Characteristics and prognosis of patients with acute myocardial infarction in relation to whether they were treated in the coronary care unit or in another ward

Demographics and Characteristics of Patients Admitted With Acute Coronary Syndrome to the Coronary Care Unit at King Abdulaziz University

Background Over the previous decade, the incidence of cardiovascular diseases (CVDs) has risen in the Middle East and will increase mortality to 23 million individuals in Saudi Arabia by 2030, according to the Saudi Ministry of Health. CVDs, including acute coronary syndrome (ACS), are the most common cause of mortality globally. This study aimed to analyze the demographic and clinical characteristics of patients with ACS admitted to the coronary care unit (CCU) in a tertiary hospital in Jeddah, Saudi Arabia. To the best of our knowledge, a lack of research in this region has been undertaken. Methods This retrospective records review study was conducted in a tertiary center in Jeddah, Saudi Arabia. All patients admitted to our CCU in 2017 with a final diagnosis of ACS were retrospectively enrolled. Demographic details, coronary risk factors, investigation and procedures, management, and clinical outcomes are all part of the data. Results Of the 615 patients included in the study, 491 (79.84%) were males, 226 (36.75%) were 55-64 years old, and 161 (26.18%) were 45-54 years old. Males had a higher rate of ST-segment elevation myocardial infarction (STEMI) (214, 43.58%), while females had a higher rate of non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) (45.96% and 37.90%, respectively). Diabetes (62.60%), dyslipidemia (62.44%), and hypertension (61.46%) were the most prevalent risk factors. Angiography and percutaneous coronary intervention (PCI) were performed in 77.72% and 61.95% of patients, respectively. Coronary artery bypass graft was only performed in 4.39% of patients. PCI was performed more frequently in patients with STEMI than in those with NSTEMI/UA (P < 0.001). A large majority of patients (99.5%) recovered and were discharged. Of the 161 (26.18%) patients who attended a follow-up visit, only 45 (33.08%) met the therapeutic objective of 1.8 mmol/L (70 mg/dl) of low-density lipoprotein cholesterol. There were 100 (16.26%) patients readmitted to the CCU, and most of these were readmitted within a year after initial admission. Readmissions were more common in females and patients diagnosed with NSTEMI/UA during initial admission (15.47% and 19.35%, respectively). Conclusion This study revealed that our most common demographics were males between 45 and 64 years, which is a decade younger than the global average. STEMI was the most common presentation. The most common modifiable cardiovascular risk factors were hypertension, diabetes, and dyslipidemia. The most common adverse event was reinfarction, which was closely linked to hypertension and diabetes. In this study, the recovery rate was higher than in studies from other countries; however, the majority of patients did not achieve the goal of cholesterol levels at follow-up. Our population's younger age at presentation necessitates greater attention and more stringent preventive strategies, such as lifestyle changes and evidence-based treatments for CVD risk factors, to reduce the incidence and burden of ACS on CCUs.

Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study

OBJECTIVE

To evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI).

DESIGN

Retrospective cohort study.

SETTING

1727 acute care hospitals in the United States.

PARTICIPANTS

Medicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015.

MAIN OUTCOME MEASURE

30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI.

RESULTS

The analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval -11.9 to -0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (-0.9 to 3.4) percentage points).

CONCLUSIONS

ICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.

Sudden Cardiac Death in Acute Coronary Syndromes

Sudden cardiac death in acute coronary syndromes mostly results from complex ventricular arrhythmias. Although the incidence has fallen with contemporary management, they still pose a threat for many patients. Treatment consists of immediate termination by electrical cardioversion and prompt coronary revascularization for relief of ischemia. Beta-blockers administered prophylactically have a protective effect. For recurrent episodes, pharmacologic treatment consists of beta-blockers and amiodarone, or, in nonresponsive patients, lidocaine. Other antiarrhythmic drugs play only a marginal role. Catheter ablation performed in qualified centers can be effective in recurrent episodes of ventricular tachycardia or ventricular fibrillation triggered by premature ventricular contractions.

Acute coronary syndrome patients admitted to a cardiology vs non-cardiology service: variations in treatment & outcome

Background

Specialized cardiology services have contributed to reduced mortality in acute coronary syndromes (ACS).  We sought to evaluate the outcomes of ACS patients admitted to non-cardiology services in Southern Alberta.

Methods

Retrospective chart review performed on all troponin-positive patients in the Calgary Health Region identified those diagnosed with ACS by their attending team. Patients admitted to non-cardiology and cardiology services were compared, using linked data from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry and the Strategic Clinical Network for Cardiovascular Health and Stroke.

