Characteristics of Black Patients Admitted to Coronary Care Units in Metropolitan Seattle: Results from the Myocardial Infarction Triage

and Intervention Registry (MITI)* Charles Maynard, PhD, Paul E. Litwin, MS, Jenny S. Martin, RN, Manuel Cerqueira, MD,

Peter J. Kudenchuk, MD, Mary T. Ho, MD, J. Ward Kennedy, MD, Leonard A. Cobb, MD, Sharon M. Schaeffer, BA, Alfred P. Hallstrom, PhD, and W. Douglas Weaver, MD

since 1966,641 black and 11,892 white patients with chest pain of presumed cardiac origin have been admitted to coronarycareunitsin lShospi- tais in meWqMtan Seattle. Black men and women wereyounger(66vs66,p <O.OOO1),moreoften admitted to central city hospitals (p <O.OOOl), and developed evidence of acute myocardial infarction (AM) less often (19 VI 2396, p = 0.01). in the sub- set of 2,670 AMI patients, blacks (n = 121) were younger (59 VI 67, p <0.0001) and had less prior coronary artery bypass graft surgery (2 vs lo%, p = 0.008) and more prior hypertension (67 vs 46%, p <O.OOOl). During hospitaiixation, whites (n = 2,749) had higher rates of -0-y angioplasty (18 vs lo%, p = 0.03) and coronary artery bypass graft surgery (10 vs 4%, p = O&4), atthough thrombolytic therapy and cardiac catheterization were used equally in the 2 groups. Hospital mortai- ity was 74% for black and 13.1% for white pa- tients (p = 0.07). However, after adjustment for key demographic and clinical variaMes by logistic regression, this difference was not as apparent (p = 0.36).

Questkms about the premature onset of coro- nary artery disease, excess systemic hypertension, and the differenM use of interventions in black persons have been raised by other investigators. Despite differences in age, *ai patterns and the use of coronary angioplasty and bypass surgery, black and white patients with AMI in metropolitan Seattle had similar outcomes.

(Am JCardid lSS1;67:18-23)

From the Departments of Medicine, Radiology, and Biostatistics, Uni- versity of Washington, Seattle, Washington. This study was supported by Grant ROl HL38454 from the National Heart, Lung, and Blood Institute, Bethesda, Maryland, and by a grant from Genentech, Inc., South San Francisco, California. Manuscript received August 7,199O; revised manuscript received and accepted August 20, 1990.

Address for reprints: W. Douglas Weaver, MD, MIT1 Project, HL- 21, 1910 Fairview E, #205, Seattle, Washington 98102.

*See Appendix.

T he natural history of coronary artery disease and in particular acute myocardial infarction (AMI) in black populations has drawn increasing atten-

tion. Several questions have been raised in an attempt to better understand the clinical course of AM1 in black patients. First, are black men and women less likely than whites to consult a physician for chest pain and other manifestations of coronary artery disease?’ Sec- ond, is the time from symptom onset to hospital arrival longer for black patients ?2 Third, does the use of thera- py for AM1 differ according to race?3-6 Finally, does mortality from AM1 and coronary artery disease differ according to race?7-9

The objective of this prospective study was to exam- ine the clinical course of black patients with chest pain admitted to coronary care units (CCUs) in metropolitan Seattle, Washington. Specific attention will be given to the subset of patients discharged with the diagnosis of AMI. Black and white populations will be compared ac- cording to baseline and clinical features, AM1 treat- ment and outcome.

METHOD6 Patient populatII: From January 1988 to January

1990, 14,283 persons with chest pain were admitted to CCUs in 19 hospitals in King County, which includes the city of Seattle and suburban area with a population of 1.3 million in 1980.1° Patient hospital records were abstracted, and key information was recorded on study data forms and entered in the Myocardial Infarction Triage and Intervention (MITI) registry.” The MIT1 registry is a randomized trial of prehospital treatment by paramedics of patients with AM1 amidst a registry of all patients with AMI. The registry contains all pa- tients who were admitted to CCUs as indicated by CCU logs in 19 hospitals in metropolitan Seattle.

