Acute Coronary Treatment And Intervention Outcomes Network Research Articles

Modern NCDR and ACTION risk models outperform the GRACE model for prediction of in-hospital mortality in acute coronary syndrome in a German cohort

Background and purposeRisk prediction with the Global Registry of Acute Coronary Events (GRACE) risk model is guideline-recommended in acute coronary syndrome (ACS) patients. However, the performance of more contemporary scores derived from ACTION (Acute Coronary Treatment and Intervention Outcomes Network) and National Cardiovascular Data (NCDR) registries remains incompletely understood. We aimed to compare these models in German ACS patients. Methods and resultsA total of 1567 patients with (Non-)ST-segment elevation myocardial infarction (NSTEMI: 1002 patients, STEMI: 565 patients) undergoing invasive management at University Hospital Düsseldorf (Germany) from 2014 to 2018 were included. Overall in-hospital mortality was 7.5% (NSTEMI 3.7%, STEMI 14.5%). Parameters for calculation of GRACE 1.0, GRACE 2.0, ACTION and NCDR risk models and in-hospital mortality were assessed and risk model performance was compared. The GRACE 1.0 risk model for prediction of in-hospital mortality discriminated risk superior (c-index 0.84) to its successor GRACE 2.0 (c-index 0.79, pGRACE1.0vsGRACE2.0 = 0.0008). The NCDR model performed best in discrimination of risk in ACS overall (c-index 0.89; pACTIONvsNCDR < 0.0001; pGRACEvsNCDR < 0.0001) and showed superior performance compared to GRACE in NSTEMI and STEMI subgroups (pGRACEvsNCDR both < 0.02). ACTION and GRACE risk models performed comparable to each other (both c-index 0.84, pGRACEvsACTION = 0.68), with advantages for ACTION in NSTEMI patients (c-index 0.87 vs. 0.84 (GRACE); pGRACEvsACTION = 0.02). ACTION and GRACE 2.0 showed the most accurate calibration of all models. ConclusionsIn a contemporary German patient population with ACS, modern NCDR and ACTION risk models showed superior performance in prediction of in-hospital mortality compared to the gold-standard GRACE model.

ACTION and NCDR risk models outperform GRACE for prediction of in-hospital mortality in acute coronary syndrome – a retrospective analysis from a German Heart Center

Abstract Background Risk prediction with the GRACE risk model is guideline-recommended clinical practice in acute coronary syndrome (ACS). However, more modern risk models such as ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry–GWTG (Get With the Guidelines) and National Cardiovascular Data Registry (NCDR) risk models are available. We aimed to compare these models to the established GRACE risk model in ACS. Methods and results In-hospital mortality was retrospectively assessed in 1,138 patients undergoing cardiac catheterization for Non-ST-Elevation Myocardial Infarction (NSTEMI, 566 patients, 70.7% male) or ST-Elevation Myocardial Infarction (STEMI, 572 patients, 69.1% male) at a German University Hospital from 2014 to 2017. In-hospital mortality was 14.7% for STEMI and 3.7% for NSTEMI, respectively. GRACE, ACTION and NCDR risk models for prediction of in-hospital mortality were calculated for individual patients, 0.75% missing data were imputed. ACTION risk model showed a good discrimination of risk (c-index 0.85, 95% confidence interval (CI) 0.83–0.87) with a slight numerical advantage in NSTEMI (c-index 0.92, 95% CI 0.86–0.98) over STEMI patients (c-index 0.83, 95% CI 0.79–0.88). The NCDR risk model showed comparable performance in the overall cohort (c-index 0.86, 95% CI 0.84–0.88; NCDR vs. ACTION p=0.4097), also with superior performance in NSTEMI (c-index 0.89, 95% CI 0.86–0.91) vs. STEMI (c-index 0.81, 95% CI 0.78–0.84). The GRACE risk model showed significantly worse performance in the overall cohort (c-index 0.76, 95% CI 0.74–0.79; vs ACTION p&amp;lt;0.0001; vs. NCDR p&amp;lt;0.0001) and in STEMI patients (c-index 0.72, 95% CI 0.69–0.76; vs ACTION p&amp;lt;0.0001; vs. NCDR p=0.0018). In NSTEMI patients, GRACE discrimination performance was comparable to NCDR (c-index 0.87, 95% CI 0.84–0.90, p=0.73), but still inferior to ACTION (p=0.04). The ACTION risk model showed a good calibration whereas NCDR and GRACE models lacked accuracy in our cohort. Conclusion In a contemporary German patient population with acute coronary syndrome, ACTION and NCDR risk models outperform the established GRACE risk model for prediction of in-hospital mortality. This performance difference was more pronounced in STEMI than in NSTEMI. Funding Acknowledgement Type of funding source: None

