Sex differences in trends and outcomes of acute myocardial infarction with mechanical complications in the United States

BACKGROUND

Mechanical complications (MC) are rare but significant sequelae of acute myocardial infarction (AMI). Current data on sex differences in AMI with MC is limited.

METHODS

We queried the National Inpatient Sample database to identify adult patients with the primary diagnosis of AMI and MC. The main outcome of interest was sex difference in-hospital mortality. Secondary outcomes were sex differences in the incidence of acute kidney injury (AKI), major bleeding, use of inotropes, permanent pacemaker implantation (PPMI), performance of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), surgery (VSD repair and MV surgery), pericardiocentesis, use of mechanical circulatory support (MCS), ischemic stroke, and mechanical ventilation.

RESULTS

Among AMI-MC cohort, in-hospital mortality was higher among females compared to males (41.24% vs 28.13%: aOR 1.39. 95% CI 1.079-1.798; p = 0.01). Among those who had VSD, females also had higher in-hospital mortality compared to males (56.7% vs 43.1%: aOR 1.74, 95% CI 1.12-2.69; p = 0.01). Females were less likely to receive CABG compared to males (12.03% vs 20%: aOR 0.49 95% CI 0.345-0.690; p < 0.001).

CONCLUSION

Despite the decreasing trend in AMI admission, females had higher risk of MC and associated mortality. Significant sex disparities still exist in AMI treatment.

Risk of Recall Associated With Modifications to High-risk Medical Devices Approved Through US Food and Drug Administration Supplements

Importance

High-risk medical devices approved by the US Food and Drug Administration (FDA) can undergo modifications to their original premarket approval (PMA) via 1 of 5 types of supplements. Only panel track supplements (approximately 1%) require clinical data for approval. The association between device modifications and risk to patient safety has not previously been analyzed.

Objective

To determine the association between PMA supplements and the risk of any device recall and high-risk (class 1) recall.

Design, Setting, and Participants

In this cohort study, the FDA database was queried for original devices approved via PMA from January 1, 2008, through December 31, 2019. Supplement and recall data were obtained for these devices from January 1, 2008, through December 31, 2021, giving a minimum 2-year follow-up after initial approval. Data were analyzed from July 6 to August 6, 2022. Retrospective, time-to-event analysis investigated the association between the number and type of supplements and risk of recall.

Exposures

Supplements submitted by manufacturers for FDA approval to modify devices.

Main Outcomes and Measures

A mixed-effects Cox proportional hazards regression model with frailty terms was used, modeling device recall as an outcome variable during the observation period. A second model was performed for class 1 (high-risk) recall. Explanatory variables are the number of supplements, number of panel track supplements, and cardiovascular devices. Multivariable analysis was performed to identify independent risk factors for recall with hazard ratios (HRs) as the main end point.

Results

A total of 373 original PMA devices with 10 776 associated supplements were included in the analysis. A median 2.5 (IQR, 1.2-5.0) supplements per device were approved annually. Cardiovascular devices contributed 138 supplements (37.0%), followed by microbiology with 45 (12.1%). No other specialty contributed more than 10%. Multivariable analysis demonstrated that each increase of 1 supplement per year was associated with increased risk of recall (HR, 1.28 [95% CI, 1.15-1.44]; P < .001). For class 1 recall, increased number of supplements (HR, 1.32 [95% CI, 1.06-1.64]; P = .01) and cardiovascular vsnoncardiovascular classification of devices (HR, 3.51 [95% CI, 1.15-10.72]; P = .03) were significantly associated with an increased risk of recall.

Conclusions and Relevance

The findings of this cohort study suggest that PMA supplements are associated with an approximately 30% increased risk of any recall and class 1 recall. The FDA processes for approving modifications to high-risk medical devices should be reevaluated to optimize patient safety and public health.

30-Day Readmissions After Endovascular Thrombectomy for Acute Ischemic Stroke

OBJECTIVES

The authors sought to investigate the incidence, predictors, and causes of 30-day nonelective readmissions after endovascular thrombectomy (EVT).

BACKGROUND

Randomized trials have demonstrated that EVT improves outcomes in patients with acute ischemic stroke.

