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Trends in the Incidence and Management of Acute Myocardial Infarction From 1999 to 2008: Get With the Guidelines Performance Measures in Taiwan
Lee, Cheng‐Han
Cheng, Ching‐Lan
Yang, Yea‐Huei Kao
Chao, Ting‐Hsing
Chen, Ju‐Yi
Liu, Ping‐Yen
Lin, Chih‐Chan
Chan, Shih‐Hung
Tsai, Liang‐Miin
Chen, Jyh‐Hong
Lin, Li‐Jen
Li, Yi‐Heng
Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease
The American Heart Association Get With the Guidelines (GWTG) program has improved care quality of acute myocardial infarction (AMI) with important implications for other countries in the world. This study evaluated the incidence and care of AMI in Taiwan and assessed the compliance of GWTG in Taiwan.
Methods and Results
We used the Taiwan National Health Insurance Research Database (1999–2008) to identify hospitalized patients ≥18 years of age presenting with AMI. The temporal trends of annual incidence and care quality of AMI were evaluated. The age‐adjusted incidence of AMI (/100 000 person‐years) increased from 28.0 in 1999 to 44.4 in 2008 (P<0.001). The use of guideline‐based medications for AMI was evaluated. The use of dual antiplatelet therapy (DAPT) increased from 65% in 2004 to 83.9% in 2008 (P<0.001). Angiotensin‐converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) was used in 72.6% in 2004 and 71.7% in 2008 (P=NS) and β‐blocker was used in 60% in 2004 and 59.7% in 2008 (P=NS). Statin use increased from 32.1% to 50.1% from 2004 to 2008 (P<0.001). The in‐hospital mortality decreased from 15.9% in 1999 to 12.3% in 2008 (P<0.0001). Multivariable analysis showed that DAPT, ACE inhibitor/ARB, β‐blocker, and statin use during hospitalization were all associated with reduced in‐hospital mortality in our AMI patients.
AMI incidence was increasing, but the guideline‐based medications for AMI were underutilized in Taiwan. Quality improvement programs, such as GWTG, should be promoted to improve AMI care and outcomes in Taiwan.
epidemiology; incidence; myocardial infarction; population
Related Articles
Baseline characteristics, management practices, and in-hospital outcomes of patients with acute coronary syndromes: Results of the Saudi project for assessment of coronary events (SPACE) registry
AlHabib, Khalid F.
Hersi, Ahmad
AlFaleh, Hussam
AlNemer, Khalid
AlSaif, Shukri
Taraben, Amir
Kashour, Tarek
Bakheet, Anas
Qarni, Ayed Al
Soomro, Tariq
Malik, Asif
Ahmed, Waqar H.
Abuosa, Ahmed M.
Butt, Modaser A.
AlMurayeh, Mushabab A.
Zaidi, Abdulaziz Al
Hussein, Gamal A.
Balghith, Mohammed A.
Abu-Ghazala, Tareg
Journal of the Saudi Heart Association
The Saudi Project for Assessment of Coronary Events (SPACE) registry is the first in Saudi Arabia to study the clinical features, management, and in-hospital outcomes of acute coronary syndrome (ACS) patients.
We conducted a prospective registry study in 17 hospitals in Saudi Arabia between December 2005 and December 2007. ACS patients included those with ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction and unstable angina; both were reported collectively as NSTEACS (non-ST elevation acute coronary syndrome).
5055 patients were enrolled with mean age ± SD of 58 ± 12.9 years; 77.4% men, 82.4% Saudi nationals; 41.5% had STEMI, and 5.1% arrived at the hospital by ambulance. History of diabetes mellitus was present in 58.1%, hypertension in 55.3%, hyperlipidemia in 41.1%, and 32.8% were current smokers; all these were more common in NSTEACS patients, except for smoking (all P < 0.0001). In-hospital medications were: aspirin (97.7%), clopidogrel (83.7%), beta-blockers (81.6%), angiotensin converting enzyme inhibitors/angiotensin receptor blockers (75.1%), and statins (93.3%). Median time from symptom onset to hospital arrival for STEMI patients was 150 min (IQR: 223), 17.5% had primary percutaneous coronary intervention (PCI), 69.1% had thrombolytic therapy, and 14.8% received it at less than 30 min of hospital arrival. In-hospital outcomes included recurrent myocardial infarction (1.5%), recurrent ischemia (12.6%), cardiogenic shock (4.3%), stroke (0.9%), major bleeding (1.3%). In-hospital mortality was 3.0%.
ACS patients in Saudi Arabia present at a younger age, have much higher prevalence of diabetes mellitus, less access to ambulance use, delayed treatment by thrombolytic therapy, and less primary PCI compared with patients in the developed countries. This is the first national ACS registry in our country and it demonstrated knowledge-care gaps that require further improvements.
Acute coronary syndromes; Acute myocardial infarction; Unstable angina; Registry; Saudi Arabia; Middle East
Related Articles
Impact of Exposure to Evidence-Based Pharmacotherapy on Outcomes Following Acute Myocardial Infarction in Older Adults
Zuckerman, Ilene H.
Yin, Xianghua
Rattinger, Gail B.
Gottlieb, Stephen S.
Simoni-Wastila, Linda
Pierce, Sarah A.
Huang, Ting-Ying
Shenolikar, Rahul
Stuart, Bruce
Journal of the American Geriatrics Society
To assess the impact of exposure to evidence-based medication following hospital discharge for Medicare beneficiaries with acute myocardial infarction (AMI).
A discrete-time hazard model was used to estimate time-to-outcome associated with exposure to four drug classes (angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs), beta-blockers (BBs), statins, and clopidogrel) used for post-AMI secondary prevention of cardiovascular events and mortality.
Medicare administrative data for a 5% random sample of beneficiaries.
Medicare beneficiaries (n=9,538) hospitalized for an AMI between 4/1/2006 and 12/31/2007 who survived for at least 30 days after discharge. The cohort was followed until death or 12/31/2008.
Time-varying exposure was measured as proportion of days covered (PDC) for each quarter during the follow-up period. PDC was classified into five categories (0–0.2; >0.2–0.4; >0.4–0.6; >0.6–0.8; >0.8–1.0). Outcomes were mortality and a composite outcome of death or post-AMI hospitalization.
Over a median follow-up of 18 months, mean PDC rates ranged from 0.37 (clopidogrel) to 0.50 (statins). When comparing the highest versus lowest categories of exposure, the hazard of the composite outcome was significantly lower for all drug classes except BBs [statins, adjusted hazard ratio (aHR) = 0.71, ACEIs/ARBs, aHR = 0.81, clopidogrel, aHR = 0.85, BBs, aHR = 0.93]. All four drug classes were significantly associated with reductions in mortality; the magnitude of effect for the mortality outcome was largest for statins and smallest for BBs. Age modified the effect of statins on mortality.
Use of evidence-based medications for secondary prevention post-AMI is suboptimal in the Medicare population and low exposure rates are associated with significantly higher risk for subsequent hospitalization and death.
Myocardial infarction; Medicare; Pharmacotherapy; Medicare Part D; Secondary prevention
Related Articles
Long-term prognosis of diabetic patients with acute myocardial infarction in the era of acute revascularization
Takara, Ayako
Ogawa, Hiroshi
Endoh, Yasuhiro
Mori, Fumiaki
Yamaguchi, Jun-ichi
Takagi, Atsushi
Koyanagi, Ryo
Shiga, Tsuyoshi
Kasanuki, Hiroshi
Hagiwara, Nobuhisa
Cardiovascular Diabetology
The long-term prognosis of diabetic patients with acute myocardial infarction (AMI) treated by acute revascularization is uncertain, and the optimal pharmacotherapy for such cases has not been fully evaluated.
To elucidate the long-term prognosis and prognostic factors in diabetic patients with AMI, a prospective, cohort study involving 3021 consecutive AMI patients was conducted. All patients discharged alive from hospital were followed to monitor their prognosis every year. The primary endpoint of the study was all-cause mortality, and the secondary endpoint was the occurrence of major cardiovascular events. To elucidate the effect of various factors on the long-term prognosis of AMI patients with diabetes, the patients were divided into two groups matched by propensity scores and analyzed retrospectively.
Diabetes was diagnosed in 1102 patients (36.5%). During the index hospitalization, coronary angioplasty and coronary thrombolysis were performed in 58.1% and 16.3% of patients, respectively. In-hospital mortality of diabetic patients with AMI was comparable to that of non-diabetic AMI patients (9.2% and 9.3%, respectively). In total, 2736 patients (90.6%) were discharged alive and followed for a median of 4.2 years (follow-up rate, 96.0%). The long-term survival rate was worse in the diabetic group than in the non-diabetic group, but not significantly different (hazard ratio, 1.20 [0.97-1.49], p = 0.09). On the other hand, AMI patients with diabetes showed a significantly higher incidence of cardiovascular events than the non-diabetic group (1.40 [1.20-1.64], p < 0.0001). Multivariate analysis revealed that three factors were significantly associated with favorable late outcomes in diabetic AMI patients: acute revascularization (HR, 0.62); prescribing aspirin (HR, 0.27); and prescribing renin-angiotensin system (RAS) inhibitors (HR, 0.53). There was no significant correlation between late outcome and prescription of beta-blockers (HR, 0.97) or calcium channel blockers (HR, 1.27). Although standard Japanese-approved doses of statins were associated with favorable outcome in AMI patients with diabetes, this was not statistically significant (0.67 [0.39-1.06], p = 0.11).