Meta-Analysis of Bleeding Scores Performance for Acute Coronary Syndrome

Bleeding is a common and frequently devastating complication in acute coronary syndrome (ACS). It is critical to evaluate in the current era of ACS management involving invasive strategies and potent anti-thrombotics. Risk models remain under-utilised in this setting but may guide the choice and duration of therapy. We compared their performances for predicting bleeding in ACS patients in this meta-analysis. Medline, EMBASE, Cochrane and Scopus were searched for relevant articles from 1980 to 31 December 2017 assessing external validation of risk scores for bleeding after ACS. Two (2) authors independently reviewed the searched studies for eligibility, followed by pooled analyses using random effects models. Amongst 1,843 articles searched, 73 full-texts were reviewed and 17 studies totalling 18,155 patients were included for analysis. C-statistics (95% confidence interval) for predicting in-hospital major bleeding by risk model were Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) 0.714 (0.659-0.779), Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) 0.711 (0.626-0.797), Acute Coronary Treatment and Intervention Outcomes Network (ACTION) 0.767 (0.737-0.797), Global Registry of Acute Coronary Events (GRACE) 0.689 (0.473-0.905) and HAS-BLED 0.636 (0.460-0.812). CRUSADE also predicted bleeding during medium-term follow-up c=0.704 (0.644-0.765). It performed better for radial versus femoral access (c=0.826 and 0.734), invasive versus non-invasive strategy (c=0.752 and 0.625) and similarly for ST elevation myocardial infarction (STEMI) and non-ST elevation myocardial infarction (NSTEMI) (c=0.791 and 0.760). Heterogeneities of studies and paucity of studies assessing risk scores beyond CRUSADE were important limitations. Acute coronary syndrome-specific bleeding scores had moderate discrimination for bleeding, while the GRACE and HAS-BLED scores could not. The ACTION score had the highest pooled c-statistic, while the CRUSADE score was the most widely studied, and also performed better for invasive strategy and radial access subgroups.

Clinical outcomes and need for intensive care after non-ST-segment-elevation myocardial infarction

BackgroundThe decision on whether non-ST-segment elevation myocardial infarction (NSTEMI) patients should be admitted to intensive care units (ICU) takes into account several factors including hospital routines. The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU score was developed to predict complications requiring ICU care post-NSTEMI. MethodsWe described patient characteristics and clinical outcomes of 1263 NSTEMI patients admitted to a private hospital in Sao Paulo, Brazil, from 2014 to 2018. We also aimed to retrospectively identify NSTEMI patients who might not have needed to be admitted to the ICU based on the ACTION ICU risk score. We defined complications requiring ICU care post-NSTEMI as cardiac arrest, cardiogenic shock, stroke, re-infarction, death, heart block requiring pacemaker placement, respiratory failure, or sepsis. ResultsMean age was 62.3 years and 35.8% were female. A total of 94.6% of NSTEMI patients were admitted to the ICU. Most NSTEMI patients (91.9%) underwent coronary angiography. Percutaneous coronary intervention was performed in 47.1% and coronary artery bypass graft surgery in 10.3%. Complications requiring ICU care occurred in 62 patients (4.9%). In-hospital mortality rate was 1.3%. Overall, 70.4% had an ACTION ICU score ≤ 5. The C-statistics for the ACTION risk score to predict complications was 0.55 (95% confidence interval 0.47–0.63). ConclusionsComplications requiring ICU care were infrequent in a cohort of NSTEMI patients who were routinely admitted to the ICU over a 4-year period. The ACTION risk score had low accuracy in the prediction of complications requiring ICU care in our population.