The breakdown of the MIT1 population by race and AM1 status is displayed in Figure 1. The current analy- sis includes 12,534 patients (87.7%) admitted to CCUs in the metropolitan Seattle area. Patients whose race was unknown (8.6%) or was other than black or white (3.7%) were excluded, 641 black (4.4%) and 11,893 white (83.3%) patients were considered in this analysis. The 2,870 patients with the discharge diagnosis of AM1

18 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 67

I

PMIENW WITH NISSING OR OTHER RACE N=1749

CHEST WIN PATIENTS INCLUDED IN dNhL!tSIS N=12,534

88x

UHITE BLACK N=11,893 N=641

952 52

FIGURE 1. Race and myocadd infA (Ml) stab in pa- tiantsa&lliltedtowronary care mits in nwtrophnSeattk.

were of particular interest; 19% of black and 23% of white patients had confirmation of AM1 at discharge or death.

Slurry variables: For all patients, basic demographic and diagnostic variables were collected, these included permanent residence, date and hospital of admission, age, gender, race, mode of transport to the hospital, and initial and discharge diagnoses. Race was coded as white, black, Asian/Pacific islander, native American/ Alaskan native, Hispanic or unknown. Vital status at hospital discharge and cause of death were indicated.

For those patients with AM1 as the discharge diag- nosis, additional data were collected. The presence of a series of patient history variables was coded as no/not mentioned, yes, or questionable, and included history of angina, AMI, congestive heart failure or pulmonary edema, hypertension, hyperlipidemia, coronary artery surgery, coronary angioplasty and thrombolytic thera- py. Variables concerning clinical status on admission, treatments and procedures administered, and hospital events were coded as no/not mentioned or yes. Clinical status variables included the presence of chest pain, car- diogenic shock and cardiac arrest. The delay between the onset of symptoms and paramedic/emergency de- partment arrival was reported in minutes. Treatment for AMI, including thrombolytic therapy, cardiac cath- eterization, coronary angioplasty and coronary artery surgery, was noted. Finally, critical events that occurred during the course of AM1 were reported, these included embolic or hemorrhagic stroke, prolonged angina, AM1 extension, cardiac arrest and congestive heart failure.

Statistieal methodsr The chi-square statistic was used to test for differences between race and categoric variables, and the t test was used for continuous vari- ables. Multiple stepwise logistic regression was used to determine whether race was associated with mortality for AMI.

TABLE I Characteristics of Patients Admitted to Coronary Care Units in Metropolitan Seattle

White Black (n = 11,893) (n = 641) p Value

Age (years) Age 265 years Women Transporting agency

Paramedics Ambulance Self Other

King County Resident

Admitted to Central City Hospital

Admission diagnosis Rule-out myocardial

infarction Unstable angina Acute myocardial

infarction Other

Primary discharge diagnosis Acute myocardial

infarction Unstable angina Congestive heart

failure Dysrhythmia Cardiac arrest Hypertension Diabetes mellitus Noncardiac chest pain Nonspecific chest pain Other diagnoses

Hospital death

66i14 56% 42%

43% 18% 38%

(lE67) 89%

32%

74%

9% 5%

12%

23%

22% 7%

8% 1% 1%

<l% 5%

12% 19% 6%

58f14 <O.OOOl 36% 44%

18% 10%

7% 1% 9% 1% 2%

15% 18%

5%

o.Oco1 0.18 0.23

<0.0001

<0.0001

0.07

<0.0001

RESULTS Chest pain population: Characteristics of patients

admitted to the CCUs in the Seattle metropolitan area are listed according to race in Table I. Black persons were considerably younger (p <O.OOOl), whereas the proportion of women in the 2 groups was similar. In addition, the mode of transportation (paramedic versus other means) to the hospital was not different in the 2 groups. However, a significantly higher percent of black persons were Seattle area residents (p <O.OOOl); white persons were more often residents of the 2 adjacent counties (9 vs 4%). Moreover, the proportion of the black population admitted to 6 hospitals located in cen- tral Seattle was twice that of the white population. Evi- dence from Table I also indicates that blacks and whites differed with respect to discharge diagnosis. Hyperten- sion was more often the primary discharge diagnosis among black patients as was congestive heart failure to a lesser extent.