Although diabetic patients with AMI have more frequent adverse events than non-diabetic patients with AMI, the present results suggest that acute revascularization and standard therapy with aspirin and RAS inhibitors may improve their prognosis.
Related Articles
Gender-related differences in the presentation, management, and outcomes among patients with acute coronary syndrome from Oman
Sulaiman, Kadhim
Panduranga, Prashanth
Al-Zakwani, Ibrahim
Journal of the Saudi Heart Association
To assess gender-related differences in the presentation, management, and in-hospital outcomes among acute coronary syndrome (ACS) patients from Oman.
Data were analyzed from 1579 consecutive ACS patients from Oman during May 8, 2006 to June 6, 2006 and January 29, 2007 to June 29, 2007, as part of Gulf RACE (Registry of Acute Coronary Events). Analyses were conducted using univariate and multivariate statistical techniques.
In this study, 608 (39%) patients were women with mean age 62 ± 12 vs. 57 ± 13 years (p < 0.001). More women were seen in the older age groups (age <55 years: 25% vs. 43%, 55–74 years: 60% vs. 49% and >75 years: 15% vs. 8%; p < 0.001). Women had higher frequencies of diabetes, hypertension, hyperlipidemia, obesity, angina, and aspirin use, but less history of smoking. Women were significantly less likely to have ischemic chest pain, ST-elevation myocardial infarction (STEMI), non-STEMI and were more likely to have dyspnea, unstable angina, ST depression and left bundle branch block. Both groups received ACS medications and cardiac catheterization equally; however, women received anticoagulants (88% vs. 79%; p < 0.001), angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) (70% vs. 65%; p = 0.050) more and clopidogrel less (20% vs. 29%; p < 0.001). Women experienced more recurrent ischemia and heart failure but with similar in-hospital mortality (4.6% vs. 4.3%) even after adjusting for age (p = 0.500).
Women admitted with ACS were older than men, had more risk factors, presented differently with no difference in hospital mortality. This is similar to Gulf RACE study except for mortality. Women received anticoagulants/ACEIs /ARBs more but were under-treated with clopidogrel.
Gender-related differences; Women; Acute coronary syndrome; Oman
Related Articles
Cost-Effectiveness of Optimal Use of Acute Myocardial Infarction Treatments and Impact on Coronary Heart Disease Mortality in China
Wang, Miao
Moran, Andrew E.
Liu, Jing
Coxson, Pamela G.
Heidenreich, Paul A.
Gu, Dongfeng
He, Jiang
Goldman, Lee
Zhao, Dong
Circulation. Cardiovascular quality and outcomes
The cost-effectiveness of the optimal use of hospital-based acute myocardial infarction (AMI) treatments and their potential impact on coronary heart disease (CHD) mortality in China is not well known.
Methods and Results
The effectiveness and costs of optimal use of hospital-based AMI treatments were estimated by the CHD Policy Model-China, a Markov-style computer simulation model. Changes in simulated AMI, CHD mortality, quality-adjusted life years, and total healthcare costs were the outcomes. The incremental cost-effectiveness ratio was used to assess projected cost-effectiveness. Optimal use of 4 oral drugs (aspirin, β-blockers, statins, and angiotensin-converting enzyme inhibitors) in all eligible patients with AMI or unfractionated heparin in non–ST-segment–elevation myocardial infarction was a highly cost-effective strategy (incremental cost-effectiveness ratios approximately US $3100 or less). Optimal use of reperfusion therapies in eligible patients with ST-segment–elevation myocardial infarction was moderately cost effective (incremental cost-effectiveness ratio ≤$10 700). Optimal use of clopidogrel for all eligible patients with AMI or primary percutaneous coronary intervention among high-risk patients with non–ST-segment– elevation myocardial infarction in tertiary hospitals alone was less cost effective. Use of all the selected hospital-based AMI treatment strategies together would be cost-effective and reduce the total CHD mortality rate in China by ≈9.6%.
Optimal use of most standard hospital-based AMI treatment strategies, especially combined strategies, would be cost effective in China. However, because so many AMI deaths occur outside of the hospital in China, the overall impact on preventing CHD deaths was projected to be modest.
cost-benefit analysis; myocardial infarction; quality-adjusted life years; therapy
Related Articles
Evolution in the Management of Acute Myocardial Infarction in the Autonomous Community of Valencia (Spain): Ten Years of the Primvac Registry (1995-2004)
Cabadés, Adolfo
Valencia, José
Rueda, Joaquín
Echánove, Ildefonso
Sanjuán, Rafael
Cebrián, Javier
González-Hernández, Enrique
Cardona, Juan
Colomina, Francisco
Francés, Mercedes
Ortolá, Victoria
Sogorb, Francisco
International Journal of Biomedical Science : IJBS
Introduction and objectives:
Several registries of acute myocardial infarction (AMI) have been carried out in Spain, but few remain active. This work analyses the evolution of the characteristics and control of patients with AMI during the first 10 years of the PRIMVAC registry, initiated in 1995.
The demographical and clinical characteristics, therapeutic-diagnostic procedures and pharmacological treatment of patients admitted with AMI between January 1995 and December 2004, were analysed in 17 coronary centres in the Autonomous Community of Valencia (South eastern Spain).
The mean age of the 19,719 patients recruited was of 65. The percentage of women, hypertension, hypercholestrolemia and diabetes increased during registry period. The median time of symptoms onset-hospital arrival was 151 minutes, without a decrease over the time, and the delay of thrombolysis fell from 200 to 154 minutes (p<0.01). Percentage of thrombolytic treatment oscillated between 39% and 48%. The mortality in the coronary units decreased (14.1% vs. 8.9%; p<0.001). The number of coronary angiography and percutaneous revascularisation performed increased up to 61% and 32%, respectively, of patients included. On discharge, the use of beta-blockers (29.3% vs. 66.7%), angiotensin-converting enzyme (ACE) inhibitors (41.7% vs. 57.9%) and statins (29.3% vs. 71%) went up.
Overall mortality in the coronary unit decreased, without any variation in the incidence of serious complications. Time to thrombolysis was reduced over the time, with no significant increment in its use. The performance of coronary angiography and percutaneous revascularisation increased, with a low use of primary angioplasty. The use of beta-blockers, ACE inhibitors and statins increased at discharge.
myocardial infarction; registry; treatment; mortality
Related Articles
Secondary prevention of ischaemic cardiac events
Skinner, Jane S
Cooper, Angela
Clinical Evidence
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior acute myocardial infarction (MI) or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antithrombotic treatment; other drug treatments; cholesterol reduction; blood pressure reduction; non-drug treatments; and revascularisation procedures? We searched: Medline, Embase, The Cochrane Library, and other important databases up to October 2007 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 154 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review. we present information relating to the effectiveness and safety of the following interventions: advice to eat less fat; advice to eat more fibre; advice to increase consumption of fish oils; amiodarone; angiotensin-converting enzyme (ACE) inhibitors; angiotensin II receptor blockers; angiotensin II receptor blockers plus ACE inhibitors; antioxidant vitamin combinations; antiplatelet agents; beta-blockers; beta-carotene; blood pressure reduction; calcium channel blockers; cardiac rehabilitation including exercise; class I antiarrhythmic agents; coronary artery bypass grafting (CABG); percutaneous coronary intervention (PCI); fibrates; hormone replacement therapy (HRT); Mediterranean diet; multivitamins; non-specific cholesterol reduction; oral anticoagulants; oral glycoprotein IIb/IIIa receptor inhibitors; psychosocial treatment; smoking cessation; statins; vitamin C; and vitamin E.
Key Points
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior MI or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures.
Of the antithrombotic treatments, there is good evidence that aspirin (especially combined with clopidogrel in people with acute coronary syndromes or MI), clopidogrel (more effective than aspirin), and anticoagulants all effectively reduce the risk of cardiovascular events. Oral anticoagulants substantially increase the risk of haemorrhage. These risks may outweigh the benefits when combined with antiplatelet treatments. Adding oral glycoprotein IIb/IIIa receptor inhibitors to aspirin seems to increase the risk of mortality compared with aspirin alone.
Other drug treatments that reduce mortality include beta-blockers (after MI and in people with left ventricular dysfunction), ACE inhibitors (in people at high risk, after MI, or with left ventricular dysfunction), angiotensin II receptor blockers (in people with coronary artery disease), and amiodarone (in people with MI and high risk of death from cardiac arrhythmia). There is conflicting evidence on the effect of calcium channel blockers. Some types may be effective at reducing mortality in the absence of heart failure, whereas other may be harmful.Contrary to decades of large observational studies, multiple RCTs show no cardiac benefit from HRT in postmenopausal women.
Lipid-lowering treatments effectively reduce the risk of cardiovascular mortality and non-fatal cardiovascular events in people with CHD.
There is good evidence that statins reduce the risk of mortality and cardiac events in people at high risk, but the evidence is less clear for fibrates.
The magnitude of cardiovascular risk reduction in people with coronary artery disease correlates directly with the magnitude of blood pressure reduction.
Cardiac rehabilitation (including exercise), and smoking cessation all reduce the risk of cardiac events in people with CHD. Antioxidant vitamins (such as vitamin E, beta-carotene, or vitamin C) have no effect on cardiovascular events in high-risk people, and in some cases may actually increase risk of cardiac mortality.We don't know whether changing diet alters the risk of cardiac episodes, although a Mediterranean diet may have some survival benefit over a Western diet.
