assessing process change, such as CODE-MI. We demonstrated the strength of using linked administrative health data to guide the design of pragmatic clinical trials and accurately evaluate the study power.

Background: It is unknown whether insurancestatus influences care provided and patients'prognosis, in China.Methods: This retrospective cohort studyincluded medical records of 4,714 patients withacute myocardial infarction aged 20 and older,discharged consecutively from 14 Chinese hospitalsbetween January 2000 and February 2003.Uni-variate analysis, multivariate logistic regressionand linear regression were used to compare differencesin patients' characteristics, care providedand prognosis between insured patients and theuninsured.Results: The uninsured were more likely to beolder, female, have transfer admissions, and lesslikely to be hospitalized to institutions with cardiacinterventional facilities, intensive care units orcoronary care units. The uninsured were also lesslikely to undergo diagnostic procedures, interventionsand to receive medications, and stayedshorter in hospital and consumed less health careresources. In-hospital mortality in the uninsured,the non-government insured and the governmentinsured was 10.5%, 12.2% and 8.4% respectively.After adjusting for potential confounders, oddratio in hospital mortality was 1.079 (95% CI,0.836–1.392) and 0.763 (95% CI, 0.559–1.041) for thenon-government insured and the governmentinsured, compared to the uninsured. At significantlevel of 0.05, we could not assert insurance statusis a significant factor to in-hospital mortality.