Skip Navigation

This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (2)
Right arrowRequest Permissions
Google Scholar
Right arrow Articles by SCOTT, I. A.
Right arrow Articles by CLOUGH, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by SCOTT, I. A.
Right arrow Articles by CLOUGH, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?

International Journal for Quality in Health Care 15:155-161 (2003)
© 2003 International Society for Quality in Health Care

Paper

An Australian comparison of specialist care of acute myocardial infarction

IAN A. SCOTT1, KATE HEATH2,3, CATHERINE HARPER3 and ALEESA CLOUGH3

1Internal Medicine and Health Information Management Service, Princess Alexandra Hospital, Brisbane
2Health Information Management Service, Princess Alexandra Hospital, Brisbane
3Public Health Unit, West Moreton District Health Services, Goodna, Queensland, Australia

Objective. To determine whether patients hospitalized with acute myocardial infarction (AMI) in an Australian setting receive better pharmacological care if managed by cardiologists than by non-cardiologists.

Design. Retrospective chart review of patients hospitalized between 1 January 1997 and 30 June 1998, undertaken by abstractors blind to study objectives.

Setting. One tertiary and two community hospitals in south-east Queensland, Australia, in which all patients admitted with AMI were cared for by cardiologists and general physicians, respectively.

Study participants. Two cohorts of consecutive patients satisfying diagnostic criteria for AMI: 184 in the tertiary hospital and 207 in the community hospitals.

Main outcome measures. Frequency of use, in highly eligible patients, of thrombolysis, ß-blockers, aspirin, angiotensin-converting enzyme (ACE) inhibitors, lipid-lowering agents, nitrates, and calcium antagonists. Cohorts were compared for differences in prognostic factors or illness severity.

Results. In community hospital patients, there was greater use of thrombolysis [100% versus 83% in the tertiary hospital; difference 17%, 95% confidence interval (CI) 11–26%; P < 0.001] and of ACE inhibitors (84% versus 66%; difference 18%, 95% CI 3–34%; P = 0.02), and lower median length of stay (6.0 days versus 7.0 days; P = 0.001) compared with tertiary hospital patients. Frequency of use of other drugs, and adjusted rates of death and re-infarction were the same for both cohorts.

Conclusions. With respect to pharmacological management of patients hospitalized with AMI, cardiologists and general physicians appear to provide care of similar quality and achieve equivalent outcomes. Further studies are required to confirm the generalizability of these results to Australian practice as a whole.

Keywords: acute myocardial infarction, cardiologist, general physician, quality

Clinical trials have shown that the use of thrombolytic therapy [1], ß-blockers [2], aspirin [3], angiotensin-converting enzyme (ACE) inhibitors [4], and lipid-lowering agents [5] in the management of patients presenting with acute myocardial infarction (AMI) reduces mortality by up to 25%. In contrast, long-acting nitrates are of little benefit in the absence of recurrent ischaemia [6], and calcium antagonists can, in the presence of left ventricular dysfunction, be harmful [7]. Evidence-based guidelines detailing the appropriate use of such therapies exist and are readily accessible [8]. However, US studies suggest that cardiologists are more aware of, and are more likely to: (i) prescribe beneficial therapies compared with non-cardiologists [9,10]; (ii) discharge patients earlier; and (iii) achieve lower in-hospital mortality rates [11–14].

However, any differences in process and outcomes of care between cardiologists and non-cardiologists need to be adjusted for all significant confounders, particularly clinical features at presentation that predict treatment eligibility or poorer prognosis [15]. Variation in patient characteristics rather than quality of care may account for survival advantages conferred by cardiologist-directed care [16]. Moreover, the extent to which practice trends seen in the US mirror those in other countries is uncertain. In Australia, data from New South Wales (NSW) suggest few differences in drug treatment of AMI between cardiologists and general physicians, as evaluated by self-reported responses to a hypothetical case study, and by review of actual case records [17].

In the state of Queensland, where 3000 patients are hospitalized annually with AMI, ~60% of patients are admitted to community hospitals and are cared for by general physicians, the remainder receiving care from cardiologists in tertiary hospitals [18]. Recent analysis of national mortality data revealed an excess of deaths due to AMI in populations living outside capital city statistical divisions, raising concerns that management of AMI may be less optimal in community than in tertiary hospitals [19]. The primary aim of this study was to compare the care provided to patients with AMI by cardiologists in a tertiary hospital with that provided by general physicians in two community hospitals in south-east Queensland.