Deep-learning-based risk stratification for mortality of patients with acute myocardial infarction.

ObjectiveConventional risk stratification models for mortality of acute myocardial infarction (AMI) have potential limitations. This study aimed to develop and validate deep-learning-based risk stratification for the mortality of patients with AMI (DAMI).MethodsThe data of 22,875 AMI patients from the Korean working group of the myocardial infarction (KorMI) registry were exclusively divided into 12,152 derivation data of 36 hospitals and 10,723 validation data of 23 hospitals. The predictor variables were the initial demographic and laboratory data. The endpoints were in-hospital mortality and 12-months mortality. We compared the DAMI performance with the global registry of acute coronary event (GRACE) score, acute coronary treatment and intervention outcomes network (ACTION) score, and the thrombolysis in myocardial infarction (TIMI) score using the validation data.ResultsIn-hospital mortality for the study subjects was 4.4% and 6-month mortality after survival upon discharge was 2.2%. The areas under the receiver operating characteristic curves (AUCs) of the DAMI were 0.905 [95% confidence interval 0.902–0.909] and 0.870 [0.865–0.876] for the ST elevation myocardial infarction (STEMI) and non ST elevation myocardial infarction (NSTEMI) patients, respectively; these results significantly outperformed those of the GRACE (0.851 [0.846–0.856], 0.810 [0.803–0.819]), ACTION (0.852 [0.847–0.857], 0.806 [0.799–0.814] and TIMI score (0.781 [0.775–0.787], 0.593[0.585–0.603]). DAMI predicted 30.9% of patients more accurately than the GRACE score. As secondary outcome, during the 6-month follow-up, the high risk group, defined by the DAMI, has a significantly higher mortality rate than the low risk group (17.1% vs. 0.5%, p < 0.001).ConclusionsThe DAMI predicted in-hospital mortality and 12-month mortality of AMI patients more accurately than the existing risk scores and other machine-learning methods.

In-Hospital Bleeding Outcomes of Myocardial Infarction in the Era of Warfarin and Direct Oral Anticoagulants for Atrial Fibrillation in the United States: A Report From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry.

BackgroundWe sought to examine patient characteristics, peri‐infarction invasive and pharmacologic management, and in‐hospital major bleeding in myocardial infarction patients with atrial fibrillation or flutter, based on home anticoagulant use.Methods and ResultsWe stratified patients by home anticoagulant: (1) no anticoagulant, (2) warfarin, and (3) direct oral anticoagulants (DOACs) among ST‐segment–elevation myocardial infarction (STEMI) and non‐STEMI (NSTEMI) patients with atrial fibrillation or flutter treated at 761 US hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. The primary outcome of our study was in‐hospital major bleeding. Multivariable logistic regression was used to examine the independent association between home anticoagulant and in‐hospital major bleeding. Among 6471 STEMI patients with atrial fibrillation or flutter, 15.7% were on warfarin and 13.0% on DOACs; among 19 954 NSTEMI patients, 22.8% were on warfarin and 15.4% on DOACs. In STEMI, door‐to‐balloon times were slightly higher in those on anticoagulant, with similar rates of angiography within 24 hours in the 3 groups. NSTEMI patients on anticoagulant were less likely to undergo angiography (49.3% no anticoagulant, 33.4% on warfarin, 36.4% on DOACs; P<0.01) or percutaneous coronary intervention within 24 hours (21.1% no anticoagulant, 14.3% on warfarin, 15.9% on DOACs; P<0.01). After multivariate adjustment, use of home warfarin (odds ratio: 1.00 [95% CI, 0.79–1.27] in STEMI and 1.13 [95% CI, 0.97–1.30] in NSTEMI) or DOAC (odds ratio: 0.93 [95% CI, 0.73–1.20] in STEMI and 0.97 [95% CI, 0.81–1.16] in NSTEMI) was not associated with increased in‐hospital major bleeding compared with no anticoagulant.ConclusionsIn routine clinical practice, home warfarin or DOAC therapy is not associated with an increased risk of in‐hospital bleeding compared with no anticoagulant.