METHODS

The Nationwide Readmissions Database, years 2013 and 2014, was used to identify hospitalizations for a primary diagnosis of acute ischemic stroke during which patients underwent EVT, with or without intravenous thrombolysis. The incidence and reasons of 30-day readmissions were investigated. A hierarchical Cox regression model was used to identify independent predictors of 30-day nonelective readmissions. A propensity score-matched analysis was performed to compare the risk of 30-day nonelective readmissions in those who underwent EVT versus thrombolysis alone.

RESULTS

Among 2,055,365 weighted hospitalizations with acute ischemic stroke and survival to discharge, 10,795 (0.5%) underwent EVT. The 30-day readmission rate was 12.4% within a median of 9 days (interquartile range: 4 to 18 days). Diabetes mellitus, coagulopathy, Medicare or Medicaid insurance, and gastrostomy during the index hospitalization were independent predictors of 30-day readmission, but coadministration of thrombolytics with EVT was not an independent predictor. The most common reasons for readmission were infections (17.2%), cardiac causes (17.0%), and recurrent stroke or transient ischemic attack (14.8%). Compared with thrombolysis alone, the hazard of 30-day readmissions was similar (hazard ratio: 0.98; 95% confidence interval: 0.91 to 1.05; p = 0.55).

CONCLUSIONS

In patients hospitalized with acute ischemic stroke who underwent EVT, 30-day nonelective readmissions were common, occurring in approximately 1 in 8 patients, but were similar to those of patients treated with thrombolysis alone. Risk of readmission was associated with certain patient demographics, comorbidities, and complications, but not thrombolysis coadministration. Infections, cardiac causes, and recurrent stroke or transient ischemic attack are the most common reasons for readmission after EVT, emphasizing the need for comprehensive multidisciplinary treatment in the transition to outpatient care.

The Association of Frailty With In-Hospital Bleeding Among Older Adults With Acute Myocardial Infarction: Insights From the ACTION Registry

OBJECTIVES

The aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI).

BACKGROUND

Frailty is a common syndrome in older adults.

METHODS

Frailty was examined among AMI patients ≥65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding.

RESULTS

Among 129,330 AMI patients, 16.4% had any frailty. Frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14).

CONCLUSIONS

Frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population.

Association of Cognitive Impairment With Treatment and Outcomes in Older Myocardial Infarction Patients: A Report From the NCDR Chest Pain-MI Registry

Background

Little is known regarding use of cardiac therapies and clinical outcomes among older myocardial infarction (MI) patients with cognitive impairment.

Methods and Results

Patients ≥65 years old with MI in the NCDR (National Cardiovascular Data Registry) Chest Pain–MI Registry between January 2015 and December 2016 were categorized by presence and degree of chart‐documented cognitive impairment. We evaluated whether cognitive impairment was associated with all‐cause in‐hospital mortality after adjusting for known prognosticators. Among 43 812 ST‐segment–elevation myocardial infarction (STEMI) patients, 3.9% had mild and 2.0% had moderate/severe cognitive impairment; among 90 904 non–ST‐segment–elevation myocardial infarction (NSTEMI patients, 5.7% had mild and 2.6% had moderate/severe cognitive impairment. A statistically significant but numerically small difference in the use of primary percutaneous coronary intervention was observed between patients with STEMI with and without cognitive impairment (none, 92.1% versus mild, 92.8% versus moderate/severe, 90.4%; P=0.03); use of fibrinolysis was lower among patients with cognitive impairment (none, 40.9% versus mild, 27.4% versus moderate/severe, 24.2%; P<0.001). Compared with NSTEMI patients without cognitive impairment, rates of angiography, percutaneous coronary intervention, and coronary artery bypass grafting were significantly lower among patients with NSTEMI with mild (41%, 45%, and 70% lower, respectively) and moderate/severe cognitive impairment (71%, 74%, and 93% lower, respectively). After adjustment, compared with no cognitive impairment, presence of moderate/severe (STEMI: odds ratio, 2.2, 95% CI, 1.8–2.7; NSTEMI: odds ratio, 1.7, 95% CI, 1.4–2.0) and mild cognitive impairment (STEMI: OR, 1.3, 95% CI, 1.1–1.5; NSTEMI: odds ratio, 1.3, 95% CI, 1.2–1.5) was associated with higher in‐hospital mortality.

