After Acute Myocardial Infarction Hospitalization Research Articles

An empirical approach for life expectancy estimation based on survival analysis among a post-acute myocardial infarction population

BackgroundPractical communication of prognosis is pertinent in the clinical setting. Survival analysis techniques are standardly used in cohort studies; however, their results are not straightforward for interpretation as compared to the graspable notion of life expectancy (LE). The present study empirically examines the relationship between Cox regression coefficients (HRs), which reflect the relative risk of the investigated risk factors for mortality, and years of potential life lost (YPLL) values after acute myocardial infarction (AMI). MethodsThis retrospective population-based study included patients aged 40–80 years, who survived AMI hospitalization from January 1, 2002, to October 25, 2017. A survival analysis approach assessed relationships between variables and the risk for all-cause mortality in an up to 21-year follow-up period. The total score was calculated for each patient as the summation of the Cox regression coefficients (AdjHRs) values. Individual LE and YPLL were calculated. YPLL was assessed as a function of the total score. ResultsThe cohort (n = 6316, age 63.0 ± 10.5 years, 73.4 % males) was randomly split into training (n = 4243) and validation (n = 2073) datasets. Sixteen main clinical risk factors for mortality were explored (total score of 0–14.2 points). After adjustment for age, sex and nationality, a one-point increase in the total score was associated with YPLL of ∼one year. A goodness-of-fit of the prediction model found 0.624 and 0.585 for the training and validation datasets respectively. ConclusionsThis functional derivation for converting coefficients of survival analysis into the comprehensible form of YPLL/LE allows for practical prognostic calculation and communication.

The prognostic association of atrial fibrillation on heart failure hospitalizations after acute myocardial infarction

Abstract Aims The association of atrial fibrillation (AF) with heart failure (HF) specific hospitalizations after acute myocardial infarction (AMI) is unclear. We aim to study the association of AF and 6-month HF hospitalization after an AMI in a large American cohort. Methods and Results Adult survivors of a AMI hospitalization without cardiogenic shock were identified from the 2019 US Nationwide Readmissions Database. The unadjusted association of AF (pre-existing and denovo) with baseline characteristics and primary outcome of rate of 6-month HF admission, and secondary outcomes of fatal HF admission, composite of HF peri-AMI or a 6-month HF admission, and a composite of 6-month HF or death during a non−HF-related admission was evaluated using chi square tests or t-tests, and independent associations of AF on outcomes were evaluated using multivariable logistic regression. Cox proportional hazards models were used to identify the association of AF on cumulative incidence risk on HF readmission. Of 262,390 AMI survivors, AF was present in 18.0%. By 6-months, HF hospitalization occurred in 5.4% of all patients. AF was associated with a higher adjusted risk for 6-month HF admission (OR 1.42, 95% CI: 1.34-1.50). In the adjusted time-to-event analysis, AF was associated with a higher risk for 6-month HF readmission (HR 1.39, 95% CI 1.31-1.46, P<0.001). AF was associated with a higher risk for fatal HF and the composite outcomes. Conclusions AF was present in 1 in 6 AMI survivors without cardiogenic shock and AF was associated with a higher risk of HF hospitalization in the subsequent 6-month period.Cumulative Incidence CurvesOutcomes Table

Optimal P2Y12 inhibitor durations in older men and older women following an acute myocardial infarction: A nationwide cohort study using Medicare data

Study objectiveIdentify optimal P2Y12 inhibitor durations balancing ischemic-benefit and bleeding-risk outcomes after acute myocardial infarction (AMI) in older men and women. DesignObservational retrospective cohort with 2 years of follow-up, using clone-censor-weight marginal structural models to emulate randomization. Setting20 % sample of US Medicare administrative claims data. ParticipantsP2Y12 inhibitor new users ≥66 years old following 2008–2013 AMI hospitalization. Exposures12- to 24-month P2Y12 inhibitor durations in 1-month intervals. Main outcome measuresEffectiveness outcome (composite of all-cause mortality, recurrent AMI, ischemic stroke), safety outcome (hospitalized bleed), and negative control outcome (heart failure hospitalization). ResultsOf 28,488 P2Y12 inhibitor new users, 51 % were female, 50 % were > 75 years old, 88 % were White/non-Hispanic, and 93 % initiated clopidogrel. Negative control outcome results for 16- through 24-month durations appeared most likely to meet assumptions of no unmeasured confounding. Compared to men taking 24-month therapy, men taking 16-month therapy had higher 2-year risks of the composite effectiveness outcome (relative risk [RR] = 1.08; 95 % confidence interval [95%CI]:1.00–1.15) with similar bleeding risks (RR = 0.98; 95%CI:0.85–1.13). Compared to women taking 24-month therapy, women taking 16-month therapy had similar 2-year risks of the composite effectiveness outcome (RR = 0.98; 95%CI:0.92–1.04) and lower bleeding risks (RR = 0.88; 95%CI:0.80–0.96). ConclusionsOlder men taking 24-month P2Y12 inhibitor therapy had the lowest composite effectiveness outcome risk with no increased bleeding risk compared to shorter durations. Women taking 16-month versus 24-month P2Y12 inhibitor therapy had similar composite effectiveness outcome risks but a substantially lower hospitalized bleeding risk, suggesting durations beyond 15–17 months lacked benefit while increasing bleeding risk.