In selected people, such as those with more-extensive coronary disease and impaired left ventricular function, CABG may improve survival compared with an initial strategy of medical treatment. We don't know how PTCA compares with medical treatment.
We found no consistent difference in mortality or recurrent MI between CABG and PTCA with or without stenting,due to varied results among subgroups and insufficient evidence on stenting when comparing the interventions. PTCA with stenting may be more effective than PTCA alone.
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Use of evidence-based pharmacotherapy after myocardial infarction in Estonia
Marandi, Toomas
Baburin, Aleksei
Ainla, Tiia
BMC Public Health
Mortality from cardiovascular disease in Estonia is among the highest in Europe. The reasons for this have not been clearly explained. Also, there are no studies available examining outpatient drug utilization patterns in patients who suffered from acute myocardial infarction (AMI) in Estonia. The objective of the present study was to examine drug utilization in different age and gender groups following AMI in Estonia.
Patients admitted to hospital with AMI (ICD code I21-I22) during the period of 01.01.2004-31.12.2005 and who survived more than 30 days were followed 365 days from the index episode. Data about reimbursed prescriptions of beta-blockers (BBs), angiotensin converting enzyme inhibitors/angiotensin II receptor blockers (ACE/ARBs) and statins for these patients was obtained from the database of the Estonian Health Insurance Fund. Data were mainly analysed using frequency tables and, where appropriate, the Pearson's χ2 test, the Mann-Whitney U-test and the t-test were used. A logistic regression method was used to investigate the relationship between drug allocation and age and gender. We presented drug utilization data as defined daily dosages (DDD) per life day in four age groups and described proportions of different combinations used in men and women.
Four thousand nine hundred patients were hospitalized due to AMI and 3854 of them (78.7%) were treated by BBs, ACE/ARBs and/or statins. Of the 4025 inpatients who survived more than 30 days, 3799 (94.4%) were treated at least by the one of drug groups studied. Median daily dosages differed significantly between men and women in the age group 60-79 years for BBs and ACE/ARBs, respectively. Various combinations of the drugs studied were not allocated in equal proportions for men and women, although the same combinations were the most frequently used for both genders. The logistic regression analysis adjusted to gender and age revealed that some combinations of drugs were not allocated similarly in different age and gender groups.
Most of the patients were prescribed at least one of commonly recommended drugs. Only 40% of them were treated by combinations of beta-blockers, ACE inhibitors/angiotensin II receptor blockers and statins, which is inconsistent with guideline recommendations in Estonia. Standards of training and quality programs in Estonia should be reviewed and updated aiming to improve an adherence to guidelines of management of acute myocardial infarction in all age and gender groups.
Related Articles
Different Impact of Diabetes Mellitus on In-Hospital and 1-Year Mortality in Patients with Acute Myocardial Infarction Who Underwent Successful Percutaneous Coronary Intervention: Results from the Korean Acute Myocardial Infarction Registry
Park, Keun-Ho
Ahn, Youngkeun
Jeong, Myung Ho
Chae, Shung Chull
Hur, Seung Ho
Kim, Young Jo
Seong, In Whan
Chae, Jei Keon
Hong, Taek Jong
Cho, Myeong Chan
Bae, Jang Ho
Rha, Seung Woon
Jang, Yang Soo
The Korean Journal of Internal Medicine
The aim of this study was to evaluate the impact of diabetes mellitus (DM) on in-hospital and 1-year mortality in patients who suffered acute myocardial infarction (AMI) and underwent successful percutaneous coronary intervention (PCI).
Among 5,074 consecutive patients from the Korea AMI Registry with successful revascularization between November 2005 and June 2007, 1,412 patients had a history of DM.
The DM group had a higher mean age prevalence of history of hypertension, dyslipidemia, ischemic heart disease, high Killip class, and diagnoses as non-ST elevation MI than the non-DM group. Left ventricular ejection fraction (LVEF) and creatinine clearance were lower in the DM group, which also had a significantly higher incidence of in-hospital and 1-year mortality of hospital survivors (4.6% vs. 2.8%, p = 0.002; 5.0% vs. 2.5%, p < 0.001). A multivariate analysis revealed that independent predictors of in-hospital mortality were Killip class IV or III at admission, use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, LVEF, creatinine clearance, and a diagnosis of ST-elevated MI but not DM. However, a multivariate Cox regression analysis showed that DM was an independent predictor of 1-year mortality (hazard ratio, 1.504; 95% confidence interval, 1.032 to 2.191).
DM has a higher association with 1-year mortality than in-hospital mortality in patients with AMI who underwent successful PCI. Therefore, even when patients with AMI and DM undergo successful PCI, they may require further intensive treatment and continuous attention.
Diabetes mellitus; Myocardial infarction; Mortality
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Quality of care of patients with acute myocardial infarction in Bulgaria: a cross-sectional study
Ganova-Iolovska, Milka
Kalinov, Krassimir
Geraedts, Max
BMC Health Services Research
Cardiovascular diseases are the major cause of death in Bulgaria. Because of notable differences in mortality rates between Bulgaria and other European countries, we presume a tangible difference in the management of acute myocardial infarction (AMI) and an underutilization of evidence-based treatments. In order to determine the quality of care of patients with AMI in Bulgaria, we analyzed the appropriateness of current treatments and their relation to patient characteristics.
We performed a descriptive cross-sectional study, using retrospectively collected data from medical charts. We included all patients with AMI, residing and admitted to hospitals in the region of Stara Zagora, Bulgaria, between September 1st and December 31st, 2004. Socioeconomic status was surveyed within the framework of a structured patient interview. We used chi-square tests with Fisher's exact probabilities to analyze the relationship between prehospital time delay age, sex, and socio-economic status of the patients and Student's independent samples t-tests to check hypotheses about means.
From 134 patients with AMI (mean age 64.6, SD 13.2, 66% male), 7% presented to a hospital within 59 minutes, and 44% within 4 hours of symptoms onset. The use of Heparin was 98%. In the first 24 hours, ASS was administrated in 82% and β-Blockers in 73% of the cases. At discharge Aspirin, β-Blockers, Angiotensin Converting Enzyme Inhibitors or AR-Blockers and Statins were used in 85%, 79%, 66%, and 43% of cases respectively. Intravenous fibrinolysis was applied in 32% of the eligible patients with ST-segment elevation. Percutaneous coronary interventions were applied in four patients within the first month after AMI. Hospital location in relation to a patient's place of residence and manner of transportation to hospital did not influence the time delay between the onset of symptoms to the start of hospital treatment. In the study region, a relation between time delay and both age and education level was observed.
The actual quality of care of patients with AMI in Bulgaria lies far from the evidence-based recommendations. Additional research and improvements in health services are needed to reduce the burden of cardiovascular disease in Bulgaria.
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Euro Heart Survey 2009 Snapshot: regional variations in presentation and management of patients with AMI in 47 countries
Puymirat, Etienne
Battler, Alex
Birkhead, John
Bueno, Hector
Clemmensen, Peter
Cottin, Yves
Fox, Keith AA
Gorenek, Bulent
Hamm, Christian
Huber, Kurt
Lettino, Maddalena
Lindahl, Bertil
Müller, Christian
Parkhomenko, Alexander
Price, Susanna
Quinn, Tom
Schiele, Francois
Simoons, Maarten
Tatu-Chitoiu, Gabriel
Tubaro, Marco
Vrints, Christiaan
Zahger, Doron
Zeymer, Uwe
Danchin, Nicolas
European Heart Journal. Acute Cardiovascular Care
Detailed data on patients admitted for acute myocardial infarction (AMI) on a European-wide basis are lacking. The Euro Heart Survey 2009 Snapshot was designed to assess characteristics, management, and hospital outcomes of AMI patients throughout European Society of Cardiology (ESC) member countries in a contemporary 'real-world' setting, using a methodology designed to improve the representativeness of the survey.
Member countries of the ESC were invited to participate in a 1-week survey of all patients admitted for documented AMI in December 2009. Data on baseline characteristics, type of AMI, management, and complications were recorded using a dedicated electronic form. In addition, we used data collected during the same time period in national registries in Sweden, England, and Wales. Data were centralized at the European Heart House.
Overall, 4236 patients (mean age 66±13 years; 31% women) were included in the study in 47 countries. Sixty per cent of patients had ST-segment elevation myocardial infarction, with 50% having primary percutaneous coronary intervention and 21% fibrinolysis. Aspirin and thienopyridines were used in >90%. Unfractionated and low-molecular-weight heparins were the most commonly used anticoagulants. Statins, beta-blockers, and angiotensin-converting enzyme inhibitors were used in >80% of the patients. In-hospital mortality was 6.2%. Regional differences were observed, both in terms of population characteristics, management, and outcomes.
In-hospital mortality of patients admitted for AMI in Europe is low. Although regional variations exist in their presentation and management, differences are limited and have only moderate impact on early outcomes.
Acute myocardial infarction; Europe; hospital outcomes; survey
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Compliance of pharmacological treatment for non-ST-elevation acute coronary syndromes with contemporary guidelines: influence on outcomes
Dores, Hélder
Aguiar, Carlos
Ferreira, Jorge
Mimoso, Jorge
Monteiro, Sílvia
Seixo, Filipe
Santos, José Ferreira
Cardiovascular Diagnosis and Therapy
Although the proven efficacy of evidence-based therapy in patients with cardiovascular diseases, the recommendations are not always instituted. We aimed to analyse the compliance of non-ST-elevation acute coronary syndrome (NSTE-ACS) patients with treatment guidelines and to assess the impact of these measures in hospital death during the index hospitalization.