Conclusions

Patients with NSTEMI with cognitive impairment are substantially less likely to receive invasive cardiac care, while patients with STEMI with cognitive impairment receive similar primary percutaneous coronary intervention but less fibrinolysis. Presence and degree of cognitive impairment was independently associated with increased in‐hospital mortality. Approaching clinical decision making for older patients with MI with cognitive impairment requires further study.

Association of acute myocardial infarction cardiac arrest patient volume and in-hospital mortality in the United States: Insights from the National Cardiovascular Data Registry Acute Coronary Treatment And Intervention Outcomes Network Registry

BACKGROUND

Little is known about how differences in out of hospital cardiac arrest patient volume affect in-hospital myocardial infarction (MI) mortality.

HYPOTHESIS

Hospitals accepting cardiac arrest transfers will have increased hospital MI mortality.

METHODS

MI patients (ST elevation MI [STEMI] and non-ST elevation MI [NSTEMI]) in the Acute Coronary Treatment Intervention Outcomes Network Registry were included. Hospital variation of cardiac arrest and temporal trend of the proportion of cardiac arrest MI patients were explored. Hospitals were divided into tertiles based on the proportion of cardiac arrest MI patients, and association between in-hospital mortality and hospital tertiles of cardiac arrest was compared using logistic regression adjusting for case mix.

RESULTS

A total of 252 882 patients from 224 hospitals were included, of whom 9682 (3.8%) had cardiac arrest (1.6% of NSTEMI and 7.5% of STEMI patients). The proportion of MI patients who had cardiac arrest admitted to each hospital was relatively low (median 3.7% [25th, 75th percentiles: 3.0%, 4.5%]).with a range of 4.2% to 12.4% in the high-volume tertiles. Unadjusted in-hospital mortality increased with tertile: low 3.8%, intermediate 4.6%, and high 4.7% (P < 0.001); this was no longer significantly different after adjustment (intermediate vs high tertile odds ratio (OR) = 1.02; 95% confidence interval [0.90-1.16], low vs high tertile OR = 0.93 [0.83, 1.05]).

CONCLUSIONS

The proportion of MI patients who have cardiac arrest is low. In-hospital mortality among all MI patients did not differ significantly between hospitals that had increased proportions of cardiac arrest MI patients. For most hospitals, overall MI mortality is unlikely to be adversely affected by treating cardiac arrest patients with MI.

Advanced Practice Provider Versus Physician-Only Outpatient Follow-Up After Acute Myocardial Infarction

Background Physician shortages and reimbursement changes have led to greater use of advanced practice providers ( APP s). Prevalence of and outcomes associated with APP care following myocardial infarction are unknown. Methods and Results We examined outpatient cardiology or primary care visits within 90 days post-myocardial infarction among 29 477 Medicare-insured patients aged ≥65 years from 364 hospitals in Acute Coronary Treatment Intervention Outcomes Network Registry. We compared medication adherence, all-cause readmission risk, mortality, and major adverse cardiovascular events between patients seen by APP s versus physicians only. Overall, 11% of myocardial infarction patients were treated by an APP . Patients seen by APP s were more likely to have diabetes mellitus (37% versus 33%) and heart failure (20% versus 16%), be discharged to a nursing facility (21% versus 13%) and had more outpatient visits within 90 days post-discharge (median 6 versus 5, P<0.01 for all) than those seen by physicians only. Adherence to evidence-based medications (adjusted odds ratio, 0.98; 95% confidence interval, 0.89-1.08) and readmission risks (adjusted hazard ratio, 1.11; 95% confidence interval, 0.99-1.26) were similar between patients seen by APP s versus physicians only. Risks of 90-day mortality (adjusted hazard ratio, 1.18; 95% confidence interval, 0.98-1.42) and major adverse cardiovascular events (adjusted hazard ratio, 1.06; 95% confidence interval, 0.90-1.23) were also similar between patients seen by APP s versus physicians only. Conclusions APP s were likely used to provide more frequent monitoring of high-risk post- MI patients. Medication adherence, readmission risk, mortality, and major adverse cardiovascular events did not differ substantially between patients seen by physician- APP teams than those seen by physicians only.

