AMI Mortality Research Articles

Association of Hyperandrogenaemia With Hypertension and Cardiovascular Events in Pre-menopausal Women- A Prospective Population-Based Cohort Study.

The present study aimed to clarify the conflicting association of premenopausal hyperandrogenaemia (HA) with the development of hypertension and CVDs in women. A population-based cohort study including 5889 women. The association of serum testosterone (T), sex hormone-binding globulin (SHBG), and free androgen index (FAI) at age 31 with blood pressure (BP) and hypertension (BP ≥140/90 mmHg and/or use of antihypertensive medication) at ages 31 and 46 and with CVDs (angina pectoris [AP] and/or acute myocardial infarction [AMI] n=74, transitory cerebral ischemia [TIA] and/or stroke n=150) and combined CVD events (AP, AMI, stroke, heart failure, or CVD mortality n=160) by age 53 was investigated. T and FAI were positively associated with systolic and diastolic BP at ages 31 and 46 in the multivariable model. Compared to their lowest quartile, the highest quartiles of T and FAI were positively associated with hypertension at age 31 in the multivariable model. During the 22-year follow-up, FAI was positively associated with increased risk of AP/AMI (hazard ratio [HR]:2.02, 95%CI:1.06-3.85) and overall CVD events or mortality (HR:1.54, 95%CI:1.02-2.33) in the unadjusted models. However, the significance disappeared after adjusting for BMI. Women with HA at premenopausal age had an elevated risk of hypertension, and together with BMI, increased risk of CVD events and CVD mortality during the 22-year follow-up. However, because of several study limitations regarding ethnicity and BMI characteristics, a longer follow-up of this cohort and future studies in ethnically diverse populations are needed to verify the results.

Triglyceride-glucose index correlates with the occurrence and prognosis of acute myocardial infarction complicated by cardiogenic shock: data from two large cohorts

BackgroundTriglyceride-glucose (TyG) index, a dependable indicator of insulin resistance, has been identified as a valid marker regarding multiple cardiovascular diseases. Nevertheless, the correlation of TyG index with acute myocardial infarction complicated by cardiogenic shock (AMICS) remains uncertain. Our study aims for elucidating this relationship by comprehensively analyzing two large-scale cohorts.MethodsUtilizing records from the eICU Collaborative Research Database and the Medical Information Mart for Intensive Care IV, the link between TyG and the incidence and prognosis of AMICS was assessed multicentrally and retrospectively by logistic and correlation models, as well as restricted cubic spline (RCS). Propensity score matching (PSM), inverse probability of treatment weighting (IPTW), and overlap weighting (OW) were employed to balance the potential confounders. Subgroup analyses were performed according to potential modifiers.ResultsOverall, 5208 AMI patients, consisting of 375 developing CS were finally included. The TyG index exhibited an apparently higher level in AMI populations developing CS than in those who did not experienced CS [9.2 (8.8–9.7) vs. 9.0 (8.5–9.5)], with a moderate discrimination ability to recognize AMICS from the general AMI (AUC: 0.604). Logistic analyses showed that the TyG index was significantly correlated with in-hospital and ICU mortality. RCS analysis demonstrated a linear link between elevated TyG and increased risks regarding in-hospital and ICU mortality in the AMICS population. An increased mortality risk remains evident in PSM-, OW- and IPTW-adjusted populations with higher TyG index who have undergone CS. Correlation analyses demonstrated an apparent link between TyG index and APS score. Subgroup analyses presented a stable link between elevated TyG and mortality particularly in older age, females, those who are overweight or hypertensive, as well as those without diabetes.ConclusionsElevated TyG index was related to the incidence of CS following AMI and higher mortality risks in the population with AMICS. Our findings pointed a previously undisclosed role of TyG index in regard to AMICS that still requires further validation.

Hospital mortality after acute myocardial infarction- really an indicator of quality of acute care?