Methods

Setting
Princess Alexandra Hospital (PAH) is a 780-bed tertiary public hospital located in South Brisbane, serving a secondary referral population of 250 000. All patients admitted with AMI are assigned to one of five cardiologists who provide either exclusive care for the entire hospitalization (70% of patients) or for the majority of hospital stay, transferring care to general physicians for the last 1 or 2 days prior to discharge.

Ipswich General Hospital (IGH) is a 300-bed public hospital, and St Andrews Hospital (StAH) is a 120-bed private hospital, both located in Ipswich, a centre 30 km west of Brisbane which serves a population of 180 000 within the West Moreton Health District. Neither community hospital has full-time or visiting cardiologists. All specialist services for patients with AMI in both hospitals are provided by four general physicians who have no specialist training in cardiology. Patients requiring urgent invasive cardiac procedures are transferred to cardiology centres in Brisbane, with PAH receiving ~80% of these transfers.

All study hospitals have appropriately staffed and equipped emergency departments and coronary care units, and have equal access to pathology services, stress ECG testing, and transthoracic echocardiography. All study hospitals employ quality monitoring programs comprising active dissemination of clinical practice guidelines and protocols, case-based education sessions, and periodic mortality and utilization audits. During the study period, the tertiary hospital was not undertaking primary coronary angioplasty as reperfusion therapy. The study was exempt from research ethics committee review and informed consent requirements as it used chart reviews to evaluate adherence to accepted standards of care.

Study participants
Potential subjects were all consecutive patients hospitalized with a principal discharge diagnosis of AMI [International Classification of Diseases (ICD)-9-CM code 410] to PAH during the period 1 January to 31 December 1997, and to IGH/StAH during the period 1 July 1997 to 30 June 1998. The different study periods were mandated by availability of results of an internal audit of care of AMI patients admitted to PAH during the former period, and by availability of verified registry data for patients admitted to IGH/StAH during the latter period, for which case definition and eligibility criteria for specific treatments were the same as those used in the PAH audit. Subjects were excluded if they were not acute admissions admitted directly through the emergency department, i.e. were transferred to a study hospital from another site, or failed to satisfy two out of the three following diagnostic criteria for AMI: (i) acute chest pain >=20 min; (ii) rise in serial cardiac enzyme levels to more than twice the upper normal reference range; or (iii) new ECG changes of infarction (Q waves or evolutionary ST/T wave changes in contiguous ECG leads) or left bundle branch block (LBBB). Where patients had recurrent hospitalizations for AMI during the study period, the first admission only was studied.

Study design
Medical registrars (PAH) and trained nurse data managers (IGH/StAH) who were not involved in the care of study subjects and who were blind to study objectives retrospectively abstracted the following data from hospital charts on all confirmed cases of AMI: demographic details; past cardiac history and risk factors; presenting symptoms and vital signs; ECG findings; results of laboratory tests; eligibility criteria for specific treatments; data on administration of thrombolysis; in-hospital deaths and complications; discharge destination; and specified medications (see below) at discharge.

Standardized datasheets and operational definitions were used in data collection, with nurse data managers having had experience in cardiology practice. Data reliability was >85% ({kappa} statistic), based on reabstraction of 15% of records of both cohorts by physicians blind to study objectives with regard to presenting clinical features, ECG findings on presentation, and specified discharge medications. Agreement was excellent for case definition ({kappa} = 0.96) and very good for ECG findings ({kappa} = 0.81) and discharge medications ({kappa} = 0.86).

Outcome measures
Primary endpoints were differences between cardiologist and non-cardiologist patient cohorts in the proportions of patients who received thrombolysis and received this treatment within 1 h of hospital presentation, and who were prescribed ß-blockers, aspirin, ACE inhibitors, lipid-lowering agents, calcium antagonists, and nitrates at discharge. A subset of patients defined as ‘ideal’ candidates on the basis of specific treatment eligibility criteria (defined in the Appendix and based on published clinical practice guidelines available as of mid-1997 [8]) were analysed separately for all treatments, except for nitrates and calcium antagonists.