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

ObjectivesThe aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI). BackgroundFrailty is a common syndrome in older adults. MethodsFrailty 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. ResultsAmong 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). ConclusionsFrail 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.

Ticagrelor Use in Acute Myocardial Infarction: Insights From the National Cardiovascular Data Registry.

BackgroundTicagrelor is a P2Y12 receptor inhibitor with superior clinical efficacy compared with clopidogrel. However, it is associated with reduced efficacy when combined with a high‐dose aspirin.Methods and ResultsPatients in the acute coronary treatment and intervention outcomes network (ACTION) Registry‐Get With The Guidelines (GWTG) with acute myocardial infarction from October 2013 through December 2014 were included in the study (167 455 patients; 622 sites). We evaluated temporal trends in the prescription of P2Y12 inhibitors, and identified factors associated with ticagrelor use at discharge. Among patients discharged on ticagrelor and aspirin (21 262 patients), we evaluated the temporal trends and independent factors associated with high‐dose aspirin prescription at discharge. Ticagrelor prescription at discharge increased significantly from 12% to 16.7% (P<0.0001). Decreases in prasugrel and clopidogrel use at discharge (15.7%–13.9% and 54.2%–51.1%, respectively, P<0.0001) were also observed. Independent factors associated with preferential ticagrelor prescription at discharge over clopidogrel included younger age, white race, home ticagrelor use, invasive management, and in‐hospital re‐infarction and stroke (P<0.0001 for all), whereas older age, female sex, prior stroke, home ticagrelor use, and in‐hospital stroke (P<0.0001 for all) were associated with preferential ticagrelor prescription at discharge over prasugrel. High‐dose aspirin was used in 3.1% of patients discharged on ticagrelor. Independent factors associated with high‐dose aspirin prescription at discharge included home aspirin use, diabetes mellitus, previous myocardial infarction, previous coronary artery bypass graft, ST‐segment–elevation myocardial infarction, cardiogenic shock, and geographic region (P=0.01).ConclusionsOur contemporary analysis shows a modest but significant increase in the use of ticagrelor and a high rate of adherence to the use of low‐dose aspirin at discharge.

Medication Administration Delays in Non-ST Elevation Myocardial Infarction: Analysis of 1002 Patients Admitted to an Academic Medical Center.

Our goal was to assess adherence to American College of Cardiology/American Heart Association guideline-based medical therapy in patients admitted with type I non-ST elevation myocardial infarction (NSTEMI) and to determine factors associated with medication administration delay. We performed a retrospective analysis using data from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry. Baseline patient demographics, 12-lead electrocardiogram (ECG) findings, laboratory values, medications administered and the time they were administered, and in-hospital clinical outcomes were collected. Global Registry of Acute Coronary Events risk scores were calculated for all patients. We included 1002 patients admitted from the emergency department with a type I NSTEMI. A total of 802 (80%) patients received appropriate initial therapy consisting of therapeutic anticoagulation with heparin and dual antiplatelet therapy. Of the 200 (20%) patients who did not receive therapy, documentation in the chart regarding possible contraindications for administration of the medications was missing in up to half. Female sex, older age, a normal initial ECG, and prolonged time spent in the emergency department were predictors of significant delay in receiving guideline-based medications, while an elevated initial troponin was a predictor of faster medication administration. Global Registry of Acute Coronary Events risk scores had no association with the timing of medication administration. In conclusion, 20% of NSTEMI patients did not receive American College of Cardiology/American Heart Association guideline-based medical therapy. Delay in medication administration was significant for women, older individuals, and patients who did not have ischemic findings on the initial ECG.

Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non-ST-Segment-Elevation Myocardial Infarction.