Obstructive sleep apnea modulates clinical outcomes post-acute myocardial infarction: A large longitudinal veterans’ dataset report

BackgroundWhile the longer-term Obstructive Sleep apnea (OSA)-related intermittent hypoxia (IH) leads to various comorbidities, it has become increasingly evident that OSA confers protective advantages during and after acute myocardial infarction (AMI). We hypothesized in patients who were admitted with acute MI, the presence of OSA is associated with lower in-hospital mortality compared to those without a prior diagnosis of OSA. MethodsIn this nationwide retrospective study utilizing Veterans Health Administration records, we included patients hospitalized for MI with a history of sleep disorders from 1999 to 2020. We divided patients into two cohorts: those with OSA and those without OSA. The primary outcome was in-hospital mortality during AMI hospitalization. We analyzed the data using logistic regression and calculated the odds ratio of in-hospital mortality. ResultsOut of more than four million veterans with any sleep diagnosis, 76,359 patients were hospitalized with a diagnosis of AMI. We observed 30,116 with OSA (age, 64 ± 10 years; BMI, 33 ± 7 kg/m2) and 43,480 without OSA (age, 68 ± 12 years; BMI, 29 ± 6 kg/m2). The aOR of in-patient mortality (n = 333 (1.1%)) was lower in those with OSA (aOR, 0.43; 95% CI, 0.38 to 0.49) compared to without-OSA (n = 1,102, 2.5%). However, the OSA cohort had a higher proportion of the prolonged length of stay (28.1%). ConclusionsPresence of OSA is associated with lower in-hospital mortality among patients admitted for AMI, after adjusting for various demographic and co-morbidity factors. This study highlights the complex relationship between OSA and cardiovascular health and highlights the need for further research in this area.

A risk model for decline in health status after acute myocardial infarction among older adults.

Health status is increasingly recognized as an important patient-centered outcome after acute myocardial infarction (AMI). Yet drivers of decline in health status after AMI remain largely unknown in older adults. We sought to develop and validate a predictive risk model for health status decline among older adult survivors of AMI. Using data from a prospective cohort study conducted from 2013 to 2017 of 3041 patients age ≥75 years hospitalized with acute myocardial infarction at 94 U.S. hospitals, we examined a broad array of demographic, clinical, functional, and psychosocial variables for their association with health status decline, defined as a decrease of ≥5 points in the Short Form-12 (SF-12) physical component score from hospitalization to 6 months post-discharge. Model selection was performed in logistic regression models of 20 imputed datasets to yield a parsimonious risk prediction model. Model discrimination and calibration were evaluated using c-statistics and calibration plots, respectively. Of the 2571 participants included in the main analyses, 30% of patients experienced health status decline from hospitalization to 6 months post-discharge. The risk model contained 14 factors, 10 associated with higher risk of health status decline (age, pre-existing AMI, pre-existing cancer, pre-existing COPD, pre-existing diabetes, history of falls, presenting Killip class, acute kidney injury, baseline health status, and mobility impairment) and four associated with lower risk of health status decline (male sex, higher hemoglobin, receipt of revascularization, and arrhythmia during hospitalization). The model displayed good discrimination (c-statistic=0.74 in validation cohort) and calibration (p > 0.05) in both development and validation cohorts. We used split sampling to develop and validate a risk model for health status decline in older adults after hospitalization for AMI and identified several risk factors that may be modifiable to mitigate the threat of this important patient-centered outcome. External validation of this risk model is warranted.