Secondary endpoints were differences between cohorts in: (i) in-hospital mortality rates; (ii) in-hospital rates of post-infarct angina, reinfarction, new onset heart failure, and cardiogenic shock; and (iii) median length of hospital stay.

Statistical analysis
Patient characteristics and outcome variables were evaluated by type of physician using chi-square tests for categorical variables, and Student’s t-test and Wilcoxon rank sum test for normal and non-normal continuous variables, respectively. Outcome differences were analysed by logistic regression analysis. Two-tailed P-values <0.05 were denoted as statistically significant.

As the primary endpoint was differences in process of care, a minimum number of 160 patients in each cohort provided 80% power at a significance level of 5% to detect absolute differences of >15% in the proportions of subjects receiving specific treatments for which the minimum utilization rate in both cohorts was expected to be at least 40%. Such differences were regarded as clinically important.

Between-physician variation within physician groups with regards to patient characteristics, rates of all-patient drug use, and clinical outcome were assessed using one-way ANOVA and Kruskal-Wallis tests as appropriate.

Results

Baseline characteristics
Data were obtained on 391 consecutive eligible subjects (184 tertiary and 207 community). Baseline patient characteristics recorded at time of admission are listed in Table 1. Significant differences related to pulse rate on admission only {higher pulse rates in the community group [85 beats per minute (bpm) versus 79 bpm; P = 0.02]}. There was a non-significant trend to more males in the community group (75% versus 66%; P = 0.06).


View this table:
[in this window]
[in a new window]
  		Table 1 Patient characteristics at presentation

 

Process of care
Table 2 compares the proportions of all patients, and of ‘ideal’ patients, who received specified treatments in both cohorts during index admission. More community patients who were eligible for lysis received this treatment compared with tertiary patients [100% versus 83%; difference 17%, 95% confidence interval (CI) 11–26%; P < 0.001]. Fourteen of 76 (18%) community patients receiving lysis did not meet eligibility criteria compared with none in the tertiary group. The proportions of all patients receiving ß-blockers, aspirin, ACE inhibitors, lipid-lowering agents, and calcium antagonists were not significantly different between cohorts. However, the proportion of ‘ideal’ patients receiving ACE inhibitors was higher in the community group (84% versus 66%; difference 18%, 95% CI 3–34%; P = 0.02), as was the proportion of all patients receiving nitrates (68% versus 49%; difference 19%, 95% CI 8–29%; P < 0.001).


View this table:
[in this window]
[in a new window]
  		Table 2 Comparison of treatment measures

 

Outcome measures
No differences were seen between groups with respect to in-hospital mortality or complication rates (see Table 3), both unadjusted and adjusted according to differences in pulse rate on admission. Length of hospital stay was less in community hospitals by ~1 day compared with the tertiary hospital (median stay 6.0 and 7.0 days, respectively; P = 0.001).


View this table:
[in this window]
[in a new window]
  		Table 3 Comparison of outcome measures

 

No significant between-physician variance was seen within either patient cohort in terms of patient characteristics, rates of drug use, or clinical outcomes.

Discussion

Rigorous determination of whether cardiologists manage AMI better than non-cardiologists and achieve better outcomes requires a randomized trial. However, ethical and feasibility considerations will probably prevent such a trial from being performed, thus leaving observational studies as the only alternative means of evaluation. To date, such studies have experienced difficulties in adjusting results for all possible confounders, such as differences in: (i) patient risk factors and illness severity; (ii) hospital characteristics; and (iii) case definition and eligibility criteria for specific interventions.

The present study goes some way to overcoming these limitations in that both cohorts were similar in terms of baseline clinical characteristics and risk predictors (except for statistically significant but clinically minor differences in admission pulse rate), numbers of patients managed by either type of physician, and the availability of emergency/coronary care and non-invasive ancillary services within all sites. General physicians were not limited by geographic barriers or lack of availability of tertiary beds in referring high-risk patients who they considered warranted cardiologist-mediated care. Multiple measures of process and outcome of care were applied to both groups.