Abstract Introduction ‘AMI 30-day-mortality using unlinked data’ is reported by OECD as indicator for quality of acute care. It relates to hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22). AMI hospital mortality in Germany is among the highest in Europe - indicating major problems in quality of acute care. In contrast, Germany ranks high on health expenditure and availability of cardiologists and PCI facilities. We explain these contradictory findings. Methods Literature and public health reports on AMI patient characteristics, acute care, patient registration and healthcare organisation were reviewed. OECD indicators ‘AMI 30-day-mortality using unlinked data’ and ‘average length of stay after AMI’ for European countries were downloaded for 2000-2019. The trend in AMI hospital mortality was described graphically. The influence of average length of stay (LOS) on AMI mortality was assessed by linear regression. Results Since 2000, AMI hospital mortality fell strongly. In 2019, it was 2.9% in the Netherlands, 3.2% in Norway, but 8.5% in Germany. Different patient characteristics or therapies do not account for the differences in mortality, but health care organization: 1. Day cases are not always included in OECD source data; 2. Average LOS is associated with AMI hospital mortality (R2=0.58) and is itself influenced by patient transfer frequency and reimbursement policy; 3. In centralised health systems, AMI patient transfers are more frequent. These factors reduce the registered AMI deaths or increase the number of cases, all resulting in lower hospital mortality. Discussion AMI hospital mortality is highly influenced by factors that are not related to acute patient care, but to health care organization and patient registration rules. AMI registries reporting hospital mortality include selected AMI patient populations, which hampers valid comparisons. European sentinel registries are needed to validly describe quality of acute care and outcomes in AMI. Key messages • OECD indicator ‘AMI hospital mortality’ does not allow valid conclusions on quality of acute care. • AMI hospital mortality is strongly influenced by patient registration rules and healthcare organization, namely frequency of patient transfers and length of stay in hospital after AMI.

OECD indicator 'AMI 30-day mortality' is neither comparable between countries nor suitable as indicator for quality of acute care.

Hospital mortality after acute myocardial infarction (AMI, ICD-10: I21-I22) is used as OECD indicator of the quality of acute care. The reported AMI hospital mortality in Germany is more than twice as high as in the Netherlands or Scandinavia. Yet, in Europe, Germany ranks high in health spending and availability of cardiac procedures. We provide insights into this contradictory situation. Information was collected on possible factors causing the reported differences in AMI mortality such as prevalence of risk factors or comorbidities, guideline conform treatment, patient registration, and health system structures of European countries. International experts were interviewed. Data on OECD indicators 'AMI 30-day mortality using unlinked data' and 'average length of stay after AMI' were used to describe the association between these variables graphically and by linear regression. Differences in prevalence of risk factors or comorbidities or in guideline conform acute care account only to a smaller extent for the reported differences in AMI hospital mortality. It is influenced mainly by patient registration rules and organization of health care. Non-reporting of day cases as patients and centralization of AMI care-with more frequent inter-hospital patient transfers-artificially lead to lower calculated hospital mortality. Frequency of patient transfers and national reimbursement policies affect the average length of stay in hospital which is strongly associated with AMI hospital mortality (adj R2 = 0.56). AMI mortality reported from registries is distorted by different underlying populations. Most of the variation in AMI hospital mortality is explained by differences in patient registration and organization of care instead of differences in quality of care, which hinders cross-country comparisons of AMI mortality. Europe-wide sentinel regions with comparable registries are necessary to compare (acute) care after myocardial infarction.

Results after intraoperative open and endovascular revascularization of acute mesenteric ischemia requiring a laparotomy

BackgroundAcute mesenteric ischemia (AMI) is a dreaded condition with a difficult diagnosis and high mortality. Due to different baseline situations, the frequently performed comparison between endovascular and open surgical treatment is interfered with selection bias. The purpose of this study was to review outcomes in AMI treatment with an open or endovascular approach in association with laparotomy and to evaluate the endovascular-first strategy in similar clinical situations.MethodsThe clinical data of 74 patients treated for AMI from 2007 to 2021 were retrospectively reviewed and compared. In-hospital mortality was appointed as the primary study endpoint. Risk factors for mortality were identified by using univariate and multivariate analysis.ResultsIn total, 61 patients (82%) were treated open surgically (OT) and, 13 patients (18%) with an endovascular approach (ET) in combination with laparatomy. The etiology of AMI was 49% arteriosclerotic and 51% thromboembolic occlusions. The total in-hospital mortality manifested at 43% (n =32) (OT 41% vs. ET 53.8%; P=0.54). As independent risk factors for in-hospital mortality, pneumatosis intestinalis (P=0.01), increased lactate concentration (P=0.04), and ischemic intestinal sections (P=0.01) were identified. Additionally, on univariate analysis patient age, congestive heart failure (> NYHA II) and atrial fibrillation were related with higher mortality.ConclusionsMorbidity and mortality of AMI remains at a high level. Conventional open or intraoperative endovascular therapy achieved similar results in patients with indication for laparotomy. Advanced disease stage with ischemic intestinal sections at presentation and cardiovascular comorbidities were associated with adverse outcome.