Population and methods
All consecutive patients (pts) included in the Portuguese Registry on Acute Coronary Syndromes (ProACS) between January 1, 2002 and August 31, 2011 were analysed. Compliance with Guidelines for the management of NSTE-ACS was evaluated with a 6-point therapeutic score (ThSc), comprising the treatment with: aspirin, clopidogrel, heparin, beta-blocker, angiotensin-converting enzyme inhibitor and statin. One point was assigned for each drug prescribed and zero if not given. The total therapeutic compliance was defined as ThSc =6 points.
The final analysis comprised 14,276 pts (67.1% male; mean age 67.6±12.3 years), most of them admitted with non-ST elevation myocardial infarction (77.4%). The mean value of ThSc was 4.9±1.1 and total compliance occurred in 36.7% pts. Centres with percutaneous coronary intervention (PCI) capacity had a statistically significant higher ThSc (5.0±1.0 vs. 4.8±1.1, P<0.001) and were associated with higher total compliance [OR 1.53, 95% confidence intervals (CI), 1.42-1.65, P<0.001]. In-hospital mortality was 2.4% (354 deaths). Compared to pts who died, the survivors had a higher ThSc (4.9±1.1 vs. 4.2±1.3, P<0.001) and this score was independently associated with lower risk of in-hospital mortality (OR 0.70, 95% CI, 0.64-0.77, P<0.001). Receiver operating characteristics curve analysis showed a good accuracy of ThSc for the occurrence of in-hospital mortality with the area under the curve (AUC) 0.82 (95% CI, 0.80-0.84, P<0.001), sensitivity 71.6% and specificity 78.0%. Age, peripheral artery disease, Killip-Kimball class >I, electrocardiogram (ECG) with ST-segment depression and positive troponin were other independent predictors of in-hospital mortality.
In the present study, patients with NSTE-ACS who received medications recommended by guidelines had better in-hospital outcomes. These findings highlight the need to clarify the clinical recommendations and to develop approaches for quality improvement in this subset of patients.
Non-ST-elevation acute coronary syndrome (NSTE-ACS); compliance; guidelines
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Secondary prevention of ischaemic cardiac events
Skinner, Jane S
Cooper, Angela
Clinical Evidence
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior acute myocardial infarction (MI) or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures. Secondary prevention in people with an acute MI or acute coronary syndrome within the past 6 months is not included.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of antithrombotic treatment; other drug treatments; cholesterol reduction; blood pressure reduction; non-drug treatments; and revascularisation procedures? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 137 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review, we present information relating to the effectiveness and safety of the following interventions: advice to eat less fat, advice to eat more fibre, advice to increase consumption of fish oils, amiodarone, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, angiotensin II receptor blockers plus ACE inhibitors, antioxidant vitamin combinations, antiplatelet agents, aspirin, beta-blockers, beta-carotene, blood pressure reduction, calcium channel blockers, cardiac rehabilitation including exercise, class I antiarrhythmic agents, coronary artery bypass grafting (CABG), fibrates, hormone replacement therapy (HRT), Mediterranean diet, multivitamins, non-specific cholesterol reduction, oral anticoagulants, oral glycoprotein IIb/IIIa receptor inhibitors, percutaneous coronary intervention (PCI), psychosocial treatment, smoking cessation, statins, vitamin C, and vitamin E.
Key Points
Coronary artery disease is the leading cause of mortality in resource-rich countries, and is becoming a major cause of morbidity and mortality in resource-poor countries. Secondary prevention in this context is long-term treatment to prevent recurrent cardiac morbidity and mortality in people who have had either a prior MI or acute coronary syndrome, or who are at high risk due to severe coronary artery stenoses or prior coronary surgical procedures.
Of the antithrombotic treatments, there is good evidence that aspirin (especially combined with clopidogrel in people with acute coronary syndromes or MI), clopidogrel (more effective than aspirin), and anticoagulants all effectively reduce the risk of cardiovascular events. Oral anticoagulants substantially increase the risk of haemorrhage. These risks may outweigh the benefits when combined with antiplatelet treatments.Adding oral glycoprotein IIb/IIIa receptor inhibitors to aspirin seems to increase the risk of mortality compared with aspirin alone.
Other drug treatments that reduce mortality include beta-blockers (after MI and in people with left ventricular dysfunction), ACE inhibitors (in people at high risk, after MI, or with left ventricular dysfunction), and amiodarone (in people with MI and high risk of death from cardiac arrhythmia). There is conflicting evidence on the effect of calcium channel blockers. Some types may be effective at reducing mortality in the absence of heart failure, whereas others may be harmful.Contrary to decades of large observational studies, multiple RCTs show no cardiac benefit from HRT in postmenopausal women.
Lipid-lowering treatments effectively reduce the risk of cardiovascular mortality and non-fatal cardiovascular events in people with CHD.
There is good evidence that statins reduce the risk of mortality and cardiac events in people at high risk, but the evidence is less clear for fibrates.
The magnitude of cardiovascular risk reduction in people with coronary artery disease correlates directly with the magnitude of blood pressure reduction.
Cardiac rehabilitation (including exercise) and smoking cessation reduce the risk of cardiac events in people with CHD. Antioxidant vitamins (such as vitamin E, beta-carotene, or vitamin C) have no effect on cardiovascular events in high-risk people, and in some cases may actually increase risk of cardiac mortality.We don't know whether changing diet alters the risk of cardiac episodes, although a Mediterranean diet may have some survival benefit over a Western diet. Advice to increase fish oil consumption or fish oil consumption may be beneficial in some population groups. However, evidence was weak.Some psychological interventions may be more effective than usual care at improving some cardiovascular outcomes. However, evidence was inconsistent.
In selected people, such as those with more-extensive coronary disease and impaired left ventricular function, CABG may improve survival compared with an initial strategy of medical treatment. We don't know how PTCA compares with medical treatment.
We found no consistent difference in mortality or recurrent MI between CABG and PTCA with or without stenting, because of varied results among subgroups and insufficient evidence on stenting when comparing the interventions. CABG may be more effective than PTCA with or without stenting at reducing some composite outcomes, particularly those including repeat revascularisation rates. PTCA with stenting may be more effective than PTCA alone.
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Medication Management Among Medicaid Myocardial Infarction Survivors
Oberg, Erica B.
Fitzpatrick, Annette L.
Lafferty, William E.
LoGerfo, James P.
Washington State journal of public health practice
Despite guidelines to direct appropriate medical management, the quality of care following acute myocardial infarction (AMI) may be lacking. This study characterizes medication utilization by Medicaid enrollees in the year following AMI, compares it to guidelines for secondary prevention and investigates associations with rehospitalization and survival. Using DSHS administrative claims data from Washington State, Medicaid enrollees who had an AMI in 2004 were selected. Data were de-identified and details of demographics, hospitalizations, ambulatory care, and prescriptions over the following 365 days were abstracted. Utilization of guideline-directed secondary prevention strategies was measured and associations with death and recurrent hospitalization were tested. The mortality rate was 13.4% and 38.7% were rehospitalized. Mean time to first rehospitalization was 188.6 days (SD 102.3). Prescriptions for angiotensin enzyme inhibitors or receptor blockers were initially filled by 54.0%, but year-long adherence declined to 33.3%. Beta blockers, aspirin and statins followed the same trend: 65.1% to 39.5%, 37.9% to 16.7% and 58.1% to 41.9% respectively. Twenty-two percent received all medications; 8.2% were adherent. Only the initial prescription of aspirin was significantly associated with a survival benefit (HR = 0.35, p=0.003). If the results suggested by the claims data are representative of care delivered to Medicaid enrollees, rates of application of guideline-directed medication are less than optimal. To improve survival and reduce re-hospitalization following AMI, changes in the access and delivery of healthcare could be implemented to improve medication management, both at time of discharge and over the year following AMI.
Medicaid; Access to Care; Medication Adherence; Secondary Prevention; Cardiovascular; Myocardial Infarction; Characteristics of Care
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Management of acute coronary syndrome in South Africa: insights from the ACCESS (Acute Coronary Events – a Multinational Survey of Current Management Strategies) registry
Schamroth, Colin
Cardiovascular Journal of Africa
The burden of cardiovascular diseases is predicted to escalate in developing countries. While many studies have reported the descriptive epidemiology, practice patterns and outcomes of patients hospitalised with acute coronary syndromes (ACS), these have largely been confined to the developed nations.
In this prospective, observational registry, 12 068 adults hospitalised with a diagnosis of ACS were enrolled between January 2007 and January 2008 at 134 sites in 19 countries in Africa, Latin America and the Middle East. Data on patient characteristics, treatment and outcomes were collected.
Of the 642 patients from South Africa in the registry, 615 had a confirmed ACS diagnosis and form the basis of this report; 41% had a discharge diagnosis of ST-segment elevation myocardial infarction (STEMI) and 59% a diagnosis of non-ST-segment elevation acute coronary syndrome (NSTE-ACS), including 32% with non-ST-segment elevation myocardial infarction (NSTEMI) and 27% with unstable angina (UA).
