Temporal trends in medical therapies for ST- and non-ST elevation myocardial infarction: (from the Atherosclerosis Risk in Communities [ARIC] Surveillance Study)

Patients With AMI and Severely Reduced LVEF, a Well-Defined, Still Extremely Vulnerable Population (Insights from AMIS Plus Registry)

Left ventricular ejection fraction (LVEF) represents one of the strongest predictors of both in-hospital and long-term prognosis in acute myocardial infarction (AMI). Temporal trends data coming from real-world experiences focused on patients with AMI with severely reduced LVEF (i.e., <30%) are lacking. In a total of 48,543 screened patients with AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry between 2005 and 2020, data on LVEF were available for 23,510 patients. Study patients were classified according to LVEF as patients with AMI with or without severely reduced LVEF (i.e., patients with LVEF <30% and ≥30%, respectively). Overall, 1,657 patients with AMI (7%) displayed severely reduced LVEF. The prevalence of severe LVEF reduction constantly decreased over the study period (from 11% to 4%, p <0.001). In the subgroup of patients with severely reduced LVEF, a significant increase in revascularization rate was observed (from 61% to 84%, p <0.001); however, in-hospital mortality did not significantly decrease and remained well above 20% over the study period (from 23% to 26%, p = 0.65). At discharge, prescription of optimal cardioprotective therapy (defined as an association of renin-angiotensin-aldosterone-system inhibitors, β-blocker, and mineral corticoid receptor antagonist) remained low across the study period (from 17% in 2011 to 20%, p = 0.96). In conclusion, patients with AMI with severely reduced LVEF remain a fragile subgroup of patients with an in-hospital mortality that did not significantly decrease and remained well above 20% over the study period. Moreover, access at discharge to optimal cardioprotective therapy remains suboptimal. Efforts are, therefore, needed to improve prognosis and access to guidelines-directed therapies in this fragile population.

Temporal trends in associations between severe mental illness and risk of cardiovascular disease: A systematic review and meta-analysis

BACKGROUND

Severe mental illness (SMI; schizophrenia, bipolar disorders (BDs), and other nonorganic psychoses) is associated with increased risk of cardiovascular disease (CVD) and CVD-related mortality. To date, no systematic review has investigated changes in population level CVD-related mortality over calendar time. It is unclear if this relationship has changed over time in higher-income countries with changing treatments.

METHODS AND FINDINGS

To address this gap, a systematic review was conducted, to assess the association between SMI and CVD including temporal change. Seven databases were searched (last: November 30, 2021) for cohort or case-control studies lasting ≥1 year, comparing frequency of CVD mortality or incidence in high-income countries between people with versus without SMI. No language restrictions were applied. Random effects meta-analyses were conducted to compute pooled hazard ratios (HRs) and rate ratios, pooled standardised mortality ratios (SMRs), pooled odds ratios (ORs), and pooled risk ratios (RRs) of CVD in those with versus without SMI. Temporal trends were explored by decade. Subgroup analyses by age, sex, setting, world region, and study quality (Newcastle-Ottawa scale (NOS) score) were conducted. The narrative synthesis included 108 studies, and the quantitative synthesis 59 mortality studies (with (≥1,841,356 cases and 29,321,409 controls) and 28 incidence studies (≥401,909 cases and 14,372,146 controls). The risk of CVD-related mortality for people with SMI was higher than controls across most comparisons, except for total CVD-related mortality for BD and cerebrovascular accident (CVA) for mixed SMI. Estimated risks were larger for schizophrenia than BD. Pooled results ranged from SMR = 1.55 (95% confidence interval (CI): 1.33 to 1.81, p < 0.001), for CVA in people with BD to HR/rate ratio = 2.40 (95% CI: 2.25 to 2.55, p < 0.001) for CVA in schizophrenia. For schizophrenia and BD, SMRs and pooled HRs/rate ratios for CHD and CVD mortality were larger in studies with outcomes occurring during the 1990s and 2000s than earlier decades (1980s: SMR = 1.14, 95% CI: 0.57 to 2.30, p = 0.71; 2000s: SMR = 2.59, 95% CI: 1.93 to 3.47, p < 0.001 for schizophrenia and CHD) and in studies including people with younger age. The incidence of CVA, CVD events, and heart failure in SMI was higher than controls. Estimated risks for schizophrenia ranged from HR/rate ratio 1.25 (95% CI: 1.04 to 1.51, p = 0.016) for total CVD events to rate ratio 3.82 (95% CI: 3.1 to 4.71, p < 0.001) for heart failure. Incidence of CHD was higher in BD versus controls. However, for schizophrenia, CHD was elevated in higher-quality studies only. The HR/rate ratios for CVA and CHD were larger in studies with outcomes occurring after the 1990s. Study limitations include the high risk of bias of some studies as they drew a comparison cohort from general population rates and the fact that it was difficult to exclude studies that had overlapping populations, although attempts were made to minimise this.