Overall mortality in this diverse group of patients was 5.8%; 5.3% for black and 5.9% for white patients (p = 0.55). Hospital mortality for black and white men was 4.2 and 5.6% (p = 0.26), respectively, and did not differ when adjusted for age by the direct method of

THE AMERICAN JOURNAL OF CARDIOLOGY JANUARY 1. 1991 19

TABLE II Characteristics of Patients with Acute Myocardial Infarction as Discharge Diagnosis

White Black (n = 2,749) (n = 121) p Value

Age (years) 67f13 59f13 <0.0001 Women 35% 44% 0.35 Admitted to 33% 69% <O.Ocol

Central City Hospital

History of Hypertension 46% 67% <0.0001 Hyperlipidemia 19% 19% 0.89 Acute myocardial 28% 27% 0.89

infarction Congestive heart 13% 10% 0.33

failure Angina 42% 36% 0.19 Thrombolysis 2% 3% 0.54 Cardiac 16% 12% 0.20

catheterization Coronary 4% 2% 0.45

angioplasty Coronary bypass 10% 2% 0.005

surgery Symptoms on admission

Chest pain 90% 88% 0.50 Cardiogenic shock 4% 3% 0.97 Cardiac arrest 6% 7% 0.83

Mean time from symptom onset to hospital or emergency vehicle arrival (min)

Mean 387f929 378f869 0.91 Median 106 100

standardization. Similarly, hospital mortality for black and white women was 6.2 and 6.7% (p = 0.75), respec- tively, and did not differ when adjusted for age.

Acute myocardial infarction population: Baseline characteristics of the 121 black and 2,749 white patients with AM1 are displayed in Table II. As in the popula- tion with chest pain, black patients were younger (p <O.OOOl), had more previous hypertension (p <O.OOOl), and were more often admitted to central city hospitals (p <O.OOOl). In addition, many more white patients had undergone coronary artery surgery. Black and white pa-

tients did not differ with respect to type of symptoms on admission or time from symptom onset to hospital arrival.

Diagnostic and therapeutic procedures during hospi- talization for AM1 are listed in Figure 2. The use of thrombolytic therapy and cardiac catheterization did not differ in the 2 groups. However, there were major racial differences in the use of angioplasty and coronary artery surgery. The number of black patients who un- derwent these procedures was small; 12 or 10% had an- gioplasty and 5 or 4% received coronary artery surgery. In comparison, 18 and 10% of white patients had angio- plasty and bypass surgery, respectively; both of these rates were statistically different from those of their black counterparts. In central city hospitals, 10% of black and 15% of white patients underwent angioplasty (p = 0.20) whereas in noncentral hospitals, 11 and 20% received the procedure (p = 0.20). Furthermore, in cen- tral hospitals, 6% of black and 12% of white patients underwent coronary bypass surgery (p = 0. lo), whereas 0 and 9% of black and white patients, respectively, re- ceived this procedure in noncentral hospitals (p = 0.07).

Figure 3 indicates the occurrence of various events during hospitalization for AMI. There were no differ- ences with respect to prolonged angina, new congestive heart failure or pulmonary edema, AM1 extension or cardiac arrest. Furthermore, hemorrhagic stroke as doc- umented by computed tomographic scan was nonexis- tent in black patients and occurred in 0.6% of white patients (p = 0.50). The incidence of all strokes was 0.8% in the black and 2.2% in the white population (p = 0.32).

Hospital mortality was 7.4% for black and 13.1% for white patients (p = 0.07); it was 5.4% for black and 11.1% for white men (p = 0.124), and 10.6 and 16.8% (P = 0.27) for black and white women, respectively. Multivariate logistic regression analysis, using most of the variables in Table II, was used to examine if race was predictive of hospital mortality for acute AMI. Af- ter adjustment for key predictors of hospital mortal- ity, race was not associated with hospital mortality (p = 0.38).