Contemporary Patterns of Early Coronary Angiography Use in Patients With Non-ST-Segment Elevation Myocardial Infarction in the United States: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry

OBJECTIVES

The study sought to characterize patient- and hospital-level variation in early angiography use among non-ST-segment elevation myocardial infarction (NSTEMI) patients.

BACKGROUND

Contemporary implementation of guideline recommendations for early angiography use in NSTEMI patients in the United States have not been described.

METHODS

The study analyzed NSTEMI patients included in ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry (2012 to 2014) who underwent in-hospital angiography. Timing of angiography was categorized as early (≤24 h) vs. delayed (>24 h). The study evaluated factors associated with early angiography, hospital-level variation in early angiography use, and the relationship with quality-of-care measures.

RESULTS

A total of 79,760 of 138,688 (57.5%) patients underwent early angiography. Factors most strongly associated with delayed angiography included weekend or holiday presentation, lower initial troponin ratio values, higher initial creatinine values, heart failure on presentation, and older age. Median hospital-level use of early angiography was 58.5% with wide variation across hospitals (21.7% to 100.0%). Patient characteristics did not differ substantially across hospitals grouped by tertiles of early angiography use (low, middle, and high). Hospitals in the highest tertile tended to more commonly use guideline-recommended medications and had higher defect-free care quality scores.

CONCLUSIONS

In contemporary U.S. practice, high-risk clinical characteristics were associated with lower use of early angiography in NSTEMI patients; hospital-level use of early angiography varied widely despite few differences in case mix. Hospitals that most commonly utilized early angiography also had higher quality-of-care metrics, highlighting the need for improved NSTEMI guideline adherence.

The association of left ventricular ejection fraction with clinical outcomes after myocardial infarction: Findings from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines (GWTG) Medicare-linked database

BACKGROUND

Little is known about the relationship between ejection fraction (EF) and clinical outcomes among older patients with myocardial infarction in contemporary clinical practice.

METHODS

Data on 82,558 patients 65 years or older with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction who survived to hospital discharge in the ACTION Registry-GWTG (2007-2011) were linked to Medicare data. Multivariable Cox proportional hazard modeling was used to assess the association between EF reported during hospitalization and 1-year mortality, using EF as a categorical variable (≤35%, >35% and ≤45%, >45% and <55%, and ≥55%) and as a continuous variable. Secondary outcomes of interest were 1-year all-cause, cardiovascular, and heart failure readmissions.

RESULTS

The risk of 1-year mortality was 29.0% in patients with EF ≤ 35%, compared with 13.0% in patients in the reference group, EF ≥ 55% (adjusted hazard ratio [HR] 1.58, 95% CI 1.51-1.66). Relative to patients with EF ≥ 55%, patients with EF ≤ 35% had an increased risk of 1-year all-cause readmission (adjusted HR 1.20, 95% CI 1.17-1.24), cardiovascular readmission (adjusted HR 1.36, 95% CI 1.31-1.41), and heart failure readmission (adjusted HR 2.43, 95% CI 2.28-2.60). For patients with EF ≤ 40%, the hazard of mortality increased by 26% for every 5% decrease in EF, a finding that remained after risk adjustment (adjusted HR 1.11, 95% CI 1.09-1.12).

CONCLUSIONS

Low EF after MI remains an important risk factor for postdischarge mortality and hospital readmission, even after adjustment for patient and hospital characteristics.

Modest Associations Between Electronic Health Record Use and Acute Myocardial Infarction Quality of Care and Outcomes: Results From the National Cardiovascular Data Registry

BACKGROUND

In 2009, national legislation promoted wide-spread adoption of electronic health records (EHRs) across US hospitals; however, the association of EHR use with quality of care and outcomes after acute myocardial infarction (AMI) remains unclear.