CONCLUSIONS

In this study, we found that SMI was associated with an approximate doubling in the rate ratio of CVD-related mortality, particularly since the 1990s, and in younger groups. SMI was also associated with increased incidence of CVA and CHD relative to control participants since the 1990s. More research is needed to clarify the association between SMI and CHD and ways to mitigate this risk.

Recent trends in cardiovascular disease deaths: a state specific perspective

BACKGROUND

The rate of decline in cardiovascular disease (CVD) mortality has lessened nationally. How these findings apply to specific states or causes of CVD deaths is not known. Examining these trends at the state level is important to plan local interventions.

METHODS

We analyzed CVD mortality trends in Minnesota (MN) using the U.S. Centers for Disease Control and Prevention (CDC) Wide-ranging ONline Data for Epidemiologic Research (WONDER). Trends were analyzed by age, sex, type of CVD and location of death.

RESULTS

CVD mortality rates in MN declined in 2000-2009 and then leveled off in 2010-2018, paralleling national rates. Age- and sex-adjusted CVD mortality decreased by 3.7% per year in 2000-2009 (average annual percent changes [AAPC]: -3.7; 95% CI: - 4.8, - 2.6) with no change observed in 2010-2018. Those aged 65-84 years had the most rapid early decline in CVD mortality (AAPC: -5.9, 95% CI: - 6.2, - 5.7) and had less improvement in 2010-2018 (AAPC: -1.8, 95% CI: - 2.2, - 1.5), and the younger age group (25-64 years) now experiences the most adverse trends (AAPC: 1.2, 95% CI: 0.7-1.8). Coronary heart disease (CHD) and cerebrovascular disease had the largest relative decreases in mortality in 2000-2009 (CHD AAPC: -5.2; 95% CI: - 6.5,-3.9; cerebrovascular disease AAPC: -4.4, 95% CI: - 5.2, - 3.6) with no change 2010-2018. Heart failure (HF)/cardiomyopathy followed similar trends with a 2.5% decrease (AAPC 95% CI: - 3.5, - 1.5) per year in 2000-2009 and no change in 2010-2018. Deaths from other CVD also decreased in the early time period (AAPC: -1.6, 95% CI: - 2.7, - 0.5) but increased in 2010-2018 (AAPC: 1.9, 95% CI: 0.5, 3.3). In- and out-of-hospital death rates improved in 2000-2009 with a slowing in improvement for in-hospital death and no further improvement for out-of-hospital death in 2010-2018.

CONCLUSION

Concerning CVD mortality trends occurred in MN. In the most recent decade (2010-2018) mortality from all CVD subtypes plateaued or even increased. CVD mortality among the younger age groups increased as well. These data are congruent with adverse national trends supporting their generalizability. These adverse trends underscore the urgent need for CVD prevention and treatment, as well as continued surveillance to assess progress at the state and national level.

Temporal trends in latecomer STEMI patients: insights from the AMIS Plus registry 1997-2017

INTRODUCTION AND OBJECTIVES

A substantial proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) have a late presentation. There is a lack of temporal trends drawn from large real-word scenarios in these patients.

METHODS

All STEMI patients included in the AMIS Plus registry from January 1997 to December 2017 were screened and patient-related delay was assessed. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or> 12hours, respectively).

RESULTS

A total of 27 231 STEMI patients were available for the analysis. During the study period, the prevalence of late presentation decreased from 22% to 12.3% (P <.001). In latecomer STEMI patients, there was a gradual uptake of evidence-based pharmacological treatments (rate of P2Y₁₂ inhibitors at discharge, from 6% to 90.6%, P <.001) and a marked increase in the use of percutaneous coronary intervention (PCI), particularly in 12- to 48-hour latecomers (from 11.9%-87.9%; P <.001). In-hospital mortality was reduced from 12.4% to 4.5% (P <.001). On multivariate analysis, PCI had a strong independent protective effect on in-hospital mortality in 12- to 48-hour latecomers (OR, 0.29; 95%CI, 0.15-0.55).

CONCLUSIONS

During the 20-year study period, there was a progressive reduction in the prevalence of late presentation, a gradual uptake of main evidence-based pharmacological treatments, and a marked increase in PCI rate in latecomer STEMI patients. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%); in 12- to 48-hour latecomers, this reduction seemed to be mainly associated with the increasing implementation of PCI.

