Background and Purpose-Few data exist for large managed care populations on the occurrence of subsequent acute ischemic events in persons with established atherosclerotic vascular disease. We estimated the occurrence of secondary stroke, acute myocardial infarction (AMI), and vascular deaths among 2 large, managed care samples. Methods-With the use of International Classification of Diseases, Ninth Revision, Clinical Modification codes, patients aged Ն40 years and with stroke, AMI, or peripheral arterial disease (PAD) were identified from administrative data of UnitedHealthcare plans during 1995-1998. Stroke, AMI, and PAD cohorts were identified within a commercial insurance sample and a Medicare sample. Cumulative occurrences of subsequent stroke, AMI, or vascular death were estimated by survival analysis. Results-In the stroke commercial cohort (nϭ1631; mean age, 62.1 years), cumulative occurrence of subsequent events was 4.2%, 6.5%, 9.8%, and 11.8% at 0.5, 1, 2, and 3 years, respectively; cumulative secondary event occurrence in the AMI commercial cohort (nϭ6458; mean age, 56.0 years) was 3.5%, 4.8%, 7.3%, and 8.5% and in the PAD commercial cohort (nϭ5813; mean age, 59.2 years) was 1.5%, 2.8%, 4.8%, and 6.5%, respectively. Cumulative secondary event occurrences were even higher in stroke (nϭ1518; mean age, 79.5 years), AMI (nϭ2197; mean age, 76.2 years), and PAD (nϭ5033; mean age, 76.6 years) cohorts of the Medicare sample: 18.1%, 17.0%, and 8.7%, respectively, at 3 years. More than 75% of each stroke cohort's secondary events were strokes; more than 75% of each AMI cohort's secondary events were AMIs. Of the PAD cohorts' secondary events, 27% to 39% were strokes, 48% to 57% were AMIs, and 13% to 16% were vascular deaths. Conclusions-Among these managed care enrollees with existing atherosclerotic vascular disease, subsequent ischemic events represent a significant symptomatic disease burden. Given these findings, it is very important to determine whether secondary prevention strategies are being effectively used to manage patients with diagnosed atherosclerosis.

Among patients meeting criteria for the necessity of revascularization, those receiving a revascularization procedure within 1 year had lower mortality than those treated medically. These results support the validity of the RAND/UCLA criteria for detecting underuse of these procedures, but more research is needed to confirm the findings and to determine the validity of guidelines for other procedures.

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IntrodonPatientswith heart disease are at high risk for sudden death. Most of these events occur out of the hospital, in the individual's home.1-3 Thus, family members are an important target for public education efforts related to reducing the time of response to a sudden-death event. Unfortunately, few family members receive cardiopulmonary resuscitation (CPR) instruction.4 In fact, the majority of physicians and health educators are reticent to recommend CPR training for families of cardiac patients, citing fears that CPR training will be experienced as a heavy burden and that CPR may be performed inappropriately or ineffectively.5-9 The purpose of our study was to determine CPR training attitudes, practice patterns, and incidence of CPR use in CPR-trained family members of cardiac patients. MewdsFamily members (n = 337) of patients at risk for sudden cardiac death were enrolled as part of a multicenter clinical trial designed to determine the emotional consequences of different types of CPR training. Subjectswere selected from one of four hospital sites by the following criteria: (1) tention, a CPR self-study retention packet for home use was mailed to subjects 3 and 6 months after CPR training.11 Each packet consisted of the following: (1) a booklet outlining the steps in CPR and the components of properly performed CPR; (2) a poster illustrating the steps of CPR; (3) a paper pillow case with a torso imprinted on it that, when placed on a pillow, allows practice of hand placement for pulse check and cardiac compressions; and (4) guidelines for use of the packet.Of the 238 subjects who had leamed