7s

; 68 P=.9S

R

Pl.41 P-.&26 P=.Enz

THMMROLYSIS cASD1Accnm

FIGURE 2. Pnxahes used far myo-

20 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 67

DISCUSSION Despite differences in age, hypertension, referral

patterns, and the use of certain therapeutic procedures, black and white patients with documented AM1 in met- ropolitan Seattle had similar hospital mortality rates. Blacks with AM1 were, on average, 8 years younger and had considerably more systemic hypertension than their white counterparts. The premature onset of coronary artery disease with excess hypertension has been noted in other black populations.8 The differences in referral patterns are most likely a reflection of the residential distribution of blacks in metropolitan Seattle where they are the majority of residents in the areas served by these central city hospitals. Blacks were 4.4% of the MIT1 registry, and they comprised 3.5% of the metro- politan Seattle population aged >30 years in 1980.1°

It has been reported that blacks with chest pain are less likely to seek medical attention,’ and that they pre- sent more often without chest pain.‘* In the MIT1 regis- try, survey data were not available to determine wheth- er black patients with chest pain were less likely to con- sult physicians than white patients. Furthermore in Seattle, approximately equal proportions of black and white patients with AM1 presented with chest pain.

Although the use of thrombolytic therapy and cardi- ac catheterization was similar in the 2 groups, statisti- cally significant differences in the use of coronary angi- oplasty and bypass surgery were evident in the MIT1 registry. Other investigators have reported that blacks were less likely to undergo cardiac catheterization and coronary artery surgery, even after controlling for sever- ity of disease.5,6J3J4 Because angiographic data were not available in the MIT1 registry, it was not possible to adjust for extent of disease. However, there is evidence that in black men and women with significant coronary artery disease, disease is severe.4 Despite lower rates of bypass surgery, black patients have benefited from the procedure.15-17

In Seattle, where rates of coronary angioplasty and bypass surgery during initial hospitalization were 2.3 and 1.8 times higher in the white population, informa- tion was not available to explain these higher rates. Fac-

tors such as socioeconomic status, health insurance cov- erage, patient preference and extent of disease may ac- count for the racial difference. Furthermore, hospital characteristics may be relevant, although racial differ- ences in the use of angioplasty and bypass surgery were similar in central and noncentral hospitals. Small num- bers of black patients treated at each hospital precluded analysis by individual institution. However, results from the current study and others, to a greater extent,QJ4 suggest a strong and consistent racial bias in the use of coronary artery surgery and other procedures in the treatment of coronary artery disease.

In metropolitan Seattle, unadjusted hospital mortali- ty of 7.4% was lower in black patients with AM1 (p = 0.07), but race was not predictive of hospital mortality after adjustment for key demographic and clinical vari- ables. Investigators from Chicago’s Cook County Hos- pital, which serves a predominantly black population, reported a 19% 2-week mortality for 111 black patients with AM1 and a median time from symptom onset to hospital arrival of 6 hours, >3.5 times that for blacks in Seattle.* For blacks in the MIT1 registry with delay times >6 hours, hospital mortality was 13.6%, and al- though higher, was not statistically different from the 7.5% mortality associated with delay times of 16 hours (p = 0.38). Delay time was not included in the multi- variate analysis, since it was unknown for 17% of both blacks and whites.

Another possible reason for lower black mortality in Seattle was that blacks with AM1 had higher out-of- hospital death rates than whites18J9 (i.e., only relatively healthy black survivors reached the hospital). Out-of- hospital deaths due to AM1 were not recorded in the MIT1 registry, although the proportions of blacks and whites transported to the hospital with sudden death were not different.

The MIT1 registry has provided complete ascertain- ment of CCU admissions for chest pain and AM1 in a defined geographic area over a 2-year period. The care- ful evaluation of hospital records by experienced ab- stracters of medical records is a further advantage of the registry. There are, however, limitations associated

flGURE 3. Events associated with myocrdd lnfmdim (Ml) in the Myo- evdblI-TIiagoandI-- tbnmgistry.CHF=congedwhearl faue.