Twenty-Year Trends in Outcomes for Older Adults With Acute Myocardial Infarction in the United States

IMPORTANCE

Medicare and other organizations have focused on improving quality of care for patients with acute myocardial infarction (AMI) over the last 2 decades. However, there is no comprehensive perspective on the evolution of outcomes for AMI during that period, and it is unknown whether temporal changes varied by patient subgroup, hospital, or county.

OBJECTIVE

To provide a comprehensive evaluation of national trends in inpatient outcomes and costs of AMI during this period.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included analysis of data from a sample of 4 367 485 Medicare fee-for-service beneficiaries aged 65 years or older from January 1, 1995, through December 31, 2014, across 5680 hospitals in the United States. Analyses were conducted from January 15 to June 5, 2018.

MAIN OUTCOMES AND MEASURES

Thirty-day all-cause mortality at the patient, hospital, and county levels. Additional outcomes included 30-day all-cause readmissions; 1-year recurrent AMI; in-hospital mortality; length of hospital stay; 2014 Consumer Price Index-adjusted median Medicare inpatient payment per AMI discharge; and rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery.

RESULTS

The cohort included 4 367 485 Medicare fee-for-service patients aged 65 years or older hospitalized for AMI during the study period. Between 1995 and 2014, the mean (SD) age of patients increased from 76.9 (7.2) to 78.2 (8.7) years, the percentage of female patients declined from 49.5% to 46.1%, the percentage of white patients declined from 91.0% to 86.2%, and the percentage of black patients increased from 5.9% to 8.0%. There were declines in AMI hospitalizations (914 to 566 per 100 000 beneficiary-years); 30-day mortality (20.0% to 12.4%; difference, 7.6 percentage points; 95% CI, 7.3-7.8 percentage points); 30-day all-cause readmissions (21.0% to 15.3%; difference, 5.7 percentage points; 95% CI, 5.4-6.0 percentage points); and 1-year recurrent AMI (7.1% to 5.1%; difference, 2.0 percentage points; 95% CI, 1.8-2.2 percentage points). There were increases in the 2014 Consumer Price Index-adjusted median (interquartile range) Medicare inpatient payment per AMI discharge ($9282 [$6969-$12 173] to $11 031 [$8099-$16 861]); 30-day inpatient catheterization (44.2% to 59.9%; difference, 15.7 percentage points; 95% CI, 15.4-16.0 percentage points); and inpatient percutaneous coronary intervention (18.8% to 43.3%; difference, 24.5 percentage points; 95% CI, 24.2-24.7 percentage points). Coronary artery bypass graft surgery rates decreased from 14.4% to 10.2% (difference, 4.2 percentage points; 95% CI, 3.9-4.3 percentage points). There was heterogeneity by hospital and county in the mortality changes over time.

CONCLUSIONS AND RELEVANCE

This study shows marked improvements in short-term mortality and readmissions, with an increase in in-hospital procedures and payments, for the increasingly smaller number of Medicare beneficiaries with AMI.

Characteristics and Outcomes of Patients Hospitalized With Suspected Acute Coronary Syndrome in Whom the Diagnosis is not Confirmed

Patients admitted with suspected acute coronary syndrome (ACS) in whom the diagnosis is not confirmed are poorly characterized. In a contemporary registry of consecutive patients hospitalized with suspected ACS as the primary diagnosis, we assessed characteristics on admission and in-hospital and 6-month mortality of patients discharged with other diagnoses and compared this subgroup with true ACS patients. Of 2557 patients included, 9.0% were discharged with a non-ACS diagnosis such as nonspecific chest pain, myopericarditis, stress cardiomyopathy, hemodynamic disturbances, heart failure, myocardial, pulmonary or valvular disease, or others. Compared with true ACS patients, those with other diagnoses were younger, more often female, and had less cardiovascular risk factors. Both groups had comparable rates of nonchest pain presentation and similar hemodynamic characteristics on admission. Non-ACS patients presented less often with Q waves or with ST-segment or T-wave changes and had a lower Global Registry of Acute Coronary Events score than true ACS patients. In-hospital (4.3 vs 4.0%, respectively, p = 0.834) and 6-month (5.4 vs 8.0%, respectively, p = 0.163) mortality rates were comparable in both groups. However, if patients in the non-ACS group were divided into subgroups with nonspecific chest pain (6.2% of total) or other diagnoses (2.8% of total), major differences in in-hospital (0.0 vs 13.9%, respectively, p < 0.001) and 6-month (0.7 vs 15.7%, respectively, p < 0.001) mortality rates would become apparent and remain after multivariable adjustment. In conclusion, in a non-negligible proportion of patients hospitalized with suspected ACS, this diagnosis is not confirmed. Prognosis of these patients follows a bimodal pattern, being excellent in those with nonspecific chest pain but worse than that of true ACS patients in the rest. Efforts are necessary to ensure prompt identification and early risk stratification of these patients allowing appropriate management decisions.