Results

From January 1, 2007 to December 31, 2008, 2105 ACS patients were identified, with 1636 (77.7%) admitted to cardiology and 469 (22.3%) to non-cardiology services. Patients admitted to non-cardiology services were older, had more comorbidities, and rarely received cardiology consultation (5.1%). Cardiac catheterization was underutilized (5.1% vs 86.4% in cardiology patients (p < 0.0001)), as was evidence-based pharmacotherapy (p < 0.0001). Following adjustment for baseline comorbidities, 30-day through 4-year mortality was significantly higher on non-cardiology vs. cardiology services (49.1% vs. 11.0% respectively at 4-years, p < 0.0001).

Conclusion

In a large ACS population in the Calgary Health Region, 25% were admitted to non-cardiology services. These patients had worse outcomes, despite adjustment for baseline risk factor differences. Although many patients were appropriately admitted to non-cardiology services, the low use of investigations and secondary prevention medications may contribute to poorer patient outcome. Further research is required to identify process of care strategies to improve outcomes and lessen the burden of illness for patients and the health care system.

Impact of coronary intensive care unit in treatment of myocardial infarction

Introduction:

The mortality rate attributed to ST-segment elevation myocardial infarction (STEMI) has decreased in the world. However, this disease is still responsible for high costs for health systems. Several factors could decrease mortality in these patients, including implementation of cardiac intensive care units (CICU). The aim of this study was to evaluate the effect of CICU implementation on prescribed recommended treatments and mortality 30 days after STEMI.

Method:

We performed a retrospective study with patients admitted to CICU between 2005 and 2006 (after group) and between 2000 and 2002, before CICU implementation (before group).

Results:

The after group had 101 patients, while the before group had 143 patients. There were no differences in general characteristics between groups. We observed an increase in angiotensin-converting enzyme inhibitors, clopidogrel and statin prescriptions after CICU implementation. We did not find differences regarding number of patients submitted to reperfusion therapy; however, there was an increase in primary percutaneous angioplasty compared with thrombolytic therapy in the after group. There was no difference in 30-day mortality (before: 10.5%; after: 8.9%; p=0.850), but prescription of recommended treatments was high in both groups. Prescription of angiotensin-converting enzyme inhibitors and beta-blocker decreased mortality risk by 4.4 and 4.9 times, respectively.

Conclusion:

CICU implementation did not reduce mortality after 30 days in patients with STEMI; however, it increased the prescription of standard treatment for these patients.

Sex differences in in-hospital mortality following a first acute myocardial infarction: symptomatology, delayed presentation, and hospital setting

BACKGROUND

Women generally wait longer than men prior to seeking treatment for acute myocardial infarction (AMI). They are more likely to present with atypical symptoms, and are less likely to be admitted to coronary or intensive care units (CCU or ICU) compared to similarly-aged males. Women are more likely to die during hospital admission. Sex differences in the associations of delayed arrival, admitting ward, and mortality have not been thoroughly investigated.

METHODS

Focusing on presenting symptoms and time of presentation since symptom onset, we evaluated sex differences in in-hospital mortality following a first AMI in 4859 men and women presenting to three emergency departments (ED) from December 2008 to February 2014. Sex-specific risk of mortality associated with admission to either CCU/ICU or medical wards was calculated after adjusting for age, socioeconomic status, triage-assigned urgency of presentation, blood pressure, heart rate, presenting symptoms, timing of presentation since symptom onset, and treatment in the ED. Sex-specific age-adjusted attributable risks were calculated.

RESULTS

Compared to males, females waited longer before seeking treatment, presented more often with atypical symptoms, and were less likely to be admitted to CCU or ICU. Age-adjusted mortality in CCU/ICU or medical wards was higher among females (3.1 and 4.9 % respectively in CCU/ICU and medical wards in females compared to 2.6 and 3.2 % in males). However, after adjusting for variation in presenting symptoms, delayed arrival and other risk factors, risk of death was similar between males and females if they were admitted to CCU or ICU. This was in contrast to those admitted to medical wards. Females admitted to medical wards were 89 % more likely to die than their male counterparts. Arriving in the ED within 60 min of onset of symptoms was not associated with in-hospital mortality. Among males, 2.2 % of in-hospital mortality was attributed to being admitted to medical wards rather than CCU or ICU, while for females this age-adjusted attributable risk was 4.1 %.

CONCLUSIONS

Our study stresses the need to reappraise decision making in patient selection for admission to specialised care units, whilst raising awareness of possible sex-related bias in management of patients diagnosed with an AMI.