Abstract 11654: Bundled Payments for Care Improvement Advanced and Cardiac Rehabilitation Participation After Acute Myocardial Infarction

Introduction: Cardiac rehabilitation (CR) improves outcomes after acute myocardial infarction (AMI). The Bundled Payments for Care Improvement Advanced (BPCI-A) program holds participating hospitals accountable for all costs incurred within 90 days of discharge. There is concern that this financial incentive will lead participants to cut back on high-value care, including CR, in order to meet cost targets. We examined whether patients discharged from BPCI-A participating hospitals after an AMI had lower CR utilization compared to non-participating hospitals. Methods: We included patients from a 100% sample of fee-for-service Medicare beneficiaries discharged home after a hospitalization for AMI during a baseline period (January 1, 2016 to December 31, 2017) or an intervention period (October 1, 2018 to September 30, 2019). Our exposure was discharge from a hospital participating in BPCI-A. Our outcomes were the proportion attending ≥1 CR session and the mean number of CR sessions attended within 90 days of discharge. We adjusted for hospital, market, and patient level factors, including medical comorbidities. We performed difference-in-change analyses for both outcomes using linear mixed effects models, before and after adjustment for all confounders. Results: The baseline period included 50,274 discharges, with 33.7% from BPCI-A participating hospitals. The intervention period included 27,268 discharges, with 32.9% from participating hospitals. Overall, CR use was 11.3% in the baseline period and 11.7% in the intervention period. There were no differential changes between BPCI-participating and nonparticipating hospitals for either outcome over time ( Table ). Conclusions: Among Medicare patients discharged after an AMI, CR utilization was low, and we observed no difference in utilization associated with hospital participation in BPCI-A.

Fagerstrom score predicts smoking status six months after hospitalization for acute myocardial infarction: a prospective study

BackgroundFagerstrom score is a validated marker of nicotine addiction in smokers. MethodsIn a prospective study, we investigated a) the predictive value of Fagerstrom score for the smoking status in patients early after acute myocardial infarction (AMI) and b) the effectiveness of medically assisted smoking cessation programs in the prevention of relapsing to smoking post discharge. In 103 smokers (58 ± 12 years, 79.6% males), we assessed Fagerstrom score during hospitalization for AMI. Patients filled a dedicated questionnaire including data on family, marital and educational status, habits related to smoking and were followed-up at 3 and 6 months after discharge. ResultsTwenty-eight patients (27.2%) did not quit smoking throughout the 6-months follow-up period (Fagerstrom score:8.1 ± 1.6), 39 patients (37.8%) ceased smoking at 3 months but relapsed to smoking at 6 months (score:6.8 ± 2.1), and only 34 patients (33%) had ceased smoking for 6 consecutive months (score:5.2 ± 2 p < 0.05 for all comparisons between subgroups). By multivariate analysis, Fagerstrom score remained a significant predictor of smoking cessation at 6 months (OR: 0.72, 95%CI: 0.60--0.86, p < 0.001). Out of 73 patients who abstained from smoking for the first 3 months post-AMI, those who participated in a smoking cessation program displayed lower rate of relapsing to smoking compared with those who opted to cease smoking without any support (33.3% vs 61.8% p = 0.012). ConclusionFagerstrom score is a useful predictor of smoking cessation 6 months post-AMI. Patients participating in a smoking cessation program display lower relapse rates post-discharge suggesting the need of well-organized smoking cessation clinics for secondary prevention of heart disease.

Trends in 10-Year Outcomes Among Medicare Beneficiaries Who Survived an Acute Myocardial Infarction

Short-term outcomes after acute myocardial infarction (AMI) have improved, but little is known about longer-term outcomes. To evaluate trends in 10-year all-cause mortality and hospitalization for recurrent AMI by demographic subgroups and examine the association between recurrence and mortality. Medicare fee-for-service beneficiaries who survived after AMI from 1995 to 2019. Subgroups were defined by age, sex, race, dual Medicare-Medicaid-eligible status, and residence in health priority areas (geographic areas with persistently high adjusted mortality and hospitalization rates). Data were analyzed from October 2020 to February 2022. Medicare fee-for-service beneficiaries who survived an AMI. Ten-year all-cause mortality and hospitalization for recurrent AMI, beginning 30 days from the index AMI admission. Of an included 3 982 266 AMI survivors, 1 952 450 (49.0%) were female, and the mean (SD) age was 78.0 (7.4) years. Ten-year mortality and recurrent AMI rates were 72.7% (95% CI, 72.6-72.7) and 27.1% (95% CI, 27.0-27.2), respectively. Adjusted annual reductions were 1.5% (95% CI, 1.4-1.5) for mortality and 2.7% (95% CI, 2.6-2.7) for recurrence. In subgroup analyses balancing patient characteristics, hazard ratios (HRs) for mortality and recurrence were 1.13 (95% CI, 1.12-1.13) and 1.07 (95% CI, 1.06-1.07), respectively, for men vs women; 1.05 (95% CI, 1.05-1.06) and 1.08 (95% CI, 1.07-1.09) for Black vs White patients; 0.96 (95% CI, 0.95-0.96) and 1.00 (95% CI, 1.00-1.01) for other race (including American Indian and Alaska Native, Asian, Hispanic, other race or ethnicity, and unreported) vs White patients; 1.24 (95% CI, 1.24-1.24) and 1.21 (95% CI, 1.20-1.21) for dual Medicare-Medicaid-eligible vs non-dual Medicare-Medicaid-eligible patients; and 1.06 (95% CI, 1.06-1.07) and 1.00 (95% CI, 1.00-1.01) for patients in health priority areas vs other areas. For patients hospitalized in 2007 to 2009, the last 3 years for which full 10-year follow-up data were available, 10-year mortality risk was 13.9% lower than for those hospitalized in 1995 to 1997 (adjusted HR, 0.86; 95% CI, 0.85-0.87) and 10-year recurrence risk was 22.5% lower (adjusted HR, 0.77; 95% CI, 0.76-0.78). Mortality within 10 years after the initial AMI was higher for patients with a recurrent AMI (80.6%; 95% CI, 80.5-80.7) vs those without recurrence (72.4%; 95% CI, 72.3-72.5). In this study, 10-year mortality and hospitalization for recurrence rates improved over the last decades for patients who survived the acute period of AMI. There were marked differences in outcomes and temporal trends across demographic subgroups, emphasizing the urgent need for prioritization of efforts to reduce inequities in long-term outcomes.