BackgroundIntensive care unit (ICU) use for initially stable patients presenting with non–ST‐segment–elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high‐risk patients with NSTEMI for ICU admission.Methods and ResultsUsing the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high‐grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU‐level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST‐segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C‐statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU.ConclusionsThe ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources.

Improvement of Door-to-Electrocardiogram Time Using the First-Nurse Role in the ED Setting

IntroductionThis quality improvement project compared door-to-electrocardiogram (ECG) times for patients presenting with symptoms suggestive of acute coronary syndrome within a community hospital emergency department before and after first-nurse (emergency nurse stationed in the ED waiting room) training. MethodDoor-to-ECG time was compared before and after the educational intervention using Acute Coronary Treatment and Intervention Outcomes Network (ACTION) registry data reported by the facility. ResultsStatistical significance was not achieved using a 2-group t-test. However, when comparing monthly means, data trend lines showed favorable improvement for door-to-ECG time after the intervention. DiscussionLimitations included using only those patients in the ACTION registry and not accounting for RN turnover with first-nurse education. Future studies should focus on all patients presenting with symptoms of acute coronary syndrome as well as other patients presenting with time-sensitive needs to determine the efficacy of the first-nurse role.Unlabelled Box

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

ObjectivesThe study sought to characterize patient- and hospital-level variation in early angiography use among non–ST-segment elevation myocardial infarction (NSTEMI) patients. BackgroundContemporary implementation of guideline recommendations for early angiography use in NSTEMI patients in the United States have not been described. MethodsThe 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. ResultsA 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. ConclusionsIn 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.

Lipid Testing and Statin Dosing After Acute Myocardial Infarction.

BackgroundThe 2013 American College of Cardiology/American Heart Association cholesterol guidelines recommend high‐intensity statins for patients after myocardial infarction (MI) rather than treating to a low‐density lipoprotein cholesterol goal, as the previous ATP III (Adult Treatment Panel third report) guidelines had advised.Methods and ResultsTo evaluate the frequency of postdischarge lipid testing and high‐intensity statin use among MI patients discharged on a statin during the ATP III guidelines era, we linked ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry data to Medicare claims for 11 046 MI patients aged ≥65 years who were discharged alive on a statin from 347 hospitals (2007–2009). Multivariable regression was used to evaluate the association between lipid testing and 1‐year high‐intensity statin use. Only 21% of MI patients were discharged on a high‐intensity statin. By 90 days after MI, 44% of patients discharged on a statin underwent lipid testing (43% on low‐ or moderate‐intensity statins and 49% on high‐intensity statins; P=0.001). Follow‐up lipid testing rates were 47% among patients with in‐hospital low‐density lipoprotein cholesterol ≥100 mg/dL and 47% among newly prescribed statin recipients. By 1 year, only 14% of patients were on high‐intensity statins. Only 4% of patients discharged on low‐ or moderate‐dose statin were uptitrated to high intensity; postdischarge lipid testing was associated with a slightly higher likelihood of high‐intensity statin use by 1 year (5.4% versus 2.9%, adjusted odds ratio: 1.92; 95% confidence interval, 1.52–2.41).ConclusionsPrevious guidelines recommended low‐density lipoprotein cholesterol goal‐directed statin therapy, but lipid testing and high‐intensity statin use were infrequent after MI. The American College of Cardiology/American Heart Association guidelines may promote more intensive cardiovascular risk reduction by eliminating treatment dependence on lipid testing.

ACTION (acute coronary treatment and intervention outcomes network) registry-GWTG (get with the guidelines) risk score predicts long-term mortality in acute myocardial infarction.