With respects to pharmacological management of AMI, general physicians in this study provide care equivalent to that of cardiologists, with the exception of overuse of thrombolysis and nitrates. In-hospital mortality and complication rates were identical. The longer hospital stay for tertiary patients may relate to procedural interventions such as coronary angiography undertaken during the index admission.

Comparison with other studies
In comparing the present study with data relating to inter-speciality differences in AMI care reported from NSW [17], general physicians in Queensland prescribed ß-blockers to more of their patients than did their NSW counterparts (69% versus 58%; P = 0.03), while the reverse was true for use of nitrates (56% versus 90%; P < 0.001). In the present study there was less than optimal use of lipid-lowering agents, and in both this and the NSW study there was less than optimal use of ACE inhibitors, similar to findings reported by others [20,21]. In contrast, the use of thrombolysis, ß-blockers, and aspirin was near-ideal for both cardiologists and non-cardiologists in both studies, which is in stark contrast to the substantial underuse of these drugs noted in US registry data [22–24].

Comparing AMI care in the current study with that reported from other Australasian centres, the proportion of community hospital patients receiving thrombolysis within 1 h of presentation to hospital (62%) was similar to the figure of 63% reported in a 1996 audit of AMI care at the Alfred Hospital in Melbourne [25]. The utilization in eligible patients of lysis (100%), ß-blockers (85%) and ACE inhibitors (74%) was considerably better than that seen in an audit of 1081 patients admitted to coronary care units in Auckland in 1993, for which respective figures were 54%, 40% and 21% [26].

Study limitations
This study has several limitations. First, there was insufficient power to detect small but important differences in mortality and other infrequent clinical events between cohorts.

Secondly, general physicians may have consulted cardiologists for advice during the episode of care, thus introducing ‘contamination bias’ when evaluating general physician performance. However, clinical guidelines and protocols were developed and enacted independently of the tertiary hospital, and process measures were calculated for patients who were not transferred, i.e. remained under the exclusive control of general physicians. Moreover, if contamination effects were present, consultative liaison between general physicians and cardiologists may be as effective for improving quality of care of AMI as exclusive cardiologist-mediated care [27].

Thirdly, eligibility criteria used in defining ‘ideal’ patients may be regarded as too stringent given the increasing evidence arguing for more liberal use of ß-blockers [28], ACE inhibitors [29], and lipid-lowering agents [30] in AMI. This is acknowledged but we thought it more fair to assess clinical performance in 1997/98 against the standards that applied then (c. 1996 guidelines) rather than those that apply today.

Fourthly, no data were collected on post-hospital outcomes or quality of life, or on the use of investigations or invasive procedures, which may have differed between groups; this deserves further study.

Finally, our results reflect the practice of a relatively small number of physicians situated in three hospitals at two geographic sites, and thus have limited generalizability. However, the concordance between our results and those of the more representative NSW study [17] offers some indication that no systematic differences in practice exist between Australian cardiologists and general physicians with respect to similar types of patients with AMI.

Conclusion

The prime aim of this study was to investigate whether, all things being equal in regards to access to ancillary services and use of quality improvement strategies, the quality of pharmacological care provided by cardiologists or general physicians to patients with AMI in the role of primary provider is the same in an Australian regional setting. Our results suggest that it is, which, if proven to be generalizable, have implications for policy makers considering issues of patient referral to metropolitan hospitals and distribution of the specialist workforce in meeting the needs of Australians living at some distance from major tertiary centres.

Appendix: eligibility criteria for specific treatments

1. Thrombolysis
Inclusion criteria. All acute myocardial infarction (AMI) patients who present with chest pain >20 min and either electrocardiographic changes of ST segment elevation in two or more contiguous chest leads or new left bundle branch block.

Exclusion criteria. Late presentation (>12 h after symptom onset), recent transient ischaemic attack/cerebrovascular accident, recent trauma or cardiopulmonary resuscitation, coagulopathy or concurrent warfarin therapy, active peptic ulcer disease.

2. ß-blockers
Inclusion criteria. All AMI patients discharged alive and not transferred.

Exclusion criteria. Cardiogenic shock, past or current heart failure, asthma or chronic obstructive lung disease, bradyarrhythmia requiring pacing.