Effects of continuous use of metformin on cardiovascular outcomes in patients with type 2 diabetes after acute myocardial infarction: A protocol for systematic review and meta-analysis.

Background:To our knowledge, no meta-analyses or reviews have investigated the efficacy and safety of metformin on cardiovascular outcomes after acute myocardial infarction (AMI) in patients with type 2 diabetes mellitus (T2DM). We thus conduct a high-quality systematic review and meta-analysis to assess the efficacy and safety of metformin on cardiovascular outcomes after AMI in patients with T2DM.Methods:In this systematic review and meta-analysis, we will search PUBMED, Scopus, EMBASE, and Cochrane Library databases through April, 2021. The study is structured to adhere to PRISMA guidelines (i.e., Preferred Reporting Items for Systematic Reviews and Meta-analyses). The literature search, data extraction, and quality assessments are conducted independently by 2 authors. Outcome measures include all-cause mortality; complications such as acute kidney injury, lactic acidosis, hospitalization for AMI or stroke, or death. Where disagreement in the collection of data occurs, this is resolved through discussion. Review Manager Software (v 5.3; Cochrane Collaboration) is used for the meta-analysis. Two independent reviewers will assess the risk of bias of the included studies at study level.Results:It is hypothesized that metformin use at the post-AMI is associated with decreased risk of cardiovascular disease and death in patients with T2DM.Conclusions:This study expects to provide credible and scientific evidence for the efficacy and safety of metformin on cardiovascular outcomes after AMI in patients with T2DM.Registration number:10.17605/OSF.IO/S3MBP.

The effect of de-escalation of P2Y12 receptor inhibitor therapy after acute myocardial infarction in patients undergoing percutaneous coronary intervention: A nationwide cohort study.

To examine the effect of de-escalation of P2Y12 inhibitor in dual antiplatelet therapy (DAPT) on major adverse cardiovascular events (MACE) and bleeding complications after acute myocardial infarction (AMI) in Taiwanese patients undergoing percutaneous coronary intervention (PCI). Patients who had received PCI during hospitalization for AMI (between 2013 and 2016) and were initially treated with aspirin and ticagrelor and without adverse events after 3 months of treatment were retrospectively evaluated. In total, 1,901 and 8,199 patients were identified as "de-escalated DAPT" (switched to aspirin and clopidogrel) and "unchanged DAPT" (continued on aspirin and ticagrelor) cohorts, respectively. With a mean follow-up of 8 months, the incidence rates (per 100 person-year) of death, AMI readmission and MACE were 2.89, 3.68, and 4.91 in the de-escalated cohort and 2.42, 3.28, and 4.72 in the unchanged cohort, respectively, based on an inverse probability of treatment weighted approach that adjusting for baseline characteristics of the patients. Multivariate Cox regression analyses showed the two groups had no significant differences in the hazard risk of death, AMI admission, and MACE. Additionally, there was no observed difference in the risk of bleeding, including major or clinically relevant non-major bleeding. The real-world data revealed that de-escalation of P2Y12 inhibitor in DAPT was not associated with a higher risk of death or AMI readmission in Taiwanese patients with AMI undergoing successful PCI.

Risk Model for Decline in Activities of Daily Living Among Older Adults Hospitalized With Acute Myocardial Infarction: The SILVER-AMI Study.