Clinical characteristics and improvement of the guideline-based management of acute myocardial infarction in China: a national retrospective analysis

Objective

This study is to document the clinical characteristics and improvement in management of acute myocardial infarction (AMI) in Chinese population.

Results

This study included 64,654 patients (23,805 patients in 2011, 40,849 patients in 2013), of which STEMI and NSTEMI account for 85.09% and 14.91%, respectively. From 2011 to 2013, significant improvement has been achieved in the recanalization rate of PCI (96.01% vs. 98.63%, P < 0.001) and in-hospital deaths (4.52% vs. 3.55%, P = 0.038). Although the time of door-to-balloon and the duration of PCI were satisfactorily controlled within 90min and 60min, respectively, the onset-to-FMC time (≈3.5h) and door-to-thrombolysis time (≈1.1h) limited the efficiency of management. The total cost of medical care showed no increase from 2011 to 2013, but the patient's paid Portion decreased from 20.33% to 13.96%.

Materials and Methods

The AMI patients admitted in the general hospitals in 2011 and 2013 were retrospectively analyzed according to the data reported to the Single Disease Quality Control Information Systemissued by Chinese Hospital Association.

Conclusion

Compared to the Western countries, STEMI accounted for a larger portion of AMI, and the AMI management in China basically meets the standards of the quality control of guidelines. With improvement of management, there was no increase in the total medical cost, while the patient's paid portion was actually reduced. In future, improvement of transportation strategy and the public medical education are recommended to shorten the onset-to-FMC time to further improve the outcome of AMI patients.

Using big data from health records from four countries to evaluate chronic disease outcomes: a study in 114 364 survivors of myocardial infarction

AIMS

To assess the international validity of using hospital record data to compare long-term outcomes in heart attack survivors.

METHODS AND RESULTS

We used samples of national, ongoing, unselected record sources to assess three outcomes: cause death; a composite of myocardial infarction (MI), stroke, and all-cause death; and hospitalized bleeding. Patients aged 65 years and older entered the study 1 year following the most recent discharge for acute MI in 2002-11 [n = 54 841 (Sweden), 53 909 (USA), 4653 (England), and 961 (France)]. Across each of the four countries, we found consistent associations with 12 baseline prognostic factors and each of the three outcomes. In each country, we observed high 3-year crude cumulative risks of all-cause death (from 19.6% [England] to 30.2% [USA]); the composite of MI, stroke, or death [from 26.0% (France) to 36.2% (USA)]; and hospitalized bleeding [from 3.1% (France) to 5.3% (USA)]. After adjustments for baseline risk factors, risks were similar across all countries [relative risks (RRs) compared with Sweden not statistically significant], but higher in the USA for all-cause death [RR USA vs. Sweden, 1.14 (95% confidence interval 1.04-1.26)] and hospitalized bleeding [RR USA vs. Sweden, 1.54 (1.21-1.96)].

CONCLUSION

The validity of using hospital record data is supported by the consistency of estimates across four countries of a high adjusted risk of death, further MI, and stroke in the chronic phase after MI. The possibility that adjusted risks of mortality and bleeding are higher in the USA warrants further study.

Quality of medical care for persons with serious mental illness: A comprehensive review

OBJECTIVES

Prior studies suggest variation in the quality of medical care for somatic conditions such as cardiovascular disease and diabetes provided to persons with SMI, but to date no comprehensive review of the literature has been conducted. The goals of this review were to summarize the prior research on quality of medical care for the United States population with SMI; identify potential sources of variation in quality of care; and identify priorities for future research.

METHODS

Peer-reviewed studies were identified by searching four major research databases and subsequent reference searches of retrieved articles. All studies assessing quality of care for cardiovascular disease, diabetes, dyslipidemia, and HIV/AIDs among persons with schizophrenia and bipolar disorder published between January 2000 and December 2013 were included. Quality indicators and information about the study population and setting were abstracted by two trained reviewers.

RESULTS

Quality of medical care in the population with SMI varied by study population, time period, and setting. Rates of guideline-concordant care tended to be higher among veterans and lower among Medicaid beneficiaries. In many study samples with SMI, rates of guideline adherence were considerably lower than estimated rates for the overall US population.

CONCLUSIONS

Future research should identify and address modifiable provider, insurer, and delivery system factors that contribute to poor quality of medical care among persons with SMI and examine whether adherence to clinical guidelines leads to improved health and disability outcomes in this vulnerable group.