Showing papers by "Anushka Patel published in 2002"

Clinical characteristics and outcome of patients with early ( 4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction.

Abstract: Aims We examined the clinical characteristics and outcome of patients with early ( 4h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction. Methods and Results We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n=1302) vs thrombolytic therapy (n=1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories: early presentation (<2h), intermediate presentation (2–4h), and late presentation (≥4h). At 30 days the combined rate of death, non-fatal reinfarction and stroke in patients presenting early was 5·8% in the angioplasty group vs 12·5% in the thrombolysis group, in patients with intermediate presentation, 8·6% vs 14·2%, respectively, and in patients presenting late 7·7% vs 19·4%, respectively. With increasing time from symptom onset to presentation, all major adverse cardiac event rates show a trend to a larger increase in the thrombolysis group compared to the angioplasty group, both at 30 days and at 6 months after the acute event. Conclusions Major adverse cardiac event rates are lower after angioplasty compared to thrombolysis, irrespective of time to presentation. With increasing time to presentation major adverse cardiac event rates increase after thrombolysis but appear to remain relatively stable after angioplasty.

Clinical characteristics and outcome of patients with early ( 4 h) presentation treated by primary coronary angioplasty or thrombolytic therapy for acute myocardial infarction

Abstract: AIMS We examined the clinical characteristics and outcome of patients with early (<2 h), intermediate (2-4 h) and late (>4 h) presentation treated by primary angioplasty or thrombolytic therapy for acute myocardial infarction. METHODS AND RESULTS We studied 2635 patients enrolled in 10 randomized trials of primary angioplasty (n=1302) vs thrombolytic therapy (n=1333) in acute myocardial infarction, and baseline characteristics of the two groups were comparable. Increase in presentation delay is associated with older age, female gender, diabetes and an increased heart rate. We classified the patients according to the time delay from symptom onset to presentation into three categories: early presentation (<2 h), intermediate presentation (2-4 h), and late presentation (>or=4 h). At 30 days the combined rate of death, non-fatal reinfarction and stroke in patients presenting early was 5.8% in the angioplasty group vs 12.5% in the thrombolysis group, in patients with intermediate presentation, 8.6% vs 14.2%, respectively, and in patients presenting late 7.7% vs 19.4%, respectively. With increasing time from symptom onset to presentation, all major adverse cardiac event rates show a trend to a larger increase in the thrombolysis group compared to the angioplasty group, both at 30 days and at 6 months after the acute event. CONCLUSIONS Major adverse cardiac event rates are lower after angioplasty compared to thrombolysis, irrespective of time to presentation. With increasing time to presentation major adverse cardiac event rates increase after thrombolysis but appear to remain relatively stable after angioplasty.

Managing the global burden of cardiovascular disease

Abstract: There is a large and increasing global burden of cardiovascular disease. Approximately 14 million individuals died of cardiovascular disease in 1990, and this is projected to rise to about 25 million by 2020. In large part, this increase can be explained on the basis of major ongoing sociodemographic changes in developing countries, and associated effects on the numbers of individuals at risk and the levels of cardiovascular risk factors. Developing countries now experience a much greater burden of cardiovascular disease than do developed countries. In addition, developing countries are expected to experience the greatest rise in cardiovascular disease burden over the next few years. Cardiovascular disease prevention programmes designed and implemented primarily in developed countries have most likely averted much premature cardiovascular disease in those countries over the past few decades. However, cardiovascular disease prevention programmes designed for developed countries are unlikely to be directly transferable to developing countries. Reliable information to inform the design and implementation of cardiovascular disease prevention programmes, tailored to the socioeconomic circumstances of developing countries, is now required. Such programmes have great potential to impact on the current and projected global epidemic of cardiovascular disease.

The HRT furore: getting the message right

Abstract: BY ALL ACCOUNTS, many of the half million Australian women who regularly take combined oestrogen and progestin hormone replacement therapy (HRT) were alarmed by the news on Wednesday, 10 July 2002, reporting that a United States study had shown HRT to increase the risk of breast cancer by 26%, as well as causing more vascular disease. Subsequently, numerous media reports, based on press releases from organisations such as the US National Institutes of Health (NIH)1 and the Cancer Council of New South Wales,2 continued to highlight the apparently large increases in risks caused by combined HRT and called for restrictions on the use of this treatment. General practitioners and cancer help-lines were inundated by enquiries from frightened women and reports of mass withdrawals from therapy soon followed. The source of this concern was the early termination of the NIH-funded Women’s Health Initiative (WHI) trial comparing combined HRT and placebo among healthy postmenopausal women. The study was stopped after five years by an independent Safety and Data Monitoring Committee when a predetermined safety boundary for the risk of invasive breast cancer was crossed at an interim analysis. The report of the trial, published in JAMA,3 suggested that women allocated to combined HRT experienced increased risks of invasive breast cancer, coronary heart disease, stroke and venous thromboembolism, and decreased risks of colorectal cancer and hip fracture (Box 1). It was argued that, when all these outcomes were summed in a “global index”, the adverse effects outweighed the benefits. However, treatment effects on only two of the outcomes — fractures and venous thromboembolism — met conventional criteria for statistical significance when appropriate (and prespecified) account was taken of the multiplicity of statistical tests performed. Even without adjustment for the dozens of statistical tests, the 95% confidence intervals for each of the other outcomes reportedly affected by combined HRT (including the global index) were consistent with a broad range of possible effects, including little or no effect. For example, any effect on the relative risk of invasive breast cancer appeared to lie somewhere in the range from no effect to an increase of about a half to two-thirds, whereas any effect on the absolute risk of the same outcome appeared to lie somewhere in the range from no excess cases to about 17 extra cases per 10 000 women per year. This very large degree of uncertainty about the true size (and arguably the existence) of most of the treatment effects reported is not reflected in any of the press releases we have seen, including that from JAMA, all of which report apparently precise estimates of the excess risks. However, the controversy that followed publicity about the results of the trial did not reflect concerns about the strength of the evidence, but rather dissatisfaction with the way in which the study outcomes were described. While the original report published in JAMA provided estimates of both relative-risk and absolute-risk differences, press releases from most sources focused on the relative increases in risk — in particular, the 26% increase in invasive breast cancer. That this increase in relative risk reflected a difference in incidence of eight cases per 10 000 women per year was much less emphasised. It was suggested by the economics editor of the Sydney Morning Herald that the reported 26% increase was likely to have been misinterpreted by many women as meaning that combined HRT conferred a one-in-four chance of developing invasive breast cancer.5 Others argued that the use of relative risks in press releases was a deliberate effort to dramatise results that would appear much less newsworthy if described in absolute terms. The same commentators suggested that press releases should focus instead on absolute treatment effects, as these are of most direct relevance to the advice provided by doctors and the decisions made by women. Are these criticisms justified? Certainly, there is little doubt that the way in which risk data are presented influences treatment preferences.6-9 In a recent randomised trial in which general practitioners were asked whether they would prescribe a preventive treatment that had negligible side effects, 91% of those given information about relative The HRT furore: getting the message right