This study aimed to test the predictive performance of the updated ACTION, GRACE, and CADILLAC risk scores (RS’s) for long-term mortality in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). The study included individuals from 2 independent cohorts: derivation cohort (N = 1901) and validation cohort (N = 728). From the derivation cohort, we used Cox regression analysis to determine that the updated ACTION, GRACE, and CADILLAC RS's were associated with long-term mortality. The concordance (C) statistics of the 3 RS's were 0.682, 0.703 and 0.734, respectively. We used the validation cohort to validate the results. Moreover, the discriminatory performance of the updated ACTION RS for predicting long-term mortality in both the respective derivation and validation cohorts was similar to the discriminatory performance of the GRACE and CADILLAC RS's (ACTION vs. GRACE: z = 0.684, p = 0.494; ACTION vs. CADILLAC: z = 1.638, p = 0.101) and (ACTION vs. GRACE: z = 0.460, p = 0.646; ACTION vs. CADILLAC: z = 0.290, p = 0.772). Despite their development over a decade ago, GRACE and CADILLAC RS's maintain good performance for predicting the long-term mortality of AMI patients undergoing PCI. As a new risk model, the updated ACTION RS also predicts long-term mortality, and its discriminatory performance is similar to that of the GRACE and CADILLAC RS’s.

Age Differences in Hospital Mortality for Acute Myocardial Infarction: Implications for Hospital Profiling.

Publicly reported hospital risk-standardized mortality rates (RSMRs) for acute myocardial infarction (AMI) are calculated for Medicare beneficiaries. Outcomes for older patients with AMI may not reflect general outcomes. To examine the relationship between hospital 30-day RSMRs for older patients (aged ≥65 years) and those for younger patients (aged 18 to 64 years) and all patients (aged ≥18 years) with AMI. Retrospective cohort study. 986 hospitals in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines. Adults hospitalized for AMI from 1 October 2010 to 30 September 2014. Hospital 30-day RSMRs were calculated for older, younger, and all patients using an electronic health record measure of AMI mortality endorsed by the National Quality Forum. Hospitals were ranked by their 30-day RSMRs for these 3 age groups, and agreement in rankings was plotted. The correlation in hospital AMI achievement scores for each age group was also calculated using the Hospital Value-Based Purchasing (HVBP) Program method computed with the electronic health record measure. 267763 and 276031 AMI hospitalizations among older and younger patients, respectively, were identified. Median hospital 30-day RSMRs were 9.4%, 3.0%, and 6.2% for older, younger, and all patients, respectively. Most top- and bottom-performing hospitals for older patients were neither top nor bottom performers for younger patients. In contrast, most top and bottom performers for older patients were also top and bottom performers for all patients. Similarly, HVBP achievement scores for older patients correlated weakly with those for younger patients (R= 0.30) and strongly with those for all patients (R= 0.92). Minority of U.S. hospitals. Hospital mortality rankings for older patients with AMI inconsistently reflect rankings for younger patients. Incorporation of younger patients into assessment of hospital outcomes would permit further examination of the presence and effect of age-related quality differences. American College of Cardiology.

Contemporary risk model for inhospital major bleeding for patients with acute myocardial infarction: The acute coronary treatment and intervention outcomes network (ACTION) registry®–Get With The Guidelines (GWTG)®

Major bleeding is a frequent complication for patients with acute myocardial infarction (AMI) and is associated with significant morbidity and mortality. To develop a contemporary model for inhospital major bleeding that can both support clinical decision-making and serve as a foundation for assessing hospital quality. An inhospital major bleeding model was developed using the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) database. Patients hospitalized with AMI between January 1, 2012 and December 31, 2013 across 657 hospitals were used to create a derivation cohort (n=144,800) and a validation cohort (n=96,684). Multivariable hierarchal logistic regression was used to identify significant predictors of major bleeding. A simplified risk score was created to enable prospective risk stratification for clinical care. The rate of major bleeding in the overall population was 7.53%. There were 8 significant, independent factors associated with major bleeding: presentation after cardiac arrest (OR 2.99 [2.77-3.22]); presentation in cardiogenic shock (OR 2.22 [2.05-2.40]); STEMI (OR 1.72 [1.65-1.80]); presentation in heart failure (OR 1.55 [1.47-1.63]); baseline hemoglobin less than 12 g/dL (1.55 [1.48-1.63]); heart rate (per 10 beat per minute increase) (OR 1.13 [1.12-1.14]); weight (per 10 kilogram decrease) (OR 1.12 [1.11-1.14]); creatinine clearance (per 5-mL decrease) (OR 1.07 [1.07-1.08]). The model discriminated well in the derivation (C-statistic = 0.74) and validation (C-statistic = 0.74) cohorts. In the validation cohort, a risk score for major bleeding corresponded well with observed bleeding: very low risk (2.2%), low risk (5.1%), moderate risk (10.1%), high risk (16.3%), and very high risk (25.2%). The new ACTION Registry-GWTG inhospital major bleeding risk model and risk score offer a robust, parsimonious, and contemporary risk-adjustment method to support clinical decision-making and enable hospital quality assessment. Strategies to mitigate risk should be developed and tested as a means to lower costs and improve outcomes in an era of alternative payment models.