During hospitalisation, most patients received aspirin (94%) and a lipid-lowering medication (91%); 69% received a beta-blocker, and 66% an ACE inhibitor/angiotensin receptor blocker. Thrombolytic therapy was used in only 18% of subjects (36% of STEMI patients and 5.5% of NSTE-ACS patients). Angiography was undertaken in 93% of patients (61.3% on the first day), of whom 53% had a percutaneous coronary intervention (PCI) and 14% were referred for coronary artery bypass surgery. Drug-eluting stents were used in 57.9% of cases. Clopidogrel was prescribed at discharge from hospital in 62.2% of patients.
All-cause death at 12 months was 5.7%, and was higher in patients with STEMI versus non-ST-elevation ACS (6.7 vs 5.0%, p < 0.0001). Clinical factors associated with higher risk of death at 12 months included age ≥ 70 years, presence of diabetes mellitus on admission, and a history of stroke/transient ischaemic attack (TIA).
In this observational study of ACS patients, the use of evidence-based pharmacological therapies for ACS was quite high. Interventional rates were high compared to international standards, and in particular the use of drug-eluting stents, yet the clinical outcomes (mortality, re-admission rates and severe bleeding episodes at one year) were favourable, with low rates compared with other studies.
acute coronary syndrome; myocardial infarction; unstable angina; registry; death
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Diabetes: prevention of cardiovascular events
Sigal, Ronald J
Malcolm, Janine C
Arnaout, Amel
BMJ Clinical Evidence
Diabetes mellitus is a major risk factor for cardiovascular disease. In the USA, a survey of deaths in 1986 suggested that 60−75% of people with diabetes die from cardiovascular causes.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of promoting smoking cessation; controlling blood pressure; treating dyslipidaemia; blood glucose control; treating multiple risk factors; revascularisation procedures; and antiplatelet drugs in people with diabetes? We searched: Medline, Embase, The Cochrane Library and other important databases up to November 2004 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 63 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antihypertensive drugs, antihypertensive treatment, aspirin, clopidogrel, coronary artery bypass graft, diet, fibrates, glycaemic control (intensive versus conventional control), heparin (with or without glycoprotein IIb/IIIa inhibitors, or clopidogrel), lower target blood pressures, metformin, multiple risk factor treatment (intensive), percutaneous transluminal coronary angioplasty (plus stent), smoking cessation, statins (aggressive or moderate lipid lowering, low or standard dose), stent (plus glycoprotein IIb/IIIa inhibitors), thrombolysis.
Key Points
People with diabetes mellitus have 2−4 times the risk of cardiovascular disease, and are up to 3 times more likely to die after a myocardial infarction, compared with normoglycaemic people.
Intensive treatment of multiple risk factors in people with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular disease compared with conventional treatment. Promotion of smoking cessation is likely to reduce cardiovascular events in people with diabetes, although no studies have specifically studied this.
Tight control of blood pressure and reduction of cholesterol reduces the risk of cardiovascular events in people with hypertension and diabetes. Angiotensin converting enzyme inhibitors, angiotensin receptor antagonists, beta-blockers, calcium channel blockers and diuretics have all been shown to have similar antihypertensive effects.Reduction of cholesterol with statins reduces cardiovascular morbidity and mortality in people with diabetes regardless of initial cholesterol levels, and fibrates may also be beneficial. Aspirin and clopidogrel have not been consistently shown to reduce cardiovascular events or mortality in people with diabetes and cardiovascular disease compared with controls, and increase the risk of bleeding.Intensive blood glucose control reduces the risk of cardiovascular events in people with type 1 diabetes, but has not been consistently shown to reduce cardiovascular morbidity or mortality in people with type 2 diabetes.
Coronary artery bypass grafts reduce 4 year mortality compared with percutaneous transluminal coronary angioplasty (PTCA) in people with diabetes, although longer term benefits are unclear. PTCA may reduce short term mortality or myocardial infarction compared with thrombolysis in people with diabetes and acute myocardial infarction.Adding glycoprotein IIb/IIIa inhibitors reduces cardiovascular morbidity and mortality compared with placebo in people with acute coronary syndrome or undergoing PTCA plus stenting.
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Hospital Performance, the Local Economy, and the Local Workforce: Findings from a US National Longitudinal Study
Blustein, Jan
Borden, William B.
Valentine, Melissa
PLoS Medicine
Blustein and colleagues examine the associations between changes in hospital performance and their local economic resources. Locationally disadvantaged hospitals perform poorly on key indicators, raising concerns that pay-for-performance models may not reduce inequality.
Pay-for-performance is an increasingly popular approach to improving health care quality, and the US government will soon implement pay-for-performance in hospitals nationwide. Yet hospital capacity to perform (and improve performance) likely depends on local resources. In this study, we quantify the association between hospital performance and local economic and human resources, and describe possible implications of pay-for-performance for socioeconomic equity.
Methods and Findings
We applied county-level measures of local economic and workforce resources to a national sample of US hospitals (n = 2,705), during the period 2004–2007. We analyzed performance for two common cardiac conditions (acute myocardial infarction [AMI] and heart failure [HF]), using process-of-care measures from the Hospital Quality Alliance [HQA], and isolated temporal trends and the contributions of individual resource dimensions on performance, using multivariable mixed models. Performance scores were translated into net scores for hospitals using the Performance Assessment Model, which has been suggested as a basis for reimbursement under Medicare's "Value-Based Purchasing" program. Our analyses showed that hospital performance is substantially associated with local economic and workforce resources. For example, for HF in 2004, hospitals located in counties with longstanding poverty had mean HQA composite scores of 73.0, compared with a mean of 84.1 for hospitals in counties without longstanding poverty (p<0.001). Hospitals located in counties in the lowest quartile with respect to college graduates in the workforce had mean HQA composite scores of 76.7, compared with a mean of 86.2 for hospitals in the highest quartile (p<0.001). Performance on AMI measures showed similar patterns. Performance improved generally over the study period. Nevertheless, by 2007—4 years after public reporting began—hospitals in locationally disadvantaged areas still lagged behind their locationally advantaged counterparts. This lag translated into substantially lower net scores under the Performance Assessment Model for hospital reimbursement.
Hospital performance on clinical process measures is associated with the quantity and quality of local economic and human resources. Medicare's hospital pay-for-performance program may exacerbate inequalities across regions, if implemented as currently proposed. Policymakers in the US and beyond may need to take into consideration the balance between greater efficiency through pay-for-performance and socioeconomic equity.
Please see later in the article for the Editors' Summary
Editors' Summary
These days, many people are rewarded for working hard and efficiently by being given bonuses when they reach preset performance targets. With a rapidly aging population and rising health care costs, policy makers in many developed countries are considering ways of maximizing value for money, including rewarding health care providers when they meet targets, under "pay-for-performance." In the UK, for example, a major pay-for-performance initiative—the Quality and Outcomes Framework—began in 2004. All the country's general practices (primary health care facilities that deal with all medical ailments) now detail their achievements in terms of numerous clinical quality indicators for common chronic conditions (for example, the regularity of blood sugar checks for people with diabetes). They are then rewarded on the basis of these results.
Why Was This Study Done?
In the US, the government is poised to implement a nationwide pay-for-performance program in hospitals within Medicare, the government program that provides health insurance to Americans aged 65 years or older, as well as people with disabilities. However, some observers are concerned about the effect that the proposed pay-for-performance program might have on the distribution of health care resources in the US. Pay-for-performance assumes that health care providers have the economic and human resources that they need to perform or to improve their performance. But, if a hospital's capacity to perform depends on local resources, payment based on performance might worsen existing health care inequalities because hospitals in under-resourced areas might lose funds to hospitals in more affluent regions. In other words, the government might act as a reverse Robin Hood, taking from the poor and giving to the rich. In this study, the researchers examine the association between hospital performance and local economic and human resources, to explore whether this scenario is a plausible result of the pending change in US hospital reimbursement.
What Did the Researchers Do and Find?
US hospitals have voluntarily reported their performance on indicators of clinical care ("process-of-care measures") for acute myocardial infarction (AMI, heart attack), heart failure (HF), and pneumonia under the Hospital Quality Alliance (HQA) program since 2004. The researchers identified 2,705 hospitals that had fully reported process-of-care measures for AMI and HF in both 2004 and 2007. They then used the "Performance Assessment Model" (a methodology developed by the US Centers for Medicare and Medicaid Services to score hospital performance) to calculate scores for each hospital. Finally, they looked for associations between these scores and measures of the hospital's local economic and human resources such as population poverty levels and the percentage of college graduates in the workforce. Hospital performance was associated with local and economic workforce capacity, they report. Thus, hospitals in counties with longstanding poverty had lower average performance scores for HF and AMI than hospitals in affluent counties. Similarly, hospitals in counties with a low percentage of college graduates in the workforce had lower average performance scores than hospitals in counties where more of the workforce had been to college. Finally, although performance improved generally over the study period, hospitals in disadvantaged areas still lagged behind hospitals in advantaged areas in 2007.
What Do These Findings Mean?
These findings indicate that hospital performance (as measured by the clinical process measures considered here) is associated with the quantity and quality of local human and economic resources. Thus, the proposed Medicare hospital pay-for-performance program may exacerbate existing US health care inequalities by leading to the transfer of funds from hospitals in disadvantaged locations to those in advantaged locations. Although further studies are needed to confirm this conclusion, these findings have important implications for pay-for-performance programs in health care. They suggest that US policy makers may need to modify how they measure performance improvement—the current Performance Assessment Model gives hospitals that start from a low baseline less credit for improvements than those that start from a high baseline. This works against hospitals in disadvantaged locations, which start at a low baseline. Second and more generally, they suggest that there may be a tension between the efficiency goals of pay-for-performance and other equity goals of health care systems. In a world where resources vary across regions, the expectation that regions can perform equally may not be realistic.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000297.
