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Ischemic Coronary Disease (ICD) [1]

Hospitals with UCIC seem to treat more effectively Ischemic Coronary patients than hospitals without UCIC. [1]. Ischemic Coronary Disease (ICD) [1]. Acute Myocardial Infarction. Angina Pectoris. (almost) Total occlusion Cellular necrosis. Obstruction Decrease of blood irrigation.

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Ischemic Coronary Disease (ICD) [1]

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  1. Hospitals with UCIC seem to treat more effectively Ischemic Coronary patients than hospitals without UCIC

  2. [1] Ischemic Coronary Disease (ICD) [1] Acute Myocardial Infarction Angina Pectoris • (almost) Total occlusion • Cellular necrosis • Obstruction • Decrease of blood irrigation [1] Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Eur Heart J 2007;28:2525–2538

  3. Symptoms [2] Sudden chest pain/squeezing sensation of the chest, which extends to the upper back, jaw, head or left arm - most frequent symptom • Anxiety • Epigastric discomfort • Sweating or cold • Nausea • Vomiting • Loss of consciousness • Pain with variable intensity (from mild to severe) • Tightness, burning or a heavy weight • Strong heart beating/palpitation • Dyspnoea/shortness of breath • Fatigue • Intermittent angina pectoris [2] World Health Organization – http://www.who.int/mediacentre/factsheets/fs317/en/index.html, in 29/10/2009

  4. Causes andRiskFactors Genetic predisposing [3] Age [4] Gender [5], [6], [7] Non-modifiable Stress [8] Psychological factors [8] Intense exertion [3] ] Grassi M, Assanelli D, Mozzini C, et al, Modeling premature occurrence of acute coronary syndrome with atherogenic and thrombogenic risk factors and gene markers in extended families, J ThrombHaemost, 2005 Oct; 3(10):2238-44 [4] Hamm C, Heeschen C, Falk E, Fox KAA. Acute coronary syndromes: pathophysiology, diagnosis and risk stratification. In: Camm AJ, Luescher TF, Serruys PW, ed. The ESC Textbook of Cardiovascular Medicine. Oxford: UK, Blackwell Publishing; 2006. p 333–366 [5] Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J 2002; 144:1012–1017 [6] Schenk-Gustafsson K, Risk factors for cardiovascular disease in women, Maturitas, 2009 Jul 20; 63(3):186-90 [7] Shaw LJ, Bugiardini R, Merz CN, Women and ischemic heart disease: evolving knowledge, J Am Cardiol., 2009 Oct 20; 54(17):1561-75 [8] Hansel B, Thomas F, Relationship between alcohol intake, health and social status and cardiovascular risk factors in the urban Paris-Ile-De-France Cohort: is the cardioprotective action of alcohol a myth?, Eur J ClinNutr., 2010 May 19

  5. Causes andRiskFactors Diabetes [9] Hypercholesterlemia[10] High blood pressure [11] Obesity [12], [13] Tobacco smoking [14] Alcohol [15] Diseases Socioeconomic [16] [9] Dresslerová I, Voiácek J, Diabetes mellitus and ischemic heart disease, VnitrLek, 2010 Apr; 56(4):301-6 [10] Zamaklar M, Vascular inflammation: effect of proatherogenicdyslipidemic trio or quartet, Med Pregl., 2009; 62 Suppl 3:37-42 [11] Martins e Silva J, Saldanha C, Cardiovascular risk factors: hemorheology and hemostatic components, Rev Port Cardiol., 2007 Feb; 26(2):161-82 [12] Dentali F, Squizzato A, The metabolic syndrome as a risk factor for venous and arterial thrombosis, SeminThrombHemost, 2009 Jul; 35(5):415-7 [13] Menotti A, Food patterns and health problems: health in Southern Europe, Ann NutrMetab., 1991; 35 Suppl 1: 69-77 [14] Wang Y, Li J, Prevalence of peripheral arterial disease and correlative risk factors among natural population in China, ZhonghuaXinXue Guan Bing ZaZhi., 2009 Dec; 37(12):1127-31 [15] Holm JE, Vogeltanz-Holm N, Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S., Public Health Rep, 2010 Jan-Feb; 125(1):68-78 [16] Eller NH, Work-related psychosocial factors and the development of ischemic heart disease: a systematic review, Cardiol Ver., 2009 Mar-Apr; 17(2):83-97