METHODS AND RESULTS

Data on EHR use were collected from the American Hospital Association Annual Surveys (2007-2010) and data on AMI care and outcomes from the National Cardiovascular Data Registry Acute Coronary Treatment and Interventions Outcomes Network Registry-Get With The Guidelines. Comparisons were made between patients treated at hospitals with fully implemented EHR (n=43 527), partially implemented EHR (n=72 029), and no EHR (n=9270). Overall EHR use increased from 82.1% (183/223) hospitals in 2007 to 99.3% (275/277) hospitals in 2010. Patients treated at hospitals with fully implemented EHRs had fewer heparin overdosing errors (45.7% versus 72.8%; P<0.01) and a higher likelihood of guideline-recommended care (adjusted odds ratio, 1.40 [confidence interval, 1.07-1.84]) compared with patients treated at hospitals with no EHR. In non-ST-segment-elevation AMI, fully implemented EHR use was associated with lower risk of major bleeding (adjusted odds ratio, 0.78 [confidence interval, 0.67-0.91]) and mortality (adjusted odds ratio, 0.82 [confidence interval, 0.69-0.97]) compared with no EHR. In ST-segment-elevation MI, outcomes did not significantly differ by EHR status.

CONCLUSIONS

EHR use has risen to high levels among hospitals in the National Cardiovascular Data Registry. EHR use was associated with less frequent heparin overdosing and modestly greater adherence to acute MI guideline-recommended therapies. In non-ST-segment-elevation MI, slightly lower adjusted risk of major bleeding and mortality were seen in hospitals implemented with full EHRs; however, in ST-segment-elevation MI, differences in outcomes were not seen.

Contemporary Patterns of Discharge Aspirin Dosing After Acute Myocardial Infarction in the United States

Background—

Accumulated data suggest that low-dose aspirin after myocardial infarction (MI) may offer similar efficacy to higher dose aspirin with reduced risk of bleeding. Few data are available on contemporary aspirin dosing patterns after MI in the United States

Methods and Results—

Aspirin dosing from 221 199 patients with MI (40.2% ST-segment–elevation MI) from 525 US hospitals enrolled in the National Cardiovascular Data Registry’s (NCDR’s) Acute Coronary Treatment and Intervention Outcomes Network Registry-Get with the Guidelines were described, overall and in clinically relevant subgroups. High-dose aspirin was defined as 325 mg and low dose as 81 mg. Between January 2007 and March 2011, 60.9% of patients with acute MI were discharged on high-dose aspirin, 35.6% on low-dose aspirin, and 3.5% on other doses. High-dose aspirin was prescribed at discharge to 73.0% of patients treated with percutaneous coronary intervention and 44.6% of patients managed medically. Among 9075 patients discharged on aspirin, thienopyridine, and warfarin, 44.0% were prescribed high-dose aspirin. Patients with an in-hospital major bleeding event were also frequently discharged on high-dose aspirin (56.7%). A 25-fold variation in the proportion prescribed high-dose aspirin at discharge was observed across participating centers.

Conclusions—

Most US patients with MI continue to be discharged on high-dose aspirin. Although aspirin dosing after percutaneous coronary intervention largely reflected prevailing guidelines before 2012, high-dose aspirin was prescribed with similar frequency in medically managed patients and to those in categories expected to be at high risk for bleeding. Wide variability in the proportional use of high-dose aspirin across centers suggests significant influence from local practice habits and uncertainty about appropriate aspirin dosing.

Use of aldosterone antagonists at discharge after myocardial infarction: results from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get with the Guidelines (GWTG)

BACKGROUND

Aldosterone antagonists (AldA) improve survival after myocardial infarction (MI) in patients with left ventricular systolic dysfunction (ejection fraction [EF] <40%) concomitant with either clinical heart failure (HF) or diabetes mellitus (DM). Although current American College of Cardiology/American Heart Association guidelines provide a class I recommendation for AldA therapy in such patients, how US practice reflects these recommendations is unclear.

METHODS

Using data from the National Cardiovascular Data Registry ACTION Registry-GWTG, we describe contemporary discharge AldA prescription patterns among 202,213 patients discharged after acute MI from 526 US sites participating in ACTION Registry-GWTG between January 2007 and March 2011.