Abstract P3119: Identifying The Windows Of Cardiac Risk And Opportunity In Menopause

Post-acute myocardial infarction (AMI) mortality has significant sex differences with a bias towards higher rates in women. While treatment inequities and access to care profoundly impact outcomes, biological factors also contribute to survival discrepancies. One complicating factor that drives worse outcomes in women is menopause. Understanding the biological basis for AMI mortality risk and the exacerbating role of menopause has been hampered by the lack of an animal model that recapitulates the dynamic changes associated with the perimenopausal transition. We used a mouse model of menopause in which ovarian failure is gradually induced following treatment with 4-vinylcyclohexene diepoxide (VCD, 160 mg/kg, 15d), allowing for examination of cardiac alterations established during perimenopause. Echocardiography revealed no contractile changes during perimenopause, but cardiac myofilament activation was significantly affected. Calcium re-uptake by SERCA was impaired by the end of perimenopause. Changes in calcium handling were associated with alterations in calcium handling protein expression and phosphorylation. Activation of RISK and SAFE signaling molecules that protect against ischemia-reperfusion (IR) injury was altered throughout perimenopause, and the RISK-SAFE response to IR differed at points during perimenopause. The myocardial response to cardioprotective estrogen receptor activation also varied throughout perimenopause. Together these data reveal significant, nonlinear alterations in myocardial physiology and endogenous protective signing pathways during perimenopause. Disruptions in endogenous protection and calcium handling are established prior to menopause, providing possible mechanisms for worse post-menopausal AMI outcomes. The altered response to estrogen receptor activation preceding menopause may explain the inconsistent effectiveness of post-menopausal estrogen replacement therapy.

Six-month cardiovascular prognostic impact of type 1 And type 2 myocardial infarction in patients hospitalized for gastrointestinal bleeding

BackgroundPatients with gastrointestinal bleeding (GIB) are at an increased risk of cardiovascular events and myocardial infarction (MI). Myocardial supply-demand mismatch results in type 2 MI(T2MI) and atherosclerotic plaque rupture leads to type 1 MI(T1MI). Data comparing the prognostic impact of these MI types in GIB are sparse. MethodsPatients hospitalized for GIB were identified in the 2019 US Nationwide Readmissions Sample. In this population, we studied the differences in management of T1MI and T2MI, and the association of these MI types with in-hospital mortality and risk for 6-month MI and MI-related mortality. ResultsOf 444,475 patients admitted for a GIB, 12,860 (2.9%) had an MI (1.7% T2MI, 1.2% T1MI). Patients with T1MI were more likely to receive coronary angiography and revascularization than patients with T2MI. In-hospital mortality occurred in 2.0% patients, at a significantly higher rate in patients with an MI (7.9% vs 1.8%; P < 0.001), and higher with T1MI (11.9%) than T2MI (5.3%; P < 0.001). Among the survivors, 2.2% patient had an MI within 6 months, at a significantly higher rate in patients with index MI (13.1% vs 2.0%, adjusted OR 4.3 95% CI 3.83–4.90; P < 0.001). Mortality during the subsequent MI occurred in 0.3% of all patients (12% with an MI), at a 6-fold higher rate in patients with index MI (1.7% vs 0.3%; adjusted OR 3.69 95% CI 2.75–4.95; P < 0.001). The elevated risks were associated with both MI types. The risks for 6-month MI and related mortality were similar between T1MI and T2MI (6-month AMI: adjusted OR for T2MI = 1.03, 95% 0.83–1.29; fatal MI: adjusted OR for T2MI = 1.5, 95% CI 0.85–2.7). ConclusionThe occurrence of an MI is associated with a substantially elevated risk for subsequent AMI and related mortality in patients hospitalized for a GIB. This future prognostic impact was similar between T1MI and T2MI.