  6. Treatment • Medicine: • Antiplateletagents • Anticoagulants • Nitro-glycerine • β-blockers • Metabolism modifiers • Inhibitor of cardiac frequency • Angiostensin converting enzyme inhibitor • Intervention Surgery: • Coronary catheterization and angioplasty • Coronary Surgery (bypass) [17] [18], [19], [20] • Secondary Prevention: • Initial patient risk assessment • Pharmacologic therapy • Therapeutic lifestyles and intervention • Psychosocial evaluation [17] Carneiro AV, Costa J, Borges M (2004 Jan), Statins for primary and secondary prevention of coronary heart disease.A [18] Arshad A, Mandava A (2008 May-Jun), Sudden cardiac death and the role of medical therapy, ProgCardiovascDis, 50(6):420-38scientific review, Rev Port Cardiol., 26(2):161-82 [19] Derby RC, Office care of patients after myocardial infarction, Postgrad Med., 2008 Apr; 120(1): 11-7 [20] Chummum H, Reducing the incidence of coronary heart disease, Br J Nurs., 2009 Jul 23-Aug 12; 18(14):865-70

  7. Relevance • Cardiovascular diseases are the first cause of death on developed countries as well as on the underdeveloped ones. • The decline in death rates from coronary heart disease amongst developed economies in Europe, North America, Australia, and New Zealand (between 39 and 52% fall in age-adjusted death rates in men and women from 1989–1999) is contrasted with an increase in mortality in several countries of Eastern and Central Europe, most notably countries of the former USSR. • Despite the decreasing age-adjusted mortality for myocardial infarction, the disease prevalence for non-fatal components of acute coronary syndromes remains high and the economic costs are immense. • In Portugal, recent data published in the annual report from Alto ComissariadodaSaúde revealed an increase of patients admitted on coronary units, from 2004 to 2008. On the other hand, the rate of mortality has consistently declined, with a higher mortality rate in men than in women. [21] [22] [21] Murray CJ, Lopez AD, Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet, 1997; 349: 1498–1504 [22] Liu JL, et al. The economic burden of coronary heart disease in the UK. Heart 2002; 88: 597–603

  8. Aims • To analyse the outcomes – fatality rate and length of stay - of ischemic coronary patients admitted (including transferred cases) in three types of Portuguese hospitals: Central hospitals (with UCIC) • Hospitals with UCIC District hospitals with UCIC • Hospitals without UCICDistrict hospitals without UCIC • To determine if there are aspects of the included population, such as gender and/or age, that influence the outcomes defined and if these may be considered as prognosis markers.

  9. Methods • Type of study, based on administrative Portuguese hospitals’ data: • Observational • Retrospective • Analytical • Target population • All ICD patients admitted in the three types of hospitals considered, between January 1st 2000 and December 31st 2007 • Study variables analysed • Gender • Type of hospital where the admission occurred • Distance of patient’s residence to the hospital • Length of stay • Fatality Rate • Transfer

  10. Studyparticipants The target population consists in all patients, admitted with ischemic coronary disease, defined by ICD9 as Ischemic Heart Disease, with the subgroups of: • Acute myocardial infarction • Other acute and subacute forms of ischemic heart disease • Angina pectoris • Other forms of chronic ischemic heart disease

  11. Studyparticipants 7 Central Hospitals 42 District with UCIC Hospitals 37 District without UCIC Hospitals Fig. 1 – Geographic distribution of participant Hospitals

  12. Studyparticipants Fig. 2 – Number of admissions in each type of hospital

  13. Study Design, Variables Description and Statistical Analysis Data used in statistical analysis (SPSS17®) • gender (nominal categorical variable) • length of stay (discrete quantitative variable) • type of hospital where the admission occurred (nominal categorical variable) • mortality – deceased/not deceased (nominal categorical variable) • distance of patient’s residence to the hospital (continuous quantitative variable) • transfer – yes/no (nominal categorical variable)

  14. Results • Comparison of fatality rate in different types of hospitals (all patients) Fig. 3 – Graphic relating the fatality rate in each year within each type of hospital for all patients (p-valueofchi-square<0.05)

  15. Results Fig. 4 – Graphic relating the deceased variable (all patients) with the type of hospital, using CI 95%

  16. Results • Comparison of fatality rate in different types of hospitals (only transferred patients) Fig. 5 – Graphic relating the fatality rate in each year within each type of hospital for transferred patients (p-valueof chi-square<0.05 except in 2003 and2004)

  17. Results Fig. 6 – Graphic relating the deceased variable (only transferred patients) with the type of hospital, using CI 95%