56

40

f

t P-.4? P-.83 P=.lb P=.3fl P=.en

R I

THE AMERICAN JOURNAL OF CARDIOLOGY JANUARY 1, 1991 21

with this analysis. First, the number of blacks in the study was small; consequently, rates of death, angio- plasty and bypass surgery are subject to considerable variability with the addition or deletion of just a few events. Second, these events were recorded only for the initial hospitalization for chest pain or AMI. Racial dif- ferences in the use of these 2 procedures and death rates, to a lesser extent, may be a function of the timing of these events. If these events were delayed until after hospital discharge in black patients but not in whites, then the relation between race and these events might be altered. Third, electrocardiographic information in- cluding infarct type (Q wave versus non-Q wave) and location was not available in this study, and could con- found or effect the relation between race and mortality.7 Fourth, risk factor information, including family history of coronary disease and prior cigarette smoking, was not collected.

Finally, to what degree are these findings for blacks in metropolitan Seattle relevant to other black popula- tions in the United States? Blacks comprised <lo% of residents of the city of Seattle and <5% of the metro politan arealo; most American cities have a much high- er proportion of black residents. Moreover, the low mor- tality for AM1 in metropolitan Seattle blacks may be a reflection of a highly responsive emergency medical sys- tem not present in all large cities. On the other hand, findings of premature coronary artery disease, excess hypertension, and the differential use of interventions have been reported.6,* These problems, which pervade black communities, require further attention and action on the part of government agencies and professional or- ganizations.

REFERENCES 1. Strogatz DS. Use of medical care for cheat pain: differences between blacks and whites Am .I Public Health 1990;80:290-294. 2. Cooper RS, Simmons B, Castaner A, Prasad R, Franklin C, Ferlinz J. Survival rates and prehospital delay during myocardial infarction among black parsons. Am J Cardiol 1986;57:208-211. 3. Gillum RF. Coronary artery bypass surgery and coronary angiography in the United States, 1979-1983. Am Heart J 1987;113:1255-1260. 4. Simmons BE, Castaner A, Campo A, Ferlinz J, Mar M, Cooper R. Coronary artery disease in blacks of lower socioeconomic status: angiographic findings from the Cook County heart disease registry. Am Heart J 1988;116:90-97. 5. Wenneker MB, Epstein AM. Racial inequalities in the use of procedures for patients with ischemic heart disease in Massachusetts. JAMA 1989;261:253-257. 6. Ford E, Cooper R, Castaner A, Simmons B, Mar M. Coronary arteriography and coronary bypass surgery among whites and other racial groups relative to hospital based incidence rates for coronary artery disease: findings from the NHDS. Am J Public Health 1989;79:437-440. 7. Tofler GH, Stone PH, Muller JE, Willich SN, Davis VG, Poole WK. Strauss HW, Willerson JT, Jaffe AS, Robertson T, Passamani E, Braunwald E. Effects of gender and race on prognosis after myocardial infarction: adverse prognosis for women, particularly black women. J Am Co11 Cardiol 1987;9:473-482. 6. Roig E, Castaner A, Simmons B, Pate1 R, Ford E, Cooper R. In-hospital mortality rates for acute myocardial infarction by race in US hospitals: findings from the National Hospital discharge survey. Circulation 1987;76:280-288. 9. Sempos C, Cooper R, Kovar MG, McMillen M. Divergence of the recent trends in coronary mortality for the four major race-sex groups in the United States. Am J Public Health 1988;78:1422-1427. 10. US Bureau of the Census. General social and economic characteristics- Washington. Part 49. Washington DC: US Department of Commerce, 1983. 11. Weaver WD, Eisenberg MS, Martin JS, Litwin PE, Shaeffer SM, Ho MT, Kudenchuk P, Hallstrom AP, Cerqueira MD, Copass MK, Kennedy JW, Cobb LA, Ritchie JL. Myocardiil infarction triage and intervention project-phase I: patient characteristics and feasibility of prehospital initiation of thrombolytic therapy. J Am Coil Cardiol 1990;15:925-931.