BackgroundFunctional decline (ie, a decrement in ability to perform everyday activities necessary to live independently) is common after acute myocardial infarction (AMI) and associated with poor long‐term outcomes; yet, we do not have a tool to identify older AMI survivors at risk for this important patient‐centered outcome.Methods and ResultsWe used data from the prospective SILVER‐AMI (Comprehensive Evaluation of Risk Factors in Older Patients With Acute Myocardial Infarction) study of 3041 patients with AMI, aged ≥75 years, recruited from 94 US hospitals. Participants were assessed during hospitalization and at 6 months to collect data on demographics, geriatric impairments, psychosocial factors, and activities of daily living. Clinical variables were abstracted from the medical record. Functional decline was defined as a decrement in ability to independently perform essential activities of daily living (ie, bathing, dressing, transferring, and ambulation) from baseline to 6 months postdischarge. The mean age of the sample was 82±5 years; 57% were men, 90% were White, and 13% reported activity of daily living decline at 6 months postdischarge. The model identified older age, longer hospital stay, mobility impairment during hospitalization, preadmission physical activity, and depression as risk factors for decline. Revascularization during AMI hospitalization and ability to walk a quarter mile before AMI were associated with decreased risk. Model discrimination (c=0.78) and calibration were good.ConclusionsWe identified a parsimonious model that predicts risk of activity of daily living decline among older patients with AMI. This tool may aid in identifying older patients with AMI who may benefit from restorative therapies to optimize function after AMI.

Effects of Statins for Secondary Prevention on Functioning and Other Outcomes Among Nursing Home Residents

ObjectivesStudies examining the effects of statins after acute myocardial infarction (AMI) excluded frail older adults, especially nursing home (NH) residents, and few examined functional outcomes. Older NH residents may benefit less from statins and be particularly susceptible to adverse drug events like myopathy-related functional decline. We evaluated the effects of statins on 1-year functional decline, rehospitalization, and death in NH residents. DesignWe conducted a retrospective cohort study using 2007-2010 linked national data from Minimum Data Set (MDS) assessments, Medicare claims, and Online Survey Certification and Reporting System records. Setting and ParticipantsWe included US NH residents 65 years and older who were statin nonusers, were hospitalized for AMI between May 2007 and March 2010, and returned to the NH. MeasuresOutcomes were functional decline, death, and rehospitalization in the first year after post-AMI NH admission. New statin users were 1:1 propensity-score matched to nonusers to adjust for 92 characteristics. We estimated hazard ratios (HRs) and restricted mean survival time differences with 95% confidence intervals (CIs) comparing individuals who did vs did not initiate statin therapy after AMI hospitalization. ResultsPropensity-score matching yielded a cohort of 5440 residents. Mean age was 83 years and 69% were female. Statin use was associated with a reduction in mortality (HR 0.80, 95% CI 0.73-0.87), corresponding to a mean of 15.9 (95% CI 9.9-22.0) days of extended life expectancy. No overall differences in rehospitalization (HR 1.06, 95% CI 0.98-1.14) or functional decline (HR 1.00, 95% CI 0.88-1.14) were observed. Conclusions and ImplicationsStatins may reduce 1-year mortality by 20% without affecting function among older NH residents who wish to live longer after AMI. During shared decision making with these patients or their representatives, clinicians should consider communicating that the average benefit of statins is 16 days of additional survival over 1 year.

Readmission and Mortality After Hospitalization for Myocardial Infarction and Heart Failure

BackgroundReadmission rates after acute myocardial infarction (AMI) and heart failure (HF) hospitalizations have decreased in the United States since the implementation of the Hospital Readmissions Reduction Program. ObjectivesThis study was designed to examine the temporal trends of readmission and mortality after AMI and HF in Ontario, Canada, where reducing hospital readmissions has not had a policy incentive. MethodsThe cohort was comprised of AMI or HF patients 65 years of age or older who had been hospitalized from 2006 to 2017. Primary outcomes were 30-day readmission and post-discharge mortality. Secondary outcomes included in-hospital mortality, 30-day mortality from admission, and in-hospital mortality or 30-day mortality post-discharge. Adjusted monthly trends for each outcome were examined over the study period. ResultsOur cohorts included 152,808 AMI and 223,283 HF patients. Age- and sex-standardized AMI hospitalization rates in Ontario declined 32% from 2006 to 2017 while HF hospitalization rates declined slightly (9.1%). For AMI, risk-adjusted 30-day readmission rates declined from 17.4% in 2006 to 14.7% in 2017. All AMI risk-adjusted mortality rates also declined from 2006 to 2017 with 30-day post-discharge mortality from 5.1% to 4.4%. For HF, overall risk-adjusted 30-day readmission was largely unchanged from 2006 to 2014 at 21.9%, followed by a decline to 20.8% in 2017. Risk-adjusted 30-day post-discharge mortality declined from 7.1% in 2006 to 6.6% in 2017. ConclusionsThe patterns of outcomes in Ontario are consistent with the United States for AMI, but diverge for HF. For AMI and HF, admissions, readmissions, and mortality rates declined over this period. The reasons for the country-specific patterns for HF need further exploration.