  18. Results • Comparison of the length of stay in each type of hospital Fig. 7 – Table relating the length of stay among the three types of hospitals. Kruskal-Wallis p = 0

  19. Results • Comparison of fatality rate according to gender in different types of hospitals Fig. 8 – Table relating fatality rate with gender among the three types of hospitals (p > 0.05) There are no significant diferences

  20. Results • Comparison of the distance to Hospital with the type of Hospital Fig. 9 – Table relating distance to Hospital with different types of Hospitals. The distance seemsinverslyrelated with fatality rate

  21. Results • After concluding that hospitals with UCIC seem to treatmore effectively Ischemic Coronary patients, it is interesting to calculate the number of deaths that could be avoided if patients who died in district without UCIC hospitals had been treated in central or district with UCIC hospitals. • To perform this analysis, it is important to remember that the number of admissions to district without UCIC hospitals in the studied period was 140264. Fig.10 – Number of admissions in each type of hospital

  22. Results • In district without UCIC hospitals: 3,8% x 140264 = 5330 patients died • In district with UCIC hospitals… 2,7% x 140264 = 3787 patients would die So, 5330 – 3787 = 1543 patients would not have died • In central hospitals… 2,4% x 140264 = 3366 patients would die So, 5330 – 3366 = 1964 patients would not have died Fig. 11 – Table relating the deceased variable with the type of hospital (p-valueofchi-square<0.05)

  23. Conclusion/Discussion • The percentage of deceased patients is higher in district with no UCIC hospitals and lower in central hospitals; • There are no significant differences in fatality rate, considering the variable “gender”, within the same type of hospital; • A greater distance to the hospital could lead to higher fatality rate, but that's not what happens. In fact, the distance, seems inversely related to fatality rate. • It was expected to find differences in the outcomes among the three types of hospitals included, and the differences really exist. • Central hospitals seems to have better resources and greater success in the treatment of individuals with IC associated diseases, because, besides having a lower proportion of dead [23] (even taking into account the transfer), patients are still less time in hospital, indicating that they are treated more quickly and efficiently. [23] Chukmaitov AS, et al. Variations in inpatient mortality among hospitals in different system types, 1995 to 2000. Med Care., 2009 Apr ;47(4):466-73.

  24. Conclusion/Discussion • It was expected that fatality rate could be higher in central hospitals, once these hospitals receive transferred patients from other facilities, which usually corresponds to the most serious cases. However, there was an opposite result: a lower fatality rate in central hospitals, due to the advanced equipments, best financial capabilities [24, 25, 26] and better facilities. • Finally, it is also important to refer the number of deaths that would probably be avoided if patients were treated in hospitals with UCIC; in fact, it was found that 1543 of the 5330 patients who died in district without UCIC hospitals would probably not have died if they had been admitted in district with UCIC hospitals and 1964 of those 5330 patients would not have died if they had been admitted in central ones. [23] Chukmaitov AS, et al. Variations in inpatient mortality among hospitals in different system types, 1995 to 2000. Med Care., 2009 Apr ;47(4):466-73. [24] Noiseux N, Bracco D, Do patients after off-pump coronary artery bypass grafting need the intensive care unit? A prospective audit of 85 patients, Interact CardiovascThorac Surg., 2008 Feb; 7(1):32-6 [25] Langa KM, Sussman EJ, The effect of cost-containment policies on rates of coronary revascularization in California, N Engl J Med., 1993 Dec 9; 329(24):1784-9 [26] Abbott BG, Jain D, Impact of myocardial perfusion imaging on clinical management and the utilization of hospital resources in suspected acute coronary syndromes, Nucl Med Commun., 2003 Oct; 24(10):1061-9

  25. Limitations • It was impossible to follow transferred patients after leaving the first hospital where they were admitted because when transferred they receive a new ID number, so that analysis was impossible to perform. • It was found no variables concerning complications and type of treatment. • The data about distance to hospital was not suitable for an explicit box plot, that we considered to be the best way to show this data. • Once the database was too big, we had to change SPSS workspace in order to be able to perform a Kruskal-Wallis test.