22 THE AMERICAN JOURNAL OF CARDIOLOGY VOLUME 67

12. Clark LT. Adams-Campbell LL, Maw M, Bridges D, Kline G. Effects of race on the presenting symptoms of mywardial infarction (abstr). Circulation 1989;80:11:11-30. 13. Oberman A, Cutter G. Issues in the natural history and treatment of coronary heart disease in black populations: surgical treatment. Am Heart J 1984;108:688- 694. 14. Maynard C, Fisher LD, Passamani ER, Pullum T. Blacks in the coronary artery surgery study (CASS): race and clinical decision making. Am J Public Health 1986;76:1446-1448. 15. Watkins L, Gardner K, Gott V, Gardner TJ. Coronary heart disease and bypass surgery in urban blacks. J iVat/ Med Assoc 1983;75:381-383. 16. Simmons BE, Castaner A, Santhanam V, Ghali J, Silverman NA, Goldfaden DM, Levitsky S, Cooper R, Ferlinz J. Outcome of coronary artery bypass grafting in black persons. Am J Cardiol 1987;59:547-551. 17. Maynard C, Fisher LD, Passamani ER. Survival of black persons compared with white persons in the Coronary Artery Surgery Study (CASS). Am J Cardiol 1987;60:513-518. 18. We&e AB, Abiuso PD. Thind IS. Acute myocardial infarction in Newark, NJ. Arch Intern Med 1977;137:1402-1405. 19. Keil JE, Saunders DE, Lackland DT, Weinrich MC, Hudson MB, Gastright JA, Baroody NB, O’Bryan EC, Zmyslinski RW. Acute myocardial infarction: period prevalence, case fatality, and comparison of black and white cases in urban and rural areas of South Carolina. Am Heart J 1985;109:776-784.

APPENDIX Participating dinical centers: Auburn General Hospi-

tal, Ballard Community Hospital, Evergreen Hospital Medical Center, Group Health Hospitals, Harborview Medical Center, Highline Community Hospital, Northwest Hospital, Gverlake Hospital Medical Center, Providence Hospital, Riverton Hos- pital, St. Cabrini Hospital, St. Francis Hospital, Swedish Hos- pital Medical Center, University of Washington Medical Cen- ter, Valley General Medical Center, Veterans Administration Hospital, Virginia Mason Hospital, West Seattle Community Hospital.

Participating dinical investigators: Denise V. Abe, MD, Peter C. Albro, MD, Ralph Althouse, MD, Lee Amsler, MD, Arthur M. Anderson, MD, Steven Anderson, MD, Wy- man Andrus, MD, Warren Appleton, MD, Nathaniel Arcega, MD, Coskun R. Ateser, MD, Nancy Auer, MD, Gust Bardy, MD, Scott Bearman, MD, Ann K. Bergert, MD, Stephen Berz- ruschka, MD, Kerry Biermann, MD, Edward W. Bigler, MD, William C. Bilnoski, MD, John R. Blackman, MD, Terence A. Block, MD, Timothy Boone, MD, David R. Broudy, MD, Gregory Brown, MD, Michael Brown, MD, Robert A. Bruce, MD, Andrew Brunskill, MD, Curtis S. Burnett, MD, Colleen S. Bursten, MD, James Caldwell, MD, Richard Christensen, MD, Lawrence Chu, MD, John Ciliberti, MD, James F. Clifton, MD, Gabriel Coulon, MD, Richard A. Crone, MD, Richard Cummins, MD, Mark Dijulio, MD, Allen E. Doan, MD, John G. Dotes, MD, Harold T. Dodge, MD, G. Lee Dolack, MD, Paul Dutky, MD, Karen Early, MD, Susan Egaas, MD, James Emch, MD, Herbert Engle, MD, Milton T. English, MD, Den- nis M. Enomoto, MD, Daniel E&on, MD, Thomas Ettinger, MD, Christopher L. Fellows, MD, David B. Ferrin, MD, Rich- ard Ferse, MD, Laura Fife, MD, Dale Fine, MD, Steven Fish, MD, Daniel Fishbein, MD, Laura Fixe, MD, George I. Frank, MD, David Freidenberg, MD, James K. Fritz, MD, Patrick Garvine, MD, F. Theodore Gibbons, MD, Warren Gibbs, MD, Joseph Gifford, MD, Daniel W. Gottlieb, MD, John D. Graber, MD, Roy Graves, MD, Bert Green, MD, H. Leon Greene, Jr., MD, Michael Grey, MD, Gregory Gross, MD, Robert Grundy, MD, Gordon Hale, MD, Dale Hall, MD, Margaret Hall, MD, Phillip L. Hall, MD, Dennis Hansen, MD, Charles E. Hansing, MD, Courtenay Harrison, MD, Peter Hartwell, MD, Jean Haulman, MD, Robert E. Haynes, MD, Theodore Hegg, MD, John Hemmen, MD, David Herrington, MD, Daniel D. Hiatt, MD, Robert Highley, MD, Carl Higuchi, MD, John T. Holder, MD, John R. Holmes, MD, Thomas R. Hornsten, MD, Chris- tine Horton, MD, Jeffrey Howard, MD, John Hynes, MD,