KaiserEDU.org is an online resource for learning about the US health care system. It includes educational modules on such topics as the Medicare program and efforts to improve the quality of care
The Hospital Quality Alliance provides information on the quality of care in US hospitals
Information about the UK National Health Service Quality and Outcomes Framework pay-for-performance initiative for general practice surgeries is available
Related Articles
A multicentre retrospective study to understand anti-platelet treatment patterns and outcomes of acute coronary syndrome patients in India (TRACE)
Kaul, Upendra
Sethi, K.K.
Dalal, Jamshed
Parikh, Keyur
Hiremath, M.S.
Mullasari, Ajit S.
Nair, Tiny
Sandhu, P.S.
Kotak, Bhavesh
Indian Heart Journal
There is limited available information for treatment of acute coronary syndrome (ACS) with respect to outcomes, therapeutic agents and treatment practices. Our retrospective registry study collected and evaluated varying anti-platelet treatment strategies and outcomes of ACS patients who were admitted to 9 different tertiary care hospitals in India. This study was carried out to provide an insight to anti-platelet treatment patterns and analyze outcomes of ACS patients in India.
All the relevant data, including anti-platelet treatment strategies, outcomes and patient treatment compliance were collected from 500 ACS (defined as STEMI, NSTEMI and unstable angina [UA]) cases from January 2007 to December 2009. These ACS cases were randomly collected from the hospital records and included in the analysis. The patient follow up data was acquired either from the hospital records or via telephonic contact for a period of one year following the event.
Out of 500 ACS patients, 59.8% had UA/NSTEMI and 40.2% had STEMI. On hospital admission, aspirin, clopidogrel, statins, beta-blockers and angiotensin converting enzyme inhibitors (ACE-Is) were used by 83%, 83%, 68%, 43.2% and 31.6% patients, respectively. On discharge, aspirin, clopidogrel, statins and beta-blockers were used by 90.2%, 88%, 80.6%, and 59% patients, respectively. The average patient compliance to statins, clopidogrel and aspirin was recorded as 74.28%, 69.7% and 68.66%, respectively during discharge and follow-up visits. Greater than 50% of ACS patients after discharge were lost to follow-up and as a result there was significant drop in the number of clinical events reported.
This pilot study conducted in tertiary care centers in India showed that patients with ACS were more often diagnosed with UA/NSTEMI as compared to STEMI and reported maximum compliance to statins, clopidogrel and aspirin after discharge over 1 year follow-up. More ACS patients were lost to follow up that resulted in low reporting of clinical outcomes, following discharge upto 1 year.
Acute coronary syndrome; ST-elevation myocardial infarction; Non-ST elevation myocardial infarction; Unstable angina
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Characteristics, In-Hospital and Long-Term Clinical Outcomes of Nonagenarian Compared with Octogenarian Acute Myocardial Infarction Patients
Lee, Ki Hong
Ahn, Youngkeun
Kim, Sung Soo
Rhew, Si Hyun
Jeong, Young Wook
Jang, Soo Young
Cho, Jae Yeong
Jeong, Hae Chang
Park, Keun-Ho
Yoon, Nam Sik
Sim, Doo Sun
Yoon, Hyun Joo
Kim, Kye Hun
Hong, Young Joon
Park, Hyung Wook
Kim, Ju Han
Cho, Jeong Gwan
Park, Jong Chun
Jeong, Myung Ho
Cho, Myeong-Chan
Kim, Chong Jin
Kim, Young Jo
Journal of Korean Medical Science
We compared clinical characteristics, management, and clinical outcomes of nonagenarian acute myocardial infarction (AMI) patients (n=270, 92.3±2.3 yr old) with octogenarian AMI patients (n=2,145, 83.5±2.7 yr old) enrolled in Korean AMI Registry (KAMIR). Nonagenarians were less likely to have hypertension, diabetes and less likely to be prescribed with beta-blockers, statins, and glycoprotein IIb/IIIa inhibitors compared with octogenarians. Although percutaneous coronary intervention (PCI) was preferred in octogenarians than nonagenarians, the success rate of PCI between the two groups was comparable. In-hospital mortality, the composite of in-hospital adverse outcomes and one year mortality were higher in nonagenarians than in octogenarians. However, the composite of the one year major adverse cardiac events (MACEs) was comparable between the two groups without differences in MI or re-PCI rate. PCI improved 1-yr mortality (adjusted hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.36-0.69, P<0.001) and MACEs (adjusted HR, 0.47; 95% CI, 0.37-0.61, P<0.001) without significant complications both in nonagenarians and octogenarians. In conclusion, nonagenarians had similar 1-yr MACEs rates despite of higher in-hospital and 1-yr mortality compared with octogenarian AMI patients. PCI in nonagenarian AMI patients was associated to better 1-yr clinical outcomes.
Graphical Abstract
Aged, Eighty and over; Myocardial Infarction; Percutaneous Coronary Intervention
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Readmissions after Hospitalization for Heart Failure, Acute Myocardial Infarction, or Pneumonia among Young and Middle-Aged Adults: A Retrospective Observational Cohort Study
Ranasinghe, Isuru
Wang, Yongfei
Dharmarajan, Kumar
Hsieh, Angela F.
Bernheim, Susannah M.
Krumholz, Harlan M.
PLoS Medicine
Isuru Ranasinghe and colleagues compare readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia in adults aged 18 to 64 years with readmissions in those aged 65 and older.
Please see later in the article for the Editors' Summary
Patients aged ≥65 years are vulnerable to readmissions due to a transient period of generalized risk after hospitalization. However, whether young and middle-aged adults share a similar risk pattern is uncertain. We compared the rate, timing, and readmission diagnoses following hospitalization for heart failure (HF), acute myocardial infarction (AMI), and pneumonia among patients aged 18–64 years with patients aged ≥65 years.
Methods and Findings
We used an all-payer administrative dataset from California consisting of all hospitalizations for HF (n = 206,141), AMI (n = 107,256), and pneumonia (n = 199,620) from 2007–2009. The primary outcomes were unplanned 30-day readmission rate, timing of readmission, and readmission diagnoses. Our findings show that the readmission rate among patients aged 18–64 years exceeded the readmission rate in patients aged ≥65 years in the HF cohort (23.4% vs. 22.0%, p<0.001), but was lower in the AMI (11.2% vs. 17.5%, p<0.001) and pneumonia (14.4% vs. 17.3%, p<0.001) cohorts. When adjusted for sex, race, comorbidities, and payer status, the 30-day readmission risk in patients aged 18–64 years was similar to patients ≥65 years in the HF (HR 0.99; 95%CI 0.97–1.02) and pneumonia (HR 0.97; 95%CI 0.94–1.01) cohorts and was marginally lower in the AMI cohort (HR 0.92; 95%CI 0.87–0.96). For all cohorts, the timing of readmission was similar; readmission risks were highest between days 2 and 5 and declined thereafter across all age groups. Diagnoses other than the index admission diagnosis accounted for a substantial proportion of readmissions among age groups <65 years; a non-cardiac diagnosis represented 39–44% of readmissions in the HF cohort and 37–45% of readmissions in the AMI cohort, while a non-pulmonary diagnosis represented 61–64% of patients in the pneumonia cohort.
When adjusted for differences in patient characteristics, young and middle-aged adults have 30-day readmission rates that are similar to elderly patients for HF, AMI, and pneumonia. A generalized risk after hospitalization is present regardless of age.
Please see later in the article for the Editors' Summary
Editors' Summary
Many elderly people who are admitted to hospital, successfully treated, and discharged are readmitted soon after, often for an unrelated illness. In the US, for example, nearly a fifth of Medicare beneficiaries are readmitted to hospital within 30 days of discharge (Medicare is a national insurance program that primarily pays for health care services for Americans aged 65 and older). Experts have recently coined the term "post-hospital syndrome" for the transient period of increased susceptibility to a range of adverse health events that elderly patients seem to experience and have suggested that exposure to stress during hospital stays may underlie the syndrome. For example, hospital patients frequently have their sleep disrupted because of hospital routines, they are often in pain, they may have insufficient food intake (sometimes because they are waiting for an operation), and they may lose physical conditioning because they are confined to bed. These and other stressors can reduce individuals' natural reserves and increase their vulnerability to a range of illnesses and conditions.
Why Was This Study Done?
Although stress is one possible determinant of the post-hospital syndrome, the underlying causes and patterns of hospital readmission are generally poorly understood. In particular, it is not known whether the post-hospital syndrome affects young and middle-aged patients as well as elderly patients. Importantly, a better understanding of the post-hospital syndrome is needed before effective strategies to reduce hospital readmissions can be developed. In this retrospective observational cohort study, the researchers compare readmission rates, timing, and diagnoses after hospitalization for heart failure (HF), acute myocardial infarction (AMI; heart attack), and pneumonia among patients aged 18–64 years living in California with readmission rates, timing, and diagnoses among patients aged 65 years or older hospitalized for the same conditions. A retrospective observational cohort study analyzes data that has been already been collected for a group (cohort) of people. Readmission is common among people of all ages who are admitted to hospital for HF, AMI, and pneumonia, and readmissions after hospitalization for these conditions among elderly Medicare patients are used in the US as a measure of hospital quality; hospitals with high readmission rates are subject to a Medicare reimbursement penalty.