  26. References: • [1]Thygesen K, Alpert JS, White HD. Universal definition of myocardial infarction. Eur Heart J 2007;28:2525–2538 • [2] World Health Organization -http://www.who.int/mediacentre/factsheets/fs317/en/index.html, in 29/10/2009 • [3] Grassi M, Assanelli D, Mozzini C, et al, Modeling premature occurrence of acute coronary syndrome with atherogenic and thrombogenic risk factors and gene markers in extended families, J ThrombHaemost, 2005 Oct; 3(10):2238-44 • [4] Hamm C, Heeschen C, Falk E, Fox KAA. Acute coronary syndromes: pathophysiology, diagnosis and risk stratification. In: Camm AJ, Luescher TF, Serruys PW, ed. The ESC Textbook of Cardiovascular Medicine. Oxford: UK, Blackwell Publishing; 2006. p 333–366 • [5] Culic V, Eterovic D, Miric D, Silic N. Symptom presentation of acute myocardial infarction: influence of sex, age, and risk factors. Am Heart J 2002; 144:1012–1017 • [6] Schenk-Gustafsson K, Risk factors for cardiovascular disease in women, Maturitas, 2009 Jul 20; 63(3):186-90

  27. [7] Shaw LJ, Bugiardini R, Merz CN, Women and ischemic heart disease: evolving knowledge, J Am Cardiol., 2009 Oct 20; 54(17):1561-75 • [8] Hansel B, Thomas F, Relationship between alcohol intake, health and social status and cardiovascular risk factors in the urban Paris-Ile-De-France Cohort: is the cardioprotective action of alcohol a myth?, Eur J ClinNutr., 2010 May 19 • [9] Dresslerová I, Voiácek J, Diabetes mellitus and ischemic heart disease, VnitrLek, 2010 Apr; 56(4):301-6 • [10] Zamaklar M, Vascular inflammation: effect of proatherogenicdyslipidemic trio or quartet, Med Pregl., 2009; 62 Suppl 3:37-42 • [11] Martins e Silva J, Saldanha C, Cardiovascular risk factors: hemorheology and hemostatic components, Rev Port Cardiol., 2007 Feb; 26(2):161-82 • [12] Dentali F, Squizzato A, The metabolic syndrome as a risk factor for venous and arterial thrombosis, SeminThrombHemost, 2009 Jul; 35(5):415-7 • [13] Menotti A, Food patterns and health problems: health in Southern Europe, Ann NutrMetab., 1991; 35 Suppl 1: 69-77 • [14] Wang Y, Li J, Prevalence of peripheral arterial disease and correlative risk factors among natural population in China, ZhonghuaXinXue Guan Bing ZaZhi., 2009 Dec; 37(12):1127-31 • [15] Holm JE, Vogeltanz-Holm N, Assessing health status, behavioral risks, and health disparities in American Indians living on the northern plains of the U.S., Public Health Rep, 2010 Jan-Feb; 125(1):68-78

  28. [16] Eller NH, Work-related psychosocial factors and the development of ischemic heart disease: a systematic review, Cardiol Ver., 2009 Mar-Apr; 17(2):83-97 • [17] Carneiro AV, Costa J, Borges M (2004 Jan), Statins for primary and secondary prevention of coronary heart disease.A • [18] Arshad A, Mandava A (2008 May-Jun), Sudden cardiac death and the role of medical therapy, ProgCardiovascDis, 50(6):420-38scientific review, Rev Port Cardiol., 26(2):161-82 • [19] Derby RC, Office care of patients after myocardial infarction, Postgrad Med., 2008 Apr; 120(1): 11-7 • [20] Chummum H, Reducing the incidence of coronary heart disease, Br J Nurs., 2009 Jul 23-Aug 12; 18(14):865-70 • [21] Murray CJ, Lopez AD, Alternative projections of mortality and disability by cause 1990–2020: Global Burden of Disease Study. Lancet, 1997; 349: 1498–1504 • [22] Liu JL, et al. The economic burden of coronary heart disease in the UK. Heart 2002; 88: 597–603 • [23] Chukmaitov AS, et al. Variations in inpatient mortality among hospitals in different system types, 1995 to 2000. Med Care., 2009 Apr ;47(4):466-73.

  29. [24] Noiseux N, Bracco D, Do patients after off-pump coronary artery bypass grafting need the intensive care unit? A prospective audit of 85 patients, Interact CardiovascThorac Surg., 2008 Feb; 7(1):32-6 • [25] Langa KM, Sussman EJ, The effect of cost-containment policies on rates of coronary revascularization in California, N Engl J Med., 1993 Dec 9; 329(24):1784-9 • [26] Abbott BG, Jain D, Impact of myocardial perfusion imaging on clinical management and the utilization of hospital resources in suspected acute coronary syndromes, Nucl Med Commun., 2003 Oct; 24(10):1061-9

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