Selection of Stent Type in Patients With Atrial Fibrillation Presenting With Acute Myocardial Infarction: An Analysis From the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry-Get With the Guidelines.

BackgroundPatients receiving oral anticoagulation in addition to dual‐antiplatelet therapy are known to be at high risk for bleeding events; thus, the selection of a drug‐eluting stent (DES) versus a bare metal stent (BMS) can have important implications for patients with atrial fibrillation (AF) presenting with acute myocardial infarction (MI).Methods and ResultsFrom the National Cardiovascular Data Registry ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry—Get With the Guidelines, we identified 14 427 AF patients presenting with acute MI undergoing percutaneous coronary intervention from 2008 to 2014. Temporal trends and hospital variation in DES use were examined, as were patterns of use by stroke risk (CHA2DS2‐VASc) and bleeding risk ATRIA (Anticoagulation and Risk Factors in Atrial Fibrillation). Among patients with linked Medicare data (n=2844), multivariable Cox regression modeling was used to compare risks for a composite outcome (all‐cause mortality, readmission for stroke, or MI), readmission for stroke, revascularization, and major bleeding at 1 year. A DES was used in 8414 (58.9%) MI patients with AF, increasing from 47.1% in 2008 to 67.9% in 2014, with wide variation among hospitals. DES placement was more common than BMS placement among patients at high stroke risk (CHA2DS2‐VASc ≥2) and high bleeding risk (ATRIA ≥4). Although aspirin and a P2Y12 inhibitor were prescribed for >95% of all patients regardless of stent type at discharge, warfarin was prescribed less frequently among patients receiving a DES than a BMS (31% versus 39%, P<0.001). The composite outcome was similar between patients with a DES or BMS at 1 year (22% versus 26%; adjusted hazard ratio: 0.88; 95% confidence interval [CI], 0.76–1.03).ConclusionsUse of DESs among MI patients with AF has increased over time, but substantial hospital‐level variation was observed. Patients with AF meeting indications for anticoagulation are more likely to receive a DES than a BMS, even among those at high predicted risk of both stroke and bleeding.

Prior beta blockers use is independently associated with increased inpatient mortality in patients presenting with acute myocardial infarction

BackgroundBeta blockers (BBs) are recommended for patients presenting with acute myocardial infarction. However, the effects of prior BBs use on inpatient mortality in patients presenting with acute myocardial infarction (AMI) are unknown. MethodsThis was a retrospective cohort study of patients presenting with AMI in Florida Hospital Orlando from January 1, 2013 to December 31, 2014. Data were collected prospectively, as part of the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry. Results1128 patients were included in the analysis, with 354 (31.4%) patients on home BBs and 774 (68.6%) not on home BBs on presentation. Patients in prior BBs group were older, had higher incidence of multiple comorbidities, and were more likely to take cardiovascular medications. During hospitalization, Patients in prior BBs group were more likely to develop decompensated heart failure (9.9% vs. 3.6%, P<0.001), less likely to have STEMI (33.9% vs. 54.4%, P<0.001), and subsequently less PCI (73.2% vs. 81.3%, P=0.002), but higher inpatient mortality (8.8% vs. 4.8%, P=0.009). In multivariable logistic regression analysis, prior BBs use was independently associated with increased inpatient mortality (adjusted OR 3.15, 95% CI 1.44-6.87, P=0.004), as well as in GRACE model (adjusted ratio=1.83, 95% CI 1.01-3.34, P<0.047). However, prior BBs use did not contribute significantly to predict inpatient mortality on the basis of GRACE model in terms of discrimination and calibration. ConclusionsPrior BBs use was independently associated with increased inpatient mortality, and should be considered a high risk marker for patients presenting with acute myocardial infarction.