3. Aspirin
Inclusion criteria. All AMI patients discharged alive and not transferred.

Exclusion criteria. Active gastrointestinal bleeding in hospital or concurrent warfarin therapy.

4. Angiotensin-converting enzyme inhibitors
Inclusion criteria. All AMI patients discharged alive and not transferred who have past history or current clinical features of heart failure or have had an anterior infarction.

Exclusion criteria. Nil.

5. Lipid-lowering agents
Inclusion criteria. All AMI patients discharged alive and not transferred whose random total serum cholesterol level on admission was >=5.5 mmol/l.

Exclusion criteria. Nil.

We thank the medical registrars, nurses, and physicians who assisted in this study, and the Health Information Centre of Queensland Health for providing data and funding research assistants.

Address reprint requests to Dr Ian A. Scott, Director of Internal Medicine, Level 5, B core, Medical Specialties, Princess Alexandra Hospital, Ipswich Road, Brisbane 4102, Australia. E-mail: ian_scott{at}health.qld.gov.au Back

Accepted for publication December 13, 2002.

References

  1. Fibrinolytic Therapy Trialists’ (FTT) Collaborative Group. Indications for fibrinolytic therapy in suspefcted acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patients. Lancet 1994; 343: 311–322.[CrossRef][Web of Science][Medline]

  2. First International Study of Infarct Survival Collaborative Group. Randomised trial of intravenous atenolol among 16,027 cases of suspected acute myocardial infarction: ISIS-1. Lancet 1986; 2: 57–66.[CrossRef][Medline]

  3. ISIS-2 (Second International Study of Infarct Survival) Collaborative Group. Randomised trial of intravenous streptokinase, oral aspirin, both, or neither among 17 187 cases of acute myocardial infarction: ISIS-2. Lancet 1988; 2: 349–360.[Medline]

  4. Latini R, Maggioni AP, Flather M, Sleight P, Togoni G. ACE inhibitor use in patients with myocardial infarction: summary of evidence from clinical trials. Circulation 1995; 92: 3132–3137.[Free Full Text]

  5. Scandinavian Simvastatin Survival Study Group. Randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the Scandinavian Simvastatin Survival Study (4S). Lancet 1994; 344:1383–1389.[CrossRef][Web of Science][Medline]

  6. Collins R, Peto R, Flather M et al. ISIS-4: A randomised factorial trial assessing early oral captopril, oral mononitrate, and intravenous magnesium sulphate in 58050 patients with suspected acute myocardial infarction. Lancet 1995; 345: 669–685.[CrossRef][Web of Science][Medline]

  7. Held PH, Yusuf S. Calcium antagonists in the treatment of ischemic heart disease: myocardial infarction. Cor Art Dis 1994; 5: 21–26.

  8. Ryan TJ, Anderson JL, Antman EM et al. ACC/AHA guidelines for the management of patients with acute myocardial infarction: a report of the American College of Cardiology/American Heart Association Taskforce on Practice Guidelines (Committee on Management of Acute Myocardial Infarction). J Am Coll Cardiol 1996; 28: 1328–1428.[CrossRef][Web of Science][Medline]

  9. Hlatky MA, Cotugno HE, Mark DB et al. Trends in physician management of uncomplicated acute myocardial infarction, 1970 to 1987. Am J Cardiol 1988; 61: 515–518.[CrossRef][Web of Science][Medline]

  10. Ayanian JZ, Hauptman PJ, Guadagnoli E et al. Knowledge and practices of generalists and specialist physicians regarding drug therapy for acute myocardial infarction. N Engl J Med 1994; 331: 1136–1142.[Abstract/Free Full Text]

  11. Jollis JG, DeLong ER, Peterson ED et al. Outcome of acute myocardial infarction according to the specialty of the admitting physician. N Engl J Med 1996; 335: 1880–1887.[Abstract/Free Full Text]

  12. Ayanian JZ, Guadagnoli E, McNeil BJ, Cleary PD. Treatment and outcomes of acute myocardial infarction among patients of cardiologists and generalist physicians. Arch Intern Med 1997; 157: 2570–2576.[Abstract/Free Full Text]