Machine learning prediction of mortality in Acute Myocardial Infarction

BackgroundAcute Myocardial Infarction (AMI) is the leading cause of death in Portugal and globally. The present investigation created a model based on machine learning for predictive analysis of mortality in patients with AMI upon admission, using different variables to analyse their impact on predictive models.MethodsThree experiments were built for mortality in AMI in a Portuguese hospital between 2013 and 2015 using various machine learning techniques. The three experiments differed in the number and type of variables used. We used a discharged patients’ episodes database, including administrative data, laboratory data, and cardiac and physiologic test results, whose primary diagnosis was AMI.ResultsResults show that for Experiment 1, Stochastic Gradient Descent was more suitable than the other classification models, with a classification accuracy of 80%, a recall of 77%, and a discriminatory capacity with an AUC of 79%. Adding new variables to the models increased AUC in Experiment 2 to 81% for the Support Vector Machine method. In Experiment 3, we obtained an AUC, in Stochastic Gradient Descent, of 88% and a recall of 80%. These results were obtained when applying feature selection and the SMOTE technique to overcome imbalanced data.ConclusionsOur results show that the introduction of new variables, namely laboratory data, impacts the performance of the methods, reinforcing the premise that no single approach is adapted to all situations regarding AMI mortality prediction. Instead, they must be selected, considering the context and the information available. Integrating Artificial Intelligence (AI) and machine learning with clinical decision-making can transform care, making clinical practice more efficient, faster, personalised, and effective. AI emerges as an alternative to traditional models since it has the potential to explore large amounts of information automatically and systematically.

Correlation between White Blood Cell Count and Myocardial Infarction Mortality in Patients admitted at Tertiary Care Center of Philippines

Introduction: Coronary artery disease (CAD) continues to be a major cause of morbidity and mortality in developed as well as developing countries. This study aims to find out the correlation between elevated WBC and AMI mortality and also to enhance as an independent marker for higher risk for in-hospital patients which would finally help for risk stratification and better care for such presentation.&#x0D; Methods: This is a retrospective research evaluating all adult patients with AMI who were admitted to Rizal Medical Center from January 1, 2016 to December 31, 2017. Clinical data were retrieved from the Medical Records Section and Department of Laboratory Medicine. Detailed history, physical examination and relevant investigations such as complete blood count and electrocardiographic results were reviewed. All data was managed by Microsoft Excel for windows and after collecting a sample size of 225 cases. Analysis was executed using SAS Software Version 9.3.&#x0D; Results: Relationship existed between clinical outcome and white blood cell count. The patients with elevated WBC on comparison to patients with normal WBC had 3 times more risk of dying (discharged(5.8%)/died(18.7%), p value 0.028. The mean WBC for favourable clinical outcome was 11.87±4.85 S.D which is lower as compared to the poor clinical outcome averaged 13.87±6.20 S.D. (p .028 &lt; .05).&#x0D; Conclusion: The results indicate that patients with elevated white blood cell count would be more likely to have poor clinical outcome compared to patients who have normal white blood cell count. White blood cell count within 24 h of admission for an AMI is a strong and independent predictor of in-hospital mortality.&#x0D;

Abstract 14356: Trends of Acute Myocardial Infarction Mortality Rates in the United States From 1999-2019: A Retrospective Study

Introduction: In the current study, we examined the temporal trends in mortality across gender, race, and 10-year age groups over last two-decades. Methods: We conducted a retrospective population-based study using Centers for Disease Control and Prevention database. Subjects with underlying cause of death from AMI were identified using validated ICD10 codes. Age adjusted mortality rates were calculated for gender and race whereas crude rates were calculated for 10-year age group. Using Poisson regression, we estimated the rate ratio between race/ethnicity pairs adjusting for age and sex in order to analyze temporal trend. Results: We identified 2,709,173 subjects with reported underlying cause of death as AMI between January-2000 to December-2019 of which 54.7% were males (n=1,483,163). The age adjusted mortality rate per 100,000 was higher in males compared to females (52.4% vs 30.7%, OR: 1.66 [1.45-1.89]). Among ethnicities African American (AA) population had the highest age adjusted mortality rate per 100,000 [Table 1]. As expected, age group &gt;85 years had the highest mortality rate per 100,000 constituting 30% of total deaths (78% of total deaths were noted in &gt;65yr age group). AMI age adjusted mortality rates/100,000 showed significant decline across gender and race with highest decline in female population (66.5% decline). Highest percentage decline in mortality was noted in AA female population (68.2%) whereas in males it was the white population (62%). In females, highest percentage decline in mortality was noted in 75-84 age-group (70%) while it was &gt;85 age-group (67%) in males. Conclusion: Over last two decades there has been a significant decline in AMI mortality rates across gender and race. AA continue to have higher age adjusted mortality rate among both male and female population (38% and 22% respectively). Further studies are needed to identify and provide targeted prevention and intervention strategies in high-risk populations.