P1931Effect of de-escalated switching dual antiplatelet therapy after acute myocardial infarction in patients undergoing percutaneous coronary intervention: real-world data from a nationwide cohort study

Abstract Background Recently, both unguided (platelet function testing independent) and guided (platelet function testing dependent) DAPT de-escalation strategies have been investigated in different clinical studies but the data is still limited and conflicting. The aim of this study was to examine the effect of switching dual antiplatelet therapy (DAPT) on the major vascular risk after acute myocardial infarction (AMI) in patients undergoing percutaneous coronary intervention (PCI) by using Taiwan National Health Insurance Research Database. Methods In total, 1,903 and 4,059 patients defined as switched to aspirin and clopidogrel (switched DAPT) and continuation of aspirin and ticagrelor (unswitched DAPT) cohort, respectively who had received PCI during AMI hospitalization, on aspirin and ticagrelor initially and without occurring adverse events at 3 months were evaluated between 2013 and 2015. An inverse probability treatment of weighted approach was adopted to balance the baseline differences between two groups and Cox proportional hazard regression and competing risk regression were used to evaluated the effect of switching DAPT on death, AMI readmission, major bleeding and non-major clinically relevant bleeding. Results The incidence rates (per 100 person-year) of death and AMI readmission were 3.97 (95% confidence interval [CI] = 3.19–4.84) and 3.84 (95% CI = 3.09–4.73) in switched cohort and 1.83 (95% CI = 1.47–2.24) and 2.23 (95% CI = 1.82–2.68) in unswitched cohort, respectively. After adjustment for patients' clinical variables, switched cohort had higher risk of death (adjusted hazard ratio = 2.18, 95% CI = 1.62–2.93, P&lt;0.001), and AMI readmission (adjusted sub-distribution ratio = 1.72, 95% CI = 1.27–2.34, P&lt;0.001) compared to these in unswitched cohort; however, there was no difference in the risk of bleeding. Subgroup analysis showed a similar findings in many specific groups, except the patients who were younger age and had lower comorbidity score. Conclusion Switching DAPT might increase the risk of death and AMI readmission among patients with AMI undergoing PCI.

Does outpatient cardiac rehabilitation help patients with acute myocardial infarction quit smoking?

Outpatient cardiac rehabilitation (OCR) reinforces patients' efforts to quit smoking, but the association between participation in OCR and long-term smoking status after acute myocardial infarction (AMI) is unknown. We studied hospitalized smokers with confirmed AMI from two multicenter prospective registries (PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008) to describe the association of OCR participation with smoking cessation. Eligible patients smoked at least 1 cigarette per day on average in the 30 days prior to enrollment and completed 12-month follow-up (N = 1307). Structured interviews were completed on subjects at baseline and during follow-up. OCR participation and abstinence from smoking within the prior 30-days (30-day point prevalence abstinence, PPA) were self-reported. We constructed a propensity model of OCR participation based on 22 baseline sociodemographic and clinical characteristics, and constructed hierarchical modified Poisson regression models of 30-day PPA at 12 months after matching on the propensity for OCR participation (with clinical site treated as a random effect). Seventy-four percent of subjects were referred to OCR at hospital discharge, but only 36% participated during follow-up. At 12-month follow-up, 30-day PPA was 57% in OCR participants, compared to 41% in matched OCR non-participants. Participation in OCR was a significant predictor of 30-day PPA at 12 months (adjusted RR 1.38, 95% CI 1.20–1.57). In conclusion, smokers who participated in OCR were significantly more likely to abstain from smoking 12 months after AMI hospitalization.

Adherence Tradeoff to Multiple Preventive Therapies and All-Cause Mortality After Acute Myocardial Infarction