  13. Nash IS, Nash DB, Fuster V. Do cardiologists do it better? J Am Coll Cardiol 1997; 29: 475–478.[Abstract]

  14. Casale PN, Jones JL, Wolf FE, Pei Y, Eby LM. Patients treated by cardiologists have a lower in-hospital mortality for acute myocardial infarction. J Am Coll Cardiol 1998; 32: 885–889.[Abstract/Free Full Text]

  15. Lee KL, Woodlief LH, Topol EJ et al. for the GUSTO-1 Investigators. Predictors of 30-day mortality in the era of reperfusion for acute myocardial infarction. Results from an international trial of 41,021 patients. Circulation 1995; 91: 1659–1668.[Abstract/Free Full Text]

  16. Frances CD, Go AS, Dauterman KW et al. Outcome following acute myocardial infarction. Are differences among physician specialties the result of quality of care or casemix? Arch Intern Med 1999; 159: 1429–1436.[Abstract/Free Full Text]

  17. Lim LL, Heller RF, O’Connell RL, D’Este K. Stated and actual management of acute myocardial infarction among different specialties. Med J Aust 2000; 172: 208–212.[Web of Science][Medline]

  18. Queensland Health Information Centre. Profile of management of acute myocardial infarction in Queensland hospitals. Queensland Hospital Admitted Patients Data Collection (QHAPDC), July 1999.

  19. Sexton PT, Sexton TH. Excess coronary mortality among Australian men and women living outside the capital city statistical divisions. Med J Aust 2000; 172: 370–374.[Web of Science][Medline]

  20. Philbin EF, Andreou C, Rocco TA, Lynch LJ, Baker SL. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996; 77: 832–838.[CrossRef][Web of Science][Medline]

  21. Aronow WS. Underutilisation of lipid-lowering drugs in older persons with prior myocardial infarction and a serum low-density lipoprotein cholesterol >125 mg/dl. Am J Cardiol 1998; 82: 668–669.[CrossRef][Web of Science][Medline]

  22. Krumholz HM, Murillo JE, Chen J et al. Thrombolytic therapy for eligible patients with acute myocardial infarction. JAMA 1997; 277: 1683–1688.[Abstract/Free Full Text]

  23. Soumerai SB, McLaughlin TJ, Spiegelman D et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997; 277: 115–121.[Abstract/Free Full Text]

  24. Krumholz HM, Radford MJ, Ellerbeck EF et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med 1996; 124: 292–298.[Abstract/Free Full Text]

  25. Szto GY, Federman J, Pitt A. Alfred Hospital Coronary Care Unit: an acute myocardial infarction quality assurance study. J Qual Clin Pract 1996; 16: 49–60.[Medline]

  26. French J, Williams B, Hart H et al. Management of acute myocardial infarction in Auckland. N Z Med J 1996; 109: 248–251.[Web of Science][Medline]

  27. Willison DJ, Soumerai SB, McLaughlin TJ et al. Consultation between cardiologists and generalists in the management of acute myocardial infarction. Implications for quality of care. Arch Intern Med 1998; 158: 1778–1783.[Abstract/Free Full Text]

  28. Gottlieb SS, McCarter RJ, Vogel RA. Effect of beta-blockade on mortality among high-risk and low-risk patients after myocardial infarction. N Engl J Med 1998; 339: 489–497.[Abstract/Free Full Text]

  29. HOPE Study Investigators. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. N Engl J Med 2000; 342: 145–153.[Abstract/Free Full Text]

  30. The Long-term Intervention with Pravastatin in Ischaemic Disease (LIPID) Study Group. Prevention of cardiovascular events and death with pravastatin in patients with coronary heart disease and a broad range of initial cholesterol levels. N Engl J Med 1998; 339: 1349–1357.[Abstract/Free Full Text]


Add to CiteULike CiteULike   Add to Connotea Connotea   Add to Del.icio.us Del.icio.us    What's this?



This Article
Right arrow Abstract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Archive
Right arrow Download to citation manager
Right arrow Search for citing articles in:
ISI Web of Science (2)
Right arrowRequest Permissions
Google Scholar
Right arrow Articles by SCOTT, I. A.
Right arrow Articles by CLOUGH, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by SCOTT, I. A.
Right arrow Articles by CLOUGH, A.
Social Bookmarking
Add to CiteULike   Add to Connotea   Add to Del.icio.us  
What's this?