Michael Hynes, MD, Daniel Jensen, MD, Steve L. Johnson, MD, Robin R. Johnston, MD, William Johnston, MD, Elaine C. Jong, MD, Larry J. Kadeg, MD, Stanley Kaufman, MD, Daniel Kent, MD, Luba Kihichak, MD, Robert L. King, MD, Wolfgang F. Kluge, MD, William Korbonits, MD, James Krieger, MD, Kent Kreismann, MD, J. Douglas Lambrecht, MD, Gerald LaSalle, MD, Robert M. Levenson, MD, M.S. Linscott, MD, Gordon A. Logan, MD, Jose Lopez, MD, Gerald S. Larch, MD, San Lwai, MD, Rubm R. Maidan, MD, Steven Marshall, MD, Gary Martin, MD, Mary Maxwell-Young, MD, John A. Mazzarella, MD, William McKee, MD, W. Russell McMullen, MD, Terry Mengert, MD, John Mercier, MD, J.C. Michel, MD, Mark Miller, MD, Thomas Miller, MD, Robert K. Mito, MD, Maurice Montag, MD, Jerome Mueller, MD, John A. Murray, Jr., MD, John W. Nemanich, MD, John Nixon, MD, Kenneth J. O’Bara, MD, Deems Oka- moto, MD, Eileen Olinger, MD, Steven Olmstead, MD, John Olsen, MD, Catherine Otto, MD, Scott Overturff, MD, Chang S. Park, MD, Phillip Parsons, MD, David Peace, MD, Alan Pearlman, MD, David Petersen, MD, John L. Petersen, MD, Charles Pilcher, MD, Jeanne Poole, MD, Thomas A. Preston, MD, Jerald Radich, MD, Patrick J. Reagan, MD, Theodore Regimboal, MD, Arthur D. Resnick, MD, James Revkin, MD, James Rice, MD, Robert C. Riggins, MD, Paul Roberts, MD, Lawrence Robinson, MD, Simeon A. Rubenstein, MD, Thomas Ryan, MD, Werner E. Samson, MD, Sassan Sanai, MD, Roman Sanchez, MD, John Sanfelippo, MD, James S. Schneider, MD, Steven Schoenfeld, MD, Gregory Schroedl, MD, Shay Schual-Berke, MD, Joseph Schuster, MD, Robert Scale, MD, Mark Sharon, MD, Floyd A. Short, MD, Rodney Skoglund, MD, Vivian Sokitch, MD, Gary Somers, MD, Mer- rill P. Spencer, MD, Sarah M. Speck, MD, Russell Spies, MD, Wilbur Springer, MD, Bruce Stevensen, MD, Douglas Stewart, MD, Mark Swanson, MD, Stephen Swanson, MD, Alexander L. Sytman, MD, Charles Thelkeld, MD, Robert G. Thompson, Jr., MD, Fredric M. Tobis, MD, Gene Trobaugh, MD, James Trombold, MD, Rodney E. Utley, MD, James Wagner, MD, Robert Wallach, MD, John Walter, MD, Richard Watkins, MD, David C. Warth, MD, Jeffrey A. Werner, MD, Franz Wery, MD, R. Jeffrey Westcott, MD, Daniel V. Wilkinson, Jr., MD, Dennis Willerford, MD, Bruce Wilson, MD, Carl Wy- man, MD, Stephen R. Yarnall, MD, Louis R. Zibelli, MD.