Bosentan: a review of its use in pulmonary arterial hypertension and systemic sclerosis

Bosentan (Tracleer), an orally administered dual endothelin (ET)(A) and ET(B) receptor antagonist, is indicated in the treatment of pulmonary arterial hypertension (PAH). The efficacy of oral bosentan 125 mg twice daily in improving exercise capacity has been demonstrated in well designed trials in adult patients with idiopathic PAH or PAH associated with connective tissue disease or congenital systemic-to-pulmonary shunts, and in other trials in patients with idiopathic PAH or PAH associated with congenital heart disease or HIV infection. The beneficial effects of first-line bosentan treatment may be maintained for up to 1 year in patients with idiopathic PAH or PAH associated with connective tissue disease. Despite the potential for treatment-related teratogenicity and hepatotoxicity, long-term data indicate that bosentan is generally well tolerated at the approved dosages. Although well designed trials are required to establish the efficacy of bosentan versus or in combination with other specific PAH therapies, especially sildenafil, the convenient oral administration and lack of serious injection-related adverse effects may render bosentan preferable to other PAH therapies. Preliminary data indicate that bosentan may be effective in pediatric PAH patients, although randomized trials are required. Furthermore, bosentan may be a useful option for the prevention of digital ulcer development in patients with systemic sclerosis. Thus, in accordance with current clinical guidelines, bosentan is a convenient, effective, and generally well tolerated agent for use in the first-line treatment of class III PAH or second-line treatment of class IV PAH.

Resource use and survival of patients hospitalized with congestive heart failure: differences in care by specialty of the attending physician. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments

BACKGROUND

Previous studies suggest that specialty care is more costly but may produce improved outcomes for patients with acute cardiac illnesses.

OBJECTIVE

To determine whether patients with congestive heart failure who are cared for by cardiologists experienced differences in costs, care patterns, and survival compared with patients of generalists.

DESIGN

Prospective cohort study.

SETTING

5 U.S. teaching hospitals between 1989 and 1994.

PATIENTS

1298 patients hospitalized with an exacerbation of congestive heart failure.

MEASUREMENTS

Hospital costs; average daily Therapeutic Intervention Scoring System (TISS) score; and survival censored at 30, 180, and 365 days and 31 December 1994.

RESULTS

Compared with patients of generalists, patients of cardiologists were younger (mean age, 63.3 and 71.4 years; P < 0.001) and had lower Acute Physiology Scores at the time of admission (35.1 and 36.7; P < 0.001) but were more likely to have a history of ventricular arrhythmias (21.0% and 10.2%; P < 0.001). At 6 months, 201 (27%) patients of cardiologists and 149 (27%) patients of generalists had died. After adjustment for sociodemographic characteristics and severity of illness, patients of cardiologists incurred costs that were 42.9% (95% CI, 27.8% to 59.8%) higher and average daily TISS scores that were 2.83 points (CI, 1.96 to 3.68 points) higher than those of patients of generalists. Patients of cardiologists were more likely to undergo right-heart catheterization (adjusted odds ratio, 2.9 [CI, 1.7 to 4.9]) or cardiac catheterization (adjusted odds ratio, 3.9 [CI, 2.4 to 6.2]) and had higher odds for transfer to an intensive care unit and electrocardiographic monitoring. Adjusted survival did not differ significantly between groups at 30 days; however, there was a trend toward improved survival among patients of cardiologists at 1 year (adjusted relative hazard, 0.82 [CI, 0.65 to 1.04]) and at maximum follow-up (adjusted relative hazard, 0.80 [CI, 0.66 to 0.96]).

CONCLUSIONS

In this observational study of patients hospitalized with congestive heart failure, cardiologist care was associated with greater costs and resource use and no difference in survival at 30 days of follow-up. Whether the trend toward better survival at longer follow-up represents differences in care or unadjusted illness severity is uncertain.

Five-year mortality after acute myocardial infarction in relation to previous history, level of initial care, complications in hospital, and medication at discharge

The purpose of this study was to describe the prognosis during 5 years of follow-up in a consecutive population of patients discharged from hospital after acute myocardial infarction (AMI) in relation to clinical history, level of initial care, complications during hospitalization, and medication at discharge. All patients admitted to a single hospital from February 15, 1986 to November 9, 1987 due to AMI, regardless of age and whether or not they were treated in the coronary care unit, and who were discharged alive from hospital were included in the study. There were 862 patients with AMI, 740 of whom were discharged alive. Information on medication at discharge was available in 713 patients (96%). In a multivariate analysis taking into account age, sex, history of cardiovascular diseases, whether patients were admitted to coronary care unit or not, complications during hospitalization, and medication at discharge, the following factors appeared to be independent predictors of mortality: age (p < 0.001), history of AMI (p < 0.001), congestive heart failure in hospital (p < 0.001), whether beta-blockers had been prescribed at discharge (p < 0.01), and a history of diabetes (p < 0.01). This study indicates that in consecutive patients surviving the hospital phase of AMI, the development of complications while in hospital and the manner in which medication was prescribed at discharge independently influenced their long-term prognosis, but age was the most important factor in long-term prognosis.