BackgroundAngiotensin-converting enzyme (ACE) inhibitors/angiotensin II receptor blockers (ARB), beta-blockers and statins are recommended after acute myocardial infarction (AMI). Patients may adhere to some, but not all, therapies. ObjectivesThe authors investigated the effect of tradeoffs in adherence to ACE inhibitors/ARBs, beta-blockers, and statins on survival among older people after AMI. MethodsThe authors identified 90,869 Medicare beneficiaries ≥65 years of age who had prescriptions for ACE inhibitors/ARBs, beta-blockers, and statins, and survived ≥180 days after AMI hospitalization in 2008 to 2010. Adherence was measured by proportion of days covered (PDC) during 180 days following hospital discharge. Mortality follow-up extended up to 18 months after this period. The authors used Cox proportional hazards models to estimate hazard ratios of mortality for groups adherent to 2, 1, or none of the therapies versus group adherent to all 3 therapies. ResultsOnly 49% of the patients adhered (PDC ≥80%) to all 3 therapies. Compared with being adherent to all 3 therapies, multivariable-adjusted hazard ratios (95% confidence intervals [CIs]) for mortality were 1.12 (95% CI: 1.04 to 1.21) for being adherent to ACE inhibitors/ARBs and beta-blockers only, 0.98 (95% CI: 0.91 to 1.07) for ACEI/ARBs and statins only, 1.17 (95% CI: 1.10 to 1.25) beta-blockers and statins only, 1.19 (95% CI: 1.07 to 1.32) for ACE inhibitors/ARBs only, 1.32 (95% CI: 1.21 to 1.44) for beta-blockers only, 1.26 (95% CI: 1.15 to 1.38) statins only, and 1.65 (95% CI: 1.54 to 1.76) for being nonadherent (PDC <80%) to all 3 therapies. ConclusionsPatients adherent to ACE inhibitors/ARBs and statins only had similar mortality rates as those adherent to all 3 therapies, suggesting limited additional benefit for beta-blockers in patients who were adherent to statins and ACE inhibitors/ARBs. Nonadherence to ACE inhibitors/ARBs and/or statins was associated with higher mortality.

Chronic Kidney Disease and Health Status Outcomes Following Acute Myocardial Infarction.

BackgroundThe association between chronic kidney disease (CKD) and health status outcomes after acute myocardial infarction (AMI) is unknown.Methods and ResultsPatients were enrolled between 2005 and 2008 in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) registry, a prospective multicenter observational study of AMI outcomes. The Seattle Angina Questionnaire and Short Form‐12 were collected at baseline and at 1, 6, and 12 months following AMI. CKD was defined by an estimated glomerular filtration rate <60 mL/min, calculated during the AMI hospitalization. Linear repeated‐measures models assessed the association between CKD and health status after AMI, accounting for the propensity to have follow‐up heath status measures. Of 3617 patients, 576 (16%) had CKD and 3041 (84%) did not have CKD. Patients with CKD were older and had more comorbidity. Patients with CKD were more likely to have multivessel coronary disease and less likely to undergo revascularization. Among AMI survivors, patients with and without CKD had similar health‐related quality of life (adjusted difference of 0.24, 95% CI −1.46 to 1.95), angina frequency (adjusted difference of 1.27, 95% CI −0.05 to 2.58), and mental health (adjusted difference of −0.07, 95% CI −0.90 to 0.75). In contrast, patients with CKD had lower physical health (adjusted difference −1.61, 95% CI −2.49 to −0.74), which was not clinically significant, compared with patients without CKD.ConclusionsAmong AMI survivors, patients with CKD not only had more comorbidities but also, after adjusting for these patient differences, had similar health status compared with patients without CKD. Interventions aimed at improving health status after AMI should not focus on CKD status.

Antihyperglycemic therapy and cardiovascular outcomes after acute myocardial infarction in elderly patients with diabetes.

Type 2 diabetes mellitus is a clear prognostic marker for increased cardiovascular morbidity and mortality after acute myocardial infarction (AMI). We compared diabetes patients based on therapy used (no pharmacotherapy, those prescribed oral antihyperglycemic agents and those prescribed insulin) on the composite risk of recurrent AMI, congestive heart failure and mortality among elderly patients with AMI. Using administrative data, we identified patients, aged 65 years and older, with an incident AMI hospitalization in British Columbia and the Calgary Health Region between April 1, 1995, and March 31, 2002, for a retrospective cohort study. Cox proportional hazard models were constructed to compare time to reach the composite outcome in the treatment groups. Among 22 499 patients with AMI, 5158 patients had diabetes. Women comprised 43.2% of the diabetes cohort. For the composite outcome, there was a stepwise increase in the occurrence based on medication use: no diabetes (23.55 events per 100 person-years); diabetes but no treatment (31.70 per 100 person-years); oral agents only (36.34 per 100 person-years) and insulin therapy (49.43 per 100 person-years). After adjustment, relative to patients without diabetes, no treatment (hazard ratio 1.37, 95% confidence interval, 1.22 to 1.53), oral agents only (hazard ratio 1.43, 95% confidence interval, 1.31 to 1.56) and insulin therapy (hazard ratio 1.65, 95% confidence interval, 1.48 to 1.84) were all associated with an increased risk of the outcome developing. Diabetes conferred a significant risk increase in a combination of cardiovascular events after AMI. The risk existed even for diabetes patients not prescribed therapy and showed a progressive trend as the intensity of treatment advanced toward insulin.

