Objectives: The purpose of this research was to compare coronary obstruction between clinically similar African Americans(AA) and white persons undergoing coronary angiography. Background: African Americans have highe...Objectives: The purpose of this research was to compare coronary obstruction between clinically similar African Americans(AA) and white persons undergoing coronary angiography. Background: African Americans have higher rates of coronary death than whites, but are less likely to undergo coronary revascularization. Although differences in coronary anatomy do not explain racial difference in revascularization rates, several studies of clinically diverse persons undergoing coronary angiography have found less obstructive coronary disease in AA than clinically similar whites. Methods: We studied 52 AA and 259 white male veterans who had both a positive nuclear perfusion imaging study and coronary angiography within 90 days of that study in five Department of Veterans Affairs hospitals. We used chart review and patient interview to collect demographics, clinical characteristics, and coronary anatomy results. Before angiography, we asked physicians to estimate the likelihood of coronary obstruction. Results: The treating physicians’estimates of coronary disease likelihood were similar for AA(79.5%) and whites(83.0%); AA were less likely to have any coronary obstruction(63.5%vs. 76.5%, p=0.05) and had significantly less severe coronary disease(p=0.01) than whites. African Americans continued to be less likely to have coronary obstruction in analyses controlling for clinical features, including the physicians estimate of the likelihood of coronary obstruction. Conclusions: These results suggest that AA have less coronary obstruction than apparently clinically similar whites. Further studies are required to confirm our findings and better understand the paradox that AA are less likely to have obstructive coronary disease and more likely to suffer mortality from coronary disease.展开更多
This study examined the incremental cost-effectiveness of extending clopidogrel therapy from one month to one year after percutaneous coronary intervention(PCI) in an unselected, heterogeneous patient population. Clin...This study examined the incremental cost-effectiveness of extending clopidogrel therapy from one month to one year after percutaneous coronary intervention(PCI) in an unselected, heterogeneous patient population. Clinical trials suggest that prolonging clopidogrel therapy for up to one year after PCI reduces downstream cardiac events. However, clopidogrel therapy is costly and may increase bleeding risk. Using decision analysis, we compared the outcomes and cost of prolonging clopidogrel treatment from one month to one year after PCI with the alternative strategy of discontinuing therapy one month after the procedure. Event rates were based on 3,976 PCI patients who were treated between January 1999 and December 2001 at the Duke Medical Center and received no more than one month of clopidogrel after the procedure. Baseline characteristics and event rates were obtained from Duke clinical information systems. The effect of prolonged clopidogrel therapy on event rates was based on the Clopidogrel for the Reduction of Events During Observation(CREDO) trial per-protocol data. Unit costs and the effect of myocardial infarction(MI) on life expectancy were based on published sources. Extending clopidogrel therapy from one month to one year after PCI cost ＄879 per patient and reduced the risk of MI by 2.6%. Assuming MI decreases life expectancy by two years, prolonged therapy would cost ＄15,696 per year of life saved. Economic attractiveness of therapy varied with baseline risk, the effect of prolonged therapy on MI risk, and the price of clopidogrel. Prolonging clopidogrel therapy for one year after PCI is economically attractive, particularly in high-risk patients.展开更多
文摘Objectives: The purpose of this research was to compare coronary obstruction between clinically similar African Americans(AA) and white persons undergoing coronary angiography. Background: African Americans have higher rates of coronary death than whites, but are less likely to undergo coronary revascularization. Although differences in coronary anatomy do not explain racial difference in revascularization rates, several studies of clinically diverse persons undergoing coronary angiography have found less obstructive coronary disease in AA than clinically similar whites. Methods: We studied 52 AA and 259 white male veterans who had both a positive nuclear perfusion imaging study and coronary angiography within 90 days of that study in five Department of Veterans Affairs hospitals. We used chart review and patient interview to collect demographics, clinical characteristics, and coronary anatomy results. Before angiography, we asked physicians to estimate the likelihood of coronary obstruction. Results: The treating physicians’estimates of coronary disease likelihood were similar for AA(79.5%) and whites(83.0%); AA were less likely to have any coronary obstruction(63.5%vs. 76.5%, p=0.05) and had significantly less severe coronary disease(p=0.01) than whites. African Americans continued to be less likely to have coronary obstruction in analyses controlling for clinical features, including the physicians estimate of the likelihood of coronary obstruction. Conclusions: These results suggest that AA have less coronary obstruction than apparently clinically similar whites. Further studies are required to confirm our findings and better understand the paradox that AA are less likely to have obstructive coronary disease and more likely to suffer mortality from coronary disease.
文摘This study examined the incremental cost-effectiveness of extending clopidogrel therapy from one month to one year after percutaneous coronary intervention(PCI) in an unselected, heterogeneous patient population. Clinical trials suggest that prolonging clopidogrel therapy for up to one year after PCI reduces downstream cardiac events. However, clopidogrel therapy is costly and may increase bleeding risk. Using decision analysis, we compared the outcomes and cost of prolonging clopidogrel treatment from one month to one year after PCI with the alternative strategy of discontinuing therapy one month after the procedure. Event rates were based on 3,976 PCI patients who were treated between January 1999 and December 2001 at the Duke Medical Center and received no more than one month of clopidogrel after the procedure. Baseline characteristics and event rates were obtained from Duke clinical information systems. The effect of prolonged clopidogrel therapy on event rates was based on the Clopidogrel for the Reduction of Events During Observation(CREDO) trial per-protocol data. Unit costs and the effect of myocardial infarction(MI) on life expectancy were based on published sources. Extending clopidogrel therapy from one month to one year after PCI cost ＄879 per patient and reduced the risk of MI by 2.6%. Assuming MI decreases life expectancy by two years, prolonged therapy would cost ＄15,696 per year of life saved. Economic attractiveness of therapy varied with baseline risk, the effect of prolonged therapy on MI risk, and the price of clopidogrel. Prolonging clopidogrel therapy for one year after PCI is economically attractive, particularly in high-risk patients.