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non–ST-Segment Elevation Myocardial Infarction

Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). To examine interhospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with low, moderate, or high mortality risk. This study was a retrospective analysis of 28 018 Medicare patients 65 years or older admitted with NSTEMI to 346 hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network (ACTION)-Get With the Guidelines from April 1, 2011, through December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Data analysis was performed from May 7 through October 8, 2015. Hospitals with high (>70% of patients with NSTEMI treated in an ICU during the index hospitalization), intermediate (30%-70%), or low (<30%) ICU utilization. Thirty-day mortality. Of 28 018 patients with NSTEMI 65 years or older (median age, 77 years [interquartile range, 71-84 years]; female, 13 055 [46.6%]; nonwhite race, 3931 [14.0%]), 11 934 (42.6%) had an ICU stay. The proportion of patients with NSTEMI treated in the ICU varied across hospitals (median, 38%; interquartile range, 26%-54%), but no significant differences were found in hospital or patient characteristics among high, intermediate, or low ICU utilization hospitals. Compared with high ICU utilization hospitals, low or intermediate ICU utilization hospitals were only marginally more selective of higher-risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. The median ACTION risk score for patients treated in the ICU at low and intermediate ICU utilization hospitals was 34 compared with 33 for patients not treated in the ICU; at high ICU utilization hospitals, the median ACTION mortality risk score was 33 for patients treated in the ICU and 34 for patients not treated in the ICU. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs low: 8.7% vs 8.7%; adjusted odds ratio, 0.91; 95% CI, 0.76-1.08; intermediate vs low: 9.6% vs 8.7%; adjusted odds ratio, 1.06; 95% CI, 0.94-1.20). The association between hospital ICU utilization and mortality did not change when considered among patients with ACTION risk scores greater than 40, 30 to 40, and less than 30 (adjusted interaction P = .86). Utilization of the ICU for older patients with NSTEMI varied significantly among hospitals. This variability was not explained by hospital characteristics or driven by patient risk. Mortality after myocardial infarction did not significantly differ among high, intermediate, or low ICU utilization hospitals.

Predicting In-Hospital Mortality in Patients With Acute Myocardial Infarction

BackgroundAs a foundation for quality improvement, assessing clinical outcomes across hospitals requires appropriate risk adjustment to account for differences in patient case mix, including presentation after cardiac arrest. ObjectivesThe aim of this study was to develop and validate a parsimonious patient-level clinical risk model of in-hospital mortality for contemporary patients with acute myocardial infarction. MethodsPatient characteristics at the time of presentation in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry–GWTG (Get With the Guidelines) database from January 2012 through December 2013 were used to develop a multivariate hierarchical logistic regression model predicting in-hospital mortality. The population (243,440 patients from 655 hospitals) was divided into a 60% sample for model derivation, with the remaining 40% used for model validation. A simplified risk score was created to enable prospective risk stratification in clinical care. ResultsThe in-hospital mortality rate was 4.6%. Age, heart rate, systolic blood pressure, presentation after cardiac arrest, presentation in cardiogenic shock, presentation in heart failure, presentation with ST-segment elevation myocardial infarction, creatinine clearance, and troponin ratio were all independently associated with in-hospital mortality. The C statistic was 0.88, with good calibration. The model performed well in subgroups based on age; sex; race; transfer status; and the presence of diabetes mellitus, renal dysfunction, cardiac arrest, cardiogenic shock, and ST-segment elevation myocardial infarction. Observed mortality rates varied substantially across risk groups, ranging from 0.4% in the lowest risk group (score <30) to 49.5% in the highest risk group (score >59). ConclusionsThis parsimonious risk model for in-hospital mortality is a valid instrument for risk adjustment and risk stratification in contemporary patients with acute myocardial infarction.