Emergency Medical Senior: BELLEVUE: Timothy A. Adams, Bruce A. Ansell, Arthur E. Arpin, Terrence A. Bray- ton, Richard Catlin, Arthur B. Cole, Samuel F. Crozier, Bruce E. Douglas, Michael A. Duchemin, James N. Flick, Michael J. Ganz, Frederick Helbock, Michael T. Hess, Martin LaFave, Michael A. Lane, Laurence L. Lindenmayer, Ford P. Mullen,

Stanley D. Pallo, Capt. Ronald Protitt, Lt. Michael Remington, Felipe S. Sales, Richard C. Sand, Lt. Donald M. Thompson, Troy Thompson.

EVERGREEN: Dean Crosgrove, John Frazier, Phillip Greib, Howard Harrison, Robin Hayes, Eugene Hoefling, David Knight, James Pierce, Lester Putnam, Patrick Randles, Steven Taylor.

SEATTLE: David E. Allen, Michael M. Barokas, Carolyn Bar- ton, Robert C. Block, Gregory R. Brace, Robert G. Breda, Howard B. Cannon, Janet Cardin, Robert K. Carlson, Mark C. Coolidge, Keith R. Cornie, Leslie A. Davis, Terrence R. Davis, Karen J. Dong, Laurence C. Donnelly, RaeAnn P. Eckerman, Gerald M. Ehrler, Michael D. Foley, Milton E. Footer, Richard C. Ford, Randall Q. Foy, Michael J. Garvey, Gerald W. Green, Richard A. Guenthner, Paul S. Harvey, David B. Hawkins, Ralph H. Herth, Jr., Linda Howson, Patrick L. Jasper, Jeffrey W. Jinka, Marvin W. Johnson, John C. Kerr, Michael J. Kerr, Rosemary King, Douglas D. Kjos, Jonathan M. Larsen, Jona- than Laye, Karen R. Leonard, Chief Ralph Maughan, Thadde- us Z. Mercer, Emanuel Montgomery, Raymond E. Moody, Clyde F. Neaville, Richard A. Newbrey, Stuart D. Ono, Dennis V. Pargeter, Lt. John Pritchard, Teresa M. Roddick, Randolph J. Ruwe, Peter Schwendeman, John P. Severin, Lt. Donald Sharp, G.W. Shearer Jr., C. Mitchell Schlosser, Richard A. Smith, Albert T. Sprague, Jr., Bernard J. Stender, Michael M. Storbakken, Howard H. Teschendorf, Daniel J. Wade, Lt. Thomas R. Walsh, Roy D. Waugh, Robert E. West, Henry A. Wheeler, Farrell D. Wilson, Michael F. Ylenni.

SHORELINE: Thomas Agnew, Chief Gary Castellano, Timo- thy Dahl, Penny Hulse, Captain Michael Koontz, Richard La- Due, John Mitchell, Steven H. Mitchell, Daniel Smith, J.B. Smith, Donald Warner, Donald Westfall, Barent Winant.

SOUTH KING COUNTY: Deborah Ayers, Stewart Crandall, Den- nis Doherty, Tammy J. Dunakin, Donald Flascher, Lee Fryk- holm, Thomas Gudmestad, Michael Hansen, John Herbert, Robert Hutchinson, Keith Keller, Raymond Lanier, Lynn Lough, William Marsh, Roger Matheny, Melvin McClure, Christopher Merritt, Jeffrey Merritt, Richard N. Norwood, Hokey Overland, Ronald Pentecost, Edward Plumlee, James Sandlin, Steven Sappenfield, Anthony Scoccolo, Roy Soper, Edward Stuhlman, Robert Vargas, Frank Wasicek, Tracey White, Douglas Wiggan.

Patient safety & data monitoring committee: Thomas A. Ryan, MD, Chairman, Robert Califf, MD, C. Morton Haw- kins, ScD, Laurence B. McCullough, PhD, James E. Muller, MD, Joseph Ornato, MD.

MIT1 project st& Danette Ambrozic, Pat Owliaei, Kim- berly Streitz, Marty Taylor, Mark Wirkus.

THE AMERICAN JOURNAL OF CARDIOLOGY JANUARY 1, 1991 23