RESULTS

Overall, 10.0% of patients were eligible for AldA without documented contraindication, with only 14.5% of eligible patients receiving AldA at discharge. Among the subset of AldA-eligible patients discharged on otherwise optimal medical therapy (68.9%), AldAs were prescribed to 16.1%. Aldosterone antagonist use was higher in patients with EF <40% and clinical HF with or without DM (17.7% and 16.6%, respectively), compared with patients with EF <40% and DM without clinical HF (7.8%, P < .001 for each). Fewer than 2% of participating centers used AldA in ≥50% of eligible patients.

CONCLUSIONS

Despite clinical outcome evidence and class I guideline recommendations, AldAs are underused in the United States, with only 1 in 7 eligible patients prescribed AldA at discharge after MI. This contrasts with high use of other evidence-based post-MI medications and identifies a specific gap in translation of evidence into clinical practice.

Association of chronic lung disease with treatments and outcomes patients with acute myocardial infarction

BACKGROUND

Although chronic lung disease (CLD) is common among patients with myocardial infarction (MI), little is known about the influence of CLD on patient management and outcomes following MI.

METHODS

Using the National Cardiovascular Data Registry's ACTION Registry-GWTG, demographics, clinical characteristics, treatments, processes of care, and in-hospital adverse events after acute MI were compared between patients with (n = 22,624) and without (n = 136,266) CLD. Multivariable adjustment was performed to determine the independent association of CLD with treatments and adverse events.

RESULTS

CLD (17.0% of non-ST-elevation MI [NSTEMI] and 10.1% of ST-elevation MI [STEMI] patients) was associated with older age, female sex, and a greater burden of comorbidities. Among NSTEMI patients, those with CLD were less likely to undergo cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft compared to those without; in contrast, no differences were seen in invasive therapies for STEMI patients with or without CLD. Multivariable-adjusted risk of major bleeding was significantly increased in CLD patients with NSTEMI (13.0% vs 8.1%, OR(adj) = 1.27, 95% CI = 1.20-1.34, P < .001) and STEMI (16.0% vs 10.5%, OR(adj) = 1.19, 95% CI = 1.10-1.29, P < .001). In NSTEMI, CLD was associated with a higher risk of inhospital mortality (OR(adj) = 1.21, 95% CI = 1.11-1.33); in STEMI no association between CLD and mortality was seen (OR(adj) = 1.05, 95% CI = 0.95-1.17).

CONCLUSIONS

CLD is common among patients with MI and is independently associated with an increased risk for major bleeding. In NSTEMI, CLD is also associated with receiving less revascularization and with increased in-hospital mortality. Special attention should be given to this high-risk subgroup for the prevention and management of complications after MI.

Abstract 299: Association of Chronic Lung Disease with Treatments and Outcomes of Acute Coronary Syndromes: Results from the NCDR®

Background: Previous reports are conflicting regarding outcomes, treatments, and processes of care after acute myocardial infarction (MI) for patients with chronic lung disease (CLD).

Methods: Using the NCDR ACTION Registry ® -GWTG ™ (AR-G), demographics, clinical characteristics, treatments, processes of care, and in-hospital adverse events after NSTEMI and STEMI were compared between patients with (n= 22,624; 14.2%) and without (n= 136,266; 85.8%) CLD. CLD was defined by a history of COPD, chronic bronchitis, or emphysema. Multivariable adjustment using published AR-G in-hospital mortality and major bleeding risk adjustment models was performed to quantify the impact of CLD on treatments and outcomes.

Results: CLD was present in 10.1% of STEMI patients and 17.0% of NSTEMI patients. In both STEMI and NSTEMI, CLD patients were older, more likely to be female, and had more comorbidities including diabetes, renal disease, prior MI and heart failure, compared to those without CLD. Although on admission CLD patients were more likely to be on cardiovascular medications, by discharge slightly fewer CLD patients received composite core measures (aspirin, beta-blockers, ACE-inhibitors, and statins) (table). In NSTEMI, CLD was also associated with less use of invasive procedures and with increased risk of both death and major bleeding. In STEMI, major bleeding but not mortality was increased.

Conclusions: CLD is a common comorbidity and is independently associated with an increased risk for major bleeding after MI. In NSTEMI, CLD is also associated with receiving fewer evidence-based medications, less timely angiography and revascularization, and increased in-hospital mortality. Close attention should be given to this high-risk subgroup for the prevention and management of bleeding complications after MI, and further investigation is needed to determine the reasons for treatment and outcome disparities in NSTEMI.