What Did the Researchers Do and Find?
The researchers used the Healthcare Cost and Utilization Project inpatient dataset for California to identify all the hospitalizations for HF, AMI, and pneumonia in California in 2007–2009 and to obtain data on the 30-day unplanned rehospitalization rate, timing of readmission, and readmission diagnoses for the identified patients (more than half a million patients). Nearly 30% of all hospital readmissions after hospitalization for HF, AMI, and pneumonia in California occurred among patients aged 18–64. After hospitalization for AMI, pneumonia, and HF, 11.2%, 14.4%, and 23.4%, respectively, of young and middle-aged patients were readmitted. Notably, the 30-day readmission rate among patients aged 18–64 admitted for HF exceeded the readmission rate among elderly patients admitted for the same condition. After allowing for other factors likely to affect the risk of readmission such as other illnesses, the 30-day readmission risk in patients aged 18–64 was similar to that in patients aged 65 years or older admitted for HF and pneumonia and only marginally lower among patients admitted for AMI. Finally, the timing of readmission was similar in both age groups and diagnoses other than the index admission diagnosis accounted for a substantial proportion of readmissions in both age groups.
What Do These Findings Mean?
This study shows that after adjusting for differences in patient characteristics, the 30-day hospital readmission rates among young and middle-aged patients after hospitalization for HF, AMI, and pneumonia were similar to those among elderly patients. Moreover, the timing of readmission and the reasons for readmission among young and middle-aged patients were similar to those among elderly patients. These findings may not apply to other US states or to other countries and may not reflect the pattern of hospital readmissions following conditions other than HF, AMI, and pneumonia. Nevertheless, these findings suggest that the post-hospital syndrome affects young and middle-aged as well as elderly patients. Hospital readmission should therefore be considered as a potential problem for people of all ages and broad-based, multidisciplinary strategies that target patients of all ages should be developed to mitigate the risk of hospital readmissions.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001737.
The Institute for Healthcare Improvement provides information about reducing avoidable hospital readmissions
Information about the US Centers for Medicare & Medicaid Services readmissions reduction program is available
An article written by one of the study authors about the post-hospital syndrome is available
Related Articles
Use of secondary prevention pharmacotherapy after first myocardial infarction in patients with diabetes mellitus
Jørgensen, Casper H
Gislason, Gunnar H
Ahlehoff, Ole
Andersson, Charlotte
Torp-Pedersen, Christian
Hansen, Peter R
BMC Cardiovascular Disorders
Despite recommended pharmacotherapies the use of secondary prevention therapy after myocardial infarction (MI) remains suboptimal. Patients with diabetes mellitus (DM) have worse prognosis after MI compared to patients without DM and aggressive secondary prevention pharmacotherapy in this population is therefore warranted. We examined the changes in use of evidence-based secondary prevention pharmacotherapy in patients with and without DM discharged after first MI.
All patients aged 30 years or older admitted with first MI in Denmark during 1997–2006 were identified by individual-level linkage of nationwide registries of hospitalizations. Univariate and multivariate logistic regression models were used to identify patient characteristics associated with initiation of acetylsalicylic acid, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, β-blockers, and clopidogrel within 90 days, and statins within 180 days of discharge, respectively.
A total of 78,230 patients were included, the mean age was 68.3 years (SD 13.0), 63.5% were men and 9,797 (12.5%) had diabetes. Comparison of claimed prescriptions in the period 1997–2002 and 2003–2006 showed significant (p < 0.001) increases in claims for acetylsalicylic acid (38.9% vs. 69.7%), angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (38.7% vs. 50.4%), β-blockers (69.2% vs. 77.9%), clopidogrel (16.7% vs. 66.3%), and statins (41.3% vs. 77.3%). During 2003–2006, patients with DM claimed significantly less acetylsalicylic acid (odds ratio [OR] 0.81 [95% confidence interval [CI] 0.74–0.88) and clopidogrel (OR 0.91 [95% CI 0.83–1.00]) than patients without DM.
Despite sizeable increase in use of evidence-based secondary prevention pharmacotherapy after MI from 1997 to 2006, these drugs are not used in a substantial proportion of subjects and patients with DM received significantly less antiplatelet therapy than patients without DM. Increased focus on initiation of secondary prevention pharmacotherapy after MI is warranted, especially in patients with DM.
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An assessment of composite measures of hospital performance and associated mortality for patients with acute myocardial infarction. Analysis of individual hospital performance and outcome for the National Institute for Cardiovascular Outcomes Research (NICOR)
Simms, Alexander D
Baxter, Paul D
Cattle, Brian A
Batin, Phillip D
Wilson, John I
West, Robert M
Hall, Alistair S
Weston, Clive F
Deanfield, John E
Fox, Keith A
Gale, Chris P
European Heart Journal. Acute Cardiovascular Care
To investigate whether a hospital-specific opportunity-based composite score (OBCS) was associated with mortality in 136,392 patients with acute myocardial infarction (AMI) using data from the Myocardial Ischaemia National Audit Project (MINAP) 2008–2009.
Methods and results:
For 199 hospitals a multidimensional hospital OBCS was calculated on the number of times that aspirin, thienopyridine, angiotensin-converting enzyme inhibitor (ACEi), statin, β-blocker, and referral for cardiac rehabilitation was given to individual patients, divided by the overall number of opportunities that hospitals had to give that care. OBCS and its six components were compared using funnel plots. Associations between OBCS performance and 30-day and 6-month all-cause mortality were quantified using mixed-effects regression analysis. Median hospital OBCS was 95.3% (range 75.8–100%). By OBCS, 24.1% of hospitals were below funnel plot 99.8% CI, compared to aspirin (11.1%), thienopyridine (15.1%), β-blockers (14.7%), ACEi (19.1%), statins (12.1%), and cardiac rehabilitation (17.6%) on discharge. Mortality (95% CI) decreased with increasing hospital OBCS quartile at 30 days [Q1, 2.25% (2.07–2.43%) vs. Q4, 1.40% (1.25–1.56%)] and 6 months [Q1, 7.93% (7.61–8.25%) vs. Q4, 5.53% (5.22–5.83%)]. Hospital OBCS quartile was inversely associated with adjusted 30-day and 6-month mortality [OR (95% CI), 0.87 (0.80–0.94) and 0.92 (0.88–0.96), respectively] and persisted after adjustment for coronary artery catheterization [0.89 (0.82–0.96) and 0.95 (0.91–0.98), respectively].
Multidimensional hospital OBCS in AMI survivors are high, discriminate hospital performance more readily than single performance indicators, and significantly inversely predict early and longer-term mortality.
Acute myocardial infarction; composite performance indicators; mortality; performance; quality of care
Related Articles
Mortality Trends in Patients Hospitalized with the Initial Acute Myocardial Infarction in a Middle Eastern Country over 20 Years
Ahmed, Emad
Al Suwaidi, Jassim
El-Menyar, Ayman
AlBinali, Hajar A. H.
Singh, Rajvir
Gehani, A. A.
Cardiology Research and Practice
We aimed to define the temporal trend in the initial Acute Myocardial Infarction (AMI) management and outcome during the last two decades in a Middle Eastern country. A total of 10,915 patients were admitted with initial AMI with mean age of 53 ± 11.8 years. Comparing the two decades (1991–2000) to (2001–2010), the use of antiplatelet drugs increased from 84% to 95%, β-blockers increased from 38% to 56%, and angiotensin converting enzyme inhibitors (ACEI) increased from 12% to 36% (P < 0.001 for all). The rates of PCI increased from 2.5% to 14.6% and thrombolytic therapy decreased from 71% to 65% (P < 0.001 for all). While the rate of hospitalization with Initial MI increased from 34% to 66%, and the average length of hospital stay decreased from 6.4 ± 3 to 4.6 ± 3, all hospital outcomes parameters improved significantly including a 39% reduction in in-hospital Mortality. Multivariate logistic regression analysis showed that higher utilization of antiplatelet drugs, β-blockers, and ACEI were the main contributors to better hospital outcomes. Over the study period, there was a significant increase in the hospitalization rate in patients presenting with initial AMI. Evidence-based medical therapies appear to be associated with a substantial improvement in outcome and in-hospital mortality.
Related Articles
Angiotensin receptor blocker in patients with ST segment elevation myocardial infarction with preserved left ventricular systolic function: prospective cohort study
Yang, Jeong Hoon
Hahn, Joo-Yong
Song, Young Bin
Choi, Seung-Hyuk
Choi, Jin-Ho
Lee, Sang Hoon
Jeong, Myung-Ho
Choi, Dong-Joo
Park, Jong Seon
Park, Hun Sik
Gwon, Hyeon-Cheol
BMJ : British Medical Journal
Objective To investigate the association between treatment with an angiotensin receptor blocker and clinical outcomes in patients with ST segment elevation myocardial infarction with preserved left ventricular systolic function.
Design A prospective cohort study using data from a nationwide large scale registry.
Setting 53 hospitals involved in treatment of acute myocardial infarction in Korea.
Participants Between November 2005 and September 2010, we studied 6698 patients with ST segment elevation myocardial infarction who underwent primary percutaneous coronary intervention and had a left ventricular ejection fraction ≥40%.
Main outcome measures Cardiac death or myocardial infarction. Patients were divided into an angiotensin receptor blocker group (n=1185), an angiotensin converting enzyme (ACE) inhibitor group (n=4564), and a group who did not receive any renin angiotensin system blocker (n=949). Propensity score matching analysis was also performed.