Abstract 322: Chronic Kidney Disease Does Not Impact Health Status Following Acute Myocardial Infarction

Introduction: Chronic kidney disease is strongly associated with mortality after acute myocardial infarction (AMI), however, its association with health status outcomes (symptoms, function and quality of life (QoL)) is unknown. Methods: Patients with AMI were enrolled between 2003 and 2008 in the TRIUMPH registry, a national, prospective, multi-center study of health status outcomes after AMI. Detailed interviews with the disease-specific Seattle Angina Questionnaire (SAQ) and generic Short Form-12 (SF-12) were attempted on all survivors at 1, 6 and 12 months following AMI admission. Estimated glomerular filtration rate (eGFR) was calculated using the Modification of Diet in Renal Disease equation and based on the highest calculated eGFR recorded during the AMI hospitalization. Patients with CKD, based on an eGFR &lt; 60 ml/min, were compared to those without CKD. Linear repeated measures models of SAQ angina frequency and QoL and SF-12 PCS and MCS scores were used to control for treatment site, baseline health status and known covariates to assess the independent association between CKD and health status after AMI. Results: Of 3592 3,617 patients, 3,041 (84%) had no CKD and 551 576 (16%) had CKD;, 7980% stage 3 (eGFR 30-59); 1312% stage 4 (eGFR 15-29); and 8% stage 5 (eGFR &lt;15). Patients with CKD were older (67.5 vs. 587.8) and had more co-morbidities, including heart failure, CVA, and PVD. CKD patients were more likely to have 3-vessel CAD, left ventricular dysfunction and less likely to undergo revascularization during their hospitalization. CKD patients also also had a higher 1-year mortality (8.59% vs. 2.3%; p&lt;0.0001). Among AMI survivors at 1 -year, patients with and without CKD had similar QoL 81.9 8 vs. 81.7 (adj. difference of 0.4624, [95% CI, -1.2646, ,2.181.95]), angina frequency 91.4 vs. 93.1 (adj. difference of 1.2327, [95% CI, -0.0605, ,2.589]), and mental health scores 52.7 vs. 51.9 (adj. difference of -0.0907, [95% CI, -0.90, 2,0.7475]). Physical functioning scores were low overall at 1-year and CKD patients had slightly lower scores, 38.0 4 vs. 44.4 ((adj. difference -1.6861, [95% CI, -2.562.49, -0.749]). Conclusion: Among AMI survivorspatients who survived to 1 year, CKD patients have similar quality of life and angina burden compared to those without CKD despite a higher burden of co-morbidities. While CKD patients had lower physical functioning scores, this difference was not clinically significant compared to patients without CKD. These findings suggest that among AMI patients surviving to 1 yearsurvivors, CKD patients can achieve similar health status outcomes compared to non-CKD patients.

Abstract 104: The Effect of Low Perceived Social Support on Health Outcomes in Young Patients with Acute Myocardial Infarction: Results from the VIRGO Study

Background: Social support is an important predictor of health outcomes after acute myocardial infarction (AMI), but significant variability in social support exists by sex and age. Most studies have been conducted in populations of predominately older, male patients; little is known about the impact of social support on outcomes after AMI in young patients, who may have unique demands and resources. Methods: We used data from the VIRGO study, an observational study of patients aged ≤55 years with AMI in the US and Spain, to examine the association of low perceived social support (LPSS) with baseline and 1-year health status, depression, and quality of life. Patients were categorized as having low vs. moderate/high social support using the ENRICHD Social Support Inventory (ESSI), which was collected during the index AMI hospitalization. A modified 5-item version of the 7-item ESSI was used for this study in order to examine marital status and instrumental support separately from perceived social support. Outcomes included health status (assessed by the Short Form-12 (SF-12) physical and mental component scores (PCS and MCS)), depressive symptoms (Patient Health Questionnaire (PHQ-9)), and angina-related quality of life (Seattle Angina Questionnaire (SAQ)) evaluated at baseline and 1-year. We used linear regression to compare 1-year health status between social support categories, adjusting for baseline health status, socio-demographics, comorbidities, severity of disease, and therapies used. Results: Among 3,432 patients, 728 (21.2%) were classified as having LPSS. Men and women had comparable levels of social support at baseline. On average, patients with LPSS reported lower functional status (PCS and MCS), lower quality of life, and more depressive symptoms at baseline and 1-year post-AMI. After multivariable adjustment, including baseline health status, LPSS was associated with lower mental functioning (mean MCS -2.34 (95% confidence interval [CI] -3.35, -1.34) p&lt;0.001), lower quality of life (mean SAQ -4.58 (95% CI -4.58, -2.57), p&lt;0.001), and more depressive symptoms (1.01 (95% CI 0.52, 1.51), p&lt;0.001) at 1 year. The relationship between LPSS and worse physical functioning was not significant after adjustment (mean PCS -0.28 (95% CI -1.33, 0.77), p=0.6). We observed no interactions between social support, sex or country. Conclusion: Lower social support is associated with worse health status and more depressive symptoms 1-year after AMI in both young men and women recovering from an AMI.