Increased adverse events after percutaneous coronary intervention in patients with COPD: insights from the National Heart, Lung, and Blood Institute dynamic registry

BACKGROUND

Previous studies have demonstrated that patients with COPD are at higher risk for death after percutaneous coronary intervention (PCI), but other clinical outcomes and possible associations with adverse events have not been described.

METHODS

Using waves 1 through 5 (1999-2006) of the National Heart, Lung, and Blood Institute Dynamic Registry, patients with COPD (n = 860) and without COPD (n = 10,048) were compared. Baseline demographics, angiographic characteristics, and in-hospital and 1-year adverse events were compared.

RESULTS

Patients with COPD were older (mean age 66.8 vs 63.2 years, P < .001), more likely to be women, and more likely to have a history of diabetes, prior myocardial infarction, peripheral arterial disease, renal disease, and smoking. Patients with COPD also had a lower mean ejection fraction (49.1% vs 53.0%, P < .001) and a greater mean number of significant lesions (3.2 vs 3.0, P = .006). Rates of in-hospital death (2.2% vs 1.1%, P = .003) and major entry site complications (6.6% vs 4.2%, P < .001) were higher in pulmonary patients. At discharge, pulmonary patients were significantly less likely to be prescribed aspirin (92.4% vs 95.3%, P < .001), β-blockers (55.7% vs 76.2%, P < .001), and statins (60.0% vs 66.8%, P < .001). After adjustment, patients with COPD had significantly increased risk of death (hazard ratio [HR] = 1.30, 95% CI = 1.01-1.67) and repeat revascularization (HR = 1.22, 95% CI = 1.02-1.46) at 1 year, compared with patients without COPD.

CONCLUSIONS

COPD is associated with higher mortality rates and repeat revascularization within 1 year after PCI. These higher rates of adverse outcomes may be associated with lower rates of guideline-recommended class 1 medications prescribed at discharge.

Association of a unique cardiovascular risk profile with outcomes in Hispanic patients referred for percutaneous coronary intervention (from the National Heart, Lung, and Blood Institute Dynamic Registry)

Although previous studies have demonstrated that Hispanic patients have a higher cardiovascular risk profile than Caucasians and present at a younger age for percutaneous coronary intervention (PCI), limited studies exist examining the outcomes of Hispanics after PCI and potential explanations for differences noted. Using patients from the National Heart, Lung, and Blood Institute Dynamic Registry waves 1 to 5 (1997 to 2006), demographic features, angiographic data, and 1-year outcomes of Hispanic patients (n = 542) versus Caucasian patients (n = 1,357) undergoing PCI were evaluated. Compared to Caucasians, Hispanic patients were younger and had more hypertension and diabetes mellitus, including more insulin-treated diabetes mellitus. Although mean lesion length was longer in Hispanics (15.4 vs 14.1 mm, p <0.001), there were no differences in the number of significant lesions or in the use of drug-eluting stents. At follow-up, Hispanics were more likely to report recent anginal symptoms but had a similar incidence of 1-year hospitalizations for angina. Adjusted 1-year hazard ratios for adverse events for Hispanics versus Caucasians revealed lower rates of coronary artery bypass graft surgery (hazard ratio 0.43, confidence interval 0.22 to 0.85, p = 0.02) and a trend toward lower rates of repeat revascularization (hazard ratio 0.76, confidence interval 0.57 to 1.03, p = 0.08). In conclusion, despite the presence of diabetes in almost 50% of Hispanic patients and longer lesions than in Caucasians, Hispanic patients were less likely to undergo coronary artery bypass graft surgery 1 year after PCI and had a trend toward lower rates of repeat revascularization.

Women tolerate drug therapy for coronary artery disease as well as men do, but are treated less frequently with aspirin, beta-blockers, or statins

BACKGROUND

Women have worse morbidity, mortality, and health-related quality-of-life outcomes associated with coronary artery disease (CAD) compared with men. This may be related to underutilization of drug therapies, such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or statins. No studies have sought to describe the relationship of gender with adverse reactions to drug therapy (ADRs) for CAD in clinical practice.