Results Cardiac death or myocardial infarction occurred in 21 patients (1.8%) in the angiotensin receptor blocker group, 77 patients (1.7%) in the ACE inhibitor group, and 33 patients (3.5%) in the no renin angiotensin system blocker group. After propensity score matching (1175 pairs), there was no significant difference in the rate of cardiac death or myocardial infarction between the angiotensin receptor blocker group and ACE inhibitor group (21 (1.8%) v 23 (2.0%), adjusted hazard ratio 0.65, 95% confidence interval 0.30 to 1.38; P=0.65). The angiotensin receptor blocker group had a lower rate of cardiac death or myocardial infarction than the no renin angiotensin system blocker group in matched populations (803 pairs) (14 (1.7%) v 25 (3.1%), 0.35, 0.14 to 0.90; P=0.03).
Conclusion Angiotensin receptor blocker showed beneficial effects comparable with ACE inhibitors in patients with ST segment elevation myocardial infarction with preserved left ventricular systolic function. Angiotensin receptor blockers could be used as an alternative to ACE inhibitors in such patients.
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BANDAR SERI BEGAWAN, Brunei, Oct. 8 (Yonhap) -- South Korean President Park Geun-hye spoke briefly with Japanese Prime Minister Shinzo Abe, the second time the two leaders have held such an encounter amid frayed relations between their countries.
The dialogue took place when Park and Abe attended a gala dinner Monday, along with other Pacific Rim leaders after the opening session of the Asia-Pacific Economic Cooperation summit in Indonesia's resort island of Bali, an aide to Park said Tuesday.
The official declined to provide any specifics.
It was the second time the two leaders have held such an encounter. Last month, they held a similar meeting when they attended a summit of the Group of 20 major economies in Russia's second-largest city of Saint Petersburg.
Park has shunned a formal summit with Abe as relations between Seoul and Tokyo have remained strained due to Japan's repeated claims to South Korea's easternmost islets of Dokdo and its unrepentant attitude toward its sexual enslavement of Korean women during World War II.
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I installed Sundance theme by automatic and I have latest version of jwplayer installed and with blissful theme my videos embed and works great, but when I activate sundance theme all of my videos disappear and I get a blank space where player needs to go. I also changed the post format to video. And same result no video embeds
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Entries tagged with 'Wedding'
Christian White '01
Christian White '01 and Karly Mangen were married on 06/11/2016, in Chisago Lakes, MN.
Nikolas Georgacarakos '06
Allison Stocco '06 and Nikolas Georgacarakos '06, 06/18/2016, Saint Peter, MN Alli and I were married at Christ Chapel on June 18th! Alli and I both grew up on the Gustavus campus in the '80s and '90s before becoming full-time Gusties in AY 2002-2003. We went to elementary and high school together in St. Peter, […]
Sonya (Hysing) Pickett '07
Wedding, David Pickett and Sonya Hysing '07, 11/07/2015, Saint Paul, MN.
Annie (Kleinschmidt) Martin '11
Wedding, Matthew Martin '12 and Annie Kleinschmidt '11, 10/02/2015, Stillwater, MN
Anna Morton Schild '13
Anna Morton Schild '13 is married to Colin Schild.
Cassondra Winters Tschumperlin '12
Kiel Tschumperlin '12 and Cassondra Winters '12 were married on December 19th 2015.
Laurie Iverson Hassenstab '83
Amy Hassenstab '11 married David Pedersen '12 on February 20th, 2016 in Minneapolis. In attendance at the wedding were fellow Gusties Nils Anderson '12, Erik Hassenstab '86, Kyle Hulbert '10, Marissa Augustin '10, Haley Carpenter '11, Jake Klem '12, Ron Lutes '83, Janine Norgaard, Greg Norgaard, Renee Beattie '83, Glenn Perkins '81, Mona Carson '83, Dave […]
Annie Berger Barlow '09
Annie Berger '09 and Justin Barlow '08 were married on April 23, 2016 at Lutheran Church of the Good Shepherd in Moorhead, MN. Annie is a Physician Assistant at Roger Maris Cancer Center in Fargo, ND and Justin is a Sourcing Specialist at Bobcat Company in West Fargo, ND.
Jessica Sussman '09
Jessica Sussman '09 recently married Brendan Cummins. Though the groom is not a Gustie alum, there were several guests from the class of 2008 and 2009, including three bridesmaids.
Katie Oelfke '12
Katie Oelfke '12 and Ethan Harstad were married 11/21/15.


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For us, the best part about this hotel was the art museum component. Because of that piece, it's easily a 5-star rating. Our room, however, left much to be desired. It was quite possibly the plainest room I'd ever stayed in. It was nice and comfortable, but it was startling in its staleness. This is a place to experience once, but I doubt we'll stay there again. The art museum piece is incredible, to be sure. The hotel part is just so-so. The red penguins crack me up.
- Official Description (provided by the hotel):
- 21C Museum Hotel Louisville is more than just a place to spend the night - it's a 91-room boutique hotel, contemporary art museum, award-winning restaurant and cultural civic center nestled in the heart of Museum Row in historic downtown Louisville. With over 5000 square feet of art-filled meeting and event space, 21c guests enjoy authentic Southern hospitality and accessible luxury while exploring the work of contemporary artists in America's only museum dedicated solely to art of the 21st Century. Whether you are visiting Bourbon Country, spending a day at Churchill Downs, or hosting a lavish Southern wedding, 21c is a modern epicenter for culture, activity and artistic expression. Applauded by Travel & Leisure Magazine as "one of the most ambitious unions of art and hospitality ever undertaken," and hailed by The New York Times as "an innovative concept with strong execution and prompt and enthusiastic service," come meet the infamous Red Penguins and discover how 21c Museum Hotel Louisville is redefining the art of hospitality. ... more less
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- Also Known As:
- 21c Museum Louisville
- Hotel 21c Museum


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Select Local Merchants
Cj Professional MoversRead MoreWhat services does your business offer and what makes your business stand out from the competition? Our willingness to go the extra mile in building a quality and satisfied customer clientele. We also offer services seven days a week What was the inspiration to start or run this business? The experience I had when our family relocated from another state What do you love most about your job? The interaction with customers fro' different walks of life What is the best reaction you've ever gotten from a customer? That we saved they're family the hassle and inconvience of spending a fortune on moving950 Marietta Street NorthwestAtlanta, GA US


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Celebrate all of the wonderful sights, scents and flavors of fall at the 12th Annual Fine Crafts Fall Festival, which takes place at Memorial Park — Main Street and Route 50 — in historic Mays Landing 10 a.m. to 5 p.m. Saturday, Sept. 28.
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Approved for 1.0 CLE credit hour
Approved for 1.0 CLE credit hour.
Erna K Loomis, Loomis Law Offices, LLC, Olathe
This presentation will provide an overview of the duties and responsibilities involved in representing children in Child in Need of Care and other Family Court matters as a Guardian ad litem.
For more information, please view the brochure.
7/22/2016Kansas Organizations Encouraged to Apply for a KBF IOLTA Grant
7/13/2016KCMBA to Host Award Reception
7/5/2016Electronic filing now in Kansas courts statewide
6/29/2016Kansas Supreme Court Rule Changes
7/27/20167/27/2016 Shamberg Memorial Series Morning Session
7/27/20167/27/2016 Shamberg Memorial Series Afternoon Session
7/29/2016Law Related Education Committee Meeting
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Personalize your space with must-have updates for relaxed indoor and outdoor living.
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Web has made the globe littler. What is occurring where? This is no more a troublesome undertaking to know. Here we will discuss top ten social networking websites of 2014. For any of us now and with the thought of long range interpersonal communication now it is more straightforward to stay associated with your companions. Notwithstanding it is not difficult to know where your companions are headed what they having in supper how particular their office was and how they feel about weekends.
Interpersonal interaction locales help you watch the present companions and stay in touch with the old ones. Some of these likewise help you make a social loop that helps you to get contacts to find an occupation. Life has ended up all the more simple and social while staying at home. It may astound you that not every informal communication site is the clone of the other.
There are destinations that have their own particular exceptional styles of imparting yourself to your companions and companions of companions. That could be statuses hash tags photographs or a workmanship piece made by you. Offering has barely ended up as simple as ABC. A fastidious day later at office or school and finishing every one of the one necessity is to unwind and offering is by one means or another unwinding. Here is a rundown of top ten social networking websites of which you may need to look at.
Ten Best Social Networking Websites
10. Friendster
The pionerr or the father of informal communication was Friendster. It is shocking that not whole lot individuals think about this informal community any more. It was made back in the year 2002. Nowadays the site has been overhauled and redone and is made a long range informal communication gaming site. Here you can play numerous amusements with your companions and have a fabulous time when you have a Facebook account then it might be simple for you to have a record at this site.
Tagged is an alternate long range interpersonal communication site. This site helps you join with your companions and play recreations and impart your scores. The site utilization WeGaming and Digsby informing requisition to keep you associated with your mates by means of talk and gaming how cool is that.
8. instagram
Instagram accompanies a remarkable thought of long range informal communication. It gives it a chance to clients imparts and tag their portraits to their companions loop. An alternate characteristic that this site has is that you can add computerized channels to your photographs and additionally you can impart them on your Facebook profile or tweet them.


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does anybody know her name? And where can I find her other movies?
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those are three lucky guys at the end of the vid :D
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