OBJECTIVE

The aim of this study was to determine the prevalence of ADRs associated with common CAD drug therapies in women and men in clinical practice.

METHODS

In a cohort of consecutive outpatients with CAD, detailed chart abstraction was performed to determine the use of aspirin, beta-blocker, ACE inhibitor, and statin therapy, as well as the ADRs reported for these treatments. Baseline clinical characteristics were also determined to identify the independent association of gender with use of standard drug treatments for CAD.

RESULTS

Consecutive patients with CAD (153 men, 151 women) were included in the study. Women and men were observed to have a similar prevalence of cardiac risk factors and comorbidities, except that men had significantly higher prevalence of atrial fibrillation (30 [19.6%] men vs 15 [9.9%] women; P = 0.03) and significantly lower mean (SD) high-density lipoprotein cholesterol concentrations (45 [16] mg/dL for men vs 55 [19] mg/dL for women; P < 0.001). No significant differences were observed between the sexes in the prevalence of ADRs; however, significantly fewer women than men were treated with statins (118 [78.1%] vs 139 [90.8%], respectively; P = 0.003). After adjusting for clinical characteristics, women were also found to be less likely than men to receive aspirin (odds ratio [OR] = 0.164; 95% CI, 0.083-0.322; P = 0.001) and beta-blockers (OR = 0.184; 95% CI, 0.096-0.351; P = 0.001).

CONCLUSIONS

Women and men experienced a similar prevalence of ADRs in the treatment of CAD; however, women were significantly less likely to be treated with aspirin, beta-blockers, and statins than were their male counterparts. To optimize care for women with CAD, further study is needed to identify the cause of this gender disparity in therapeutic drug use.

Assessment of and physician response to glycemic control in diabetic patients presenting with an acute coronary syndrome

BACKGROUND

Diabetes mellitus (DM) is a common comorbidity among patients with acute coronary syndrome (ACS). The frequency with which physicians assess diabetic patients' glycemic control during an ACS hospitalization is not known and may represent an opportunity for quality improvement.

METHODS

This study describes the proportion of diabetic patients who had an assessment of their glycemic control (HbA1c) at the time of an ACS hospitalization. Secondary analyses examined characteristics associated with HbA1c assessment and physicians' responses to poor glycemic control.

RESULTS

Among 968 enrolled patients with ACS, 235 (24%) had DM. HbA1c values were known or obtained in 162 (69%) patients; 60% were poorly controlled (HbA1c > 7). Older patients were less likely to have an HbA1c assessment (relative risk [RR] = 0.81 [95% CI 0.64-1.01] for patients 60-69 years and RR = 0.71 [95% CI 0.58-0.88] for those > or = 70 years compared to patients < 60 years, P = .004). Among patients without an HbA1c, only consultation by an endocrinologist was independently associated with obtaining a subsequent assessment (RR 1.60, 95% CI 1.33-1.92, P < .001). Among those with an elevated HbA1c, 42% with an HbA1c of 7 to 9 and 69% of those with HbA1c > 9 had their diabetic regimen increased.

CONCLUSIONS

Almost one third of diabetic patients with ACS do not have HbA1c assessment at discharge; particularly older patients and those not evaluated by an endocrinologist. Although > 60% of those assessed had poor control, many did not have adjustments of their diabetic therapy. Assessment of diabetes represents an opportunity to improve the quality of care for diabetic patients with ACS.

[Identification of the patient with acute severe pancreatitis. A prospective, comparative study of the Ranson and the Salvador Zubirán National Institute of Nutrition criteria]

Early detection of severe acute pancreatitis could represent a formidable task for the clinician with limited resources. We have previously proposed a series of parameters that can identify patients with severe acute pancreatitis. The aim of this prospective study was to compare Ranson criteria with those previously described by the authors (INNSZ criteria) in 78 patients with acute pancreatitis. Sensitivity, specificity, positive and negative predictive values and accuracy were similar in both scores. We found a good correlation (r = 0.65, p < 0.001) and agreement (z = 5.0, Kappa 0.69, p < 0.001) between Ranson and INNSZ criteria. Our results allow us to propose INNSZ severity criteria as an easy and inexpensive alternative in the evaluation of patients with acute pancreatitis.