Early outcomes of Intra-Aortic Balloon Pump in Patients Undergoing Coronary Artery Bypass Grafting (CABG) Surgery

Background: Care of heart patients especially after coronary artery bypass graft (CABG) surgery can be difficult to manage especially in postoperative phase due to decreased cardiac output. Inotropes used to increase cardiac output during the peri or postoperative may cause harmful effects. Mechanical circulatory support devices, such as an intra-aortic balloon pump can be beneficial in such patients. Objective: To compare early outcomes of Intra-Aortic Balloon Pump (IABP) in Patients Undergoing Coronary Artery Bypass Grafting (CABG) Surgery Methods: Systematic random samples of 134 patients were registered from the department of cardiac surgery of Punjab Institute of Cardiology (PIC), Lahore undergone open heart surgery from December 2019 to May 2020. High-risk patients with hemodynamically stable undergoing scheduled CABG were included. The patients were divided into two groups. All information including gender and age were obtained using a structured questionnaire. Death and other complications were compared between two groups. Data was entered and analyzed using SPSS. Statistical test like chi- square and Independent t-tests were applied to obtain the required results and percentages. Results: Total 134 patients enrolled and equally divided into two groups. Group A (with IABP) have mean age was 47.58± 2.0 compared with Group B (without IABP) mean age 48.43± 4.31.There were 79(63.2%) males and 46(36.8%) were females enrolled. Hypertension, diabetes mellitus, smoking, Prior CVA, recent AMI and congestive heart failure remained statistically insignificant as p-value &gt; 0.05. The duration of IABP, respiratory failure, renal dysfunction and length of ICU stay showed statistically significant p-value &lt; 0.05. Reoperation for bleeding, acute AMI, pneumonia, stroke, wound infection and surgical mortality are statistically insignificant as pvalue &gt; 0.05. Conclusion: In high-risk patients of coronary artery bypass graft, early implantation of an intra-aortic balloon pump improves the outcomes by reducing ICU stay and death; increased post-insertion creatinine levels have been proven to be an indication of approaching mortality. Keywords: Intra-aortic balloon pump, Coronary artery bypass graft, Creatinine levels, Low Cardiac Output Syndrome

Hospital competition in a national health service: Evidence from a patient choice reform

We study the impact of exposing hospitals in a National Health Service (NHS) to non-price competition by exploiting a patient choice reform in Norway in 2001. The reform facilitates a difference-in-difference approach due to plausibly exogenous (geographical) variation in pre-reform market structure. Employing rich, administrative data, covering the universe of hospital admissions from 1998 to 2005, we estimate models with hospital and treatment (DRG) fixed-effects and use only emergency admissions to limit patient selection issues. The results show that hospitals in more competitive areas have a sharper reduction in AMI mortality but no effect on stroke mortality. We also find that exposure to competition reduces all-cause mortality, shortens length of stay, but increases readmissions, though the effects are small in magnitude. In years with high (DRG) prices, the negative effect on readmissions almost vanishes. Finally, exposure to competition tends to reduce waiting times and increase admissions, but the effects must be interpreted with care as the outcomes include elective treatments.

Abstract P644: Average Daily Temperature Fluctuation and Hospitalizations and 30-Day Mortality for Stroke and AMI

Background: Daily average temperature is associated with increased hospitalizations and mortality for vascular conditions, but it is unclear if daily temperature variation is also associated with these outcomes. We assessed the relationship of daily temperature fluctuations with stroke and AMI hospitalizations and mortality in the elderly. Methods: We identified fee-for-service Medicare beneficiaries aged ≥65 y with a primary discharge diagnosis of ischemic stroke or AMI in 2014-2015. Daily temperature data from the National Centers for Environmental Information were linked with Medicare beneficiary data by county and admission date. We fit a Poisson model for the relationship between daily temperature range (county daily maximum minus minimum) and 30-day hospitalizations, adjusted for season and patient demographics. Logistic regression assessed 30-day mortality, adjusted for season, patient demographics, and clinical characteristics. Overall and NOAA climate region-stratified relationships were assessed. Results: There were 311,213 unique stroke hospitalizations (mean age 78.8 y, 53% women, 84% White) and 274,703 for AMI (mean age 77.6 y, 45.4% women, 86% White). The national hospitalization rate per 100,000 beneficiary-years was 735 for stroke and 639 for AMI. Thirty-day mortality was 12.0% for stroke and 12.8% for AMI. Each 1 o F increase in daily temperature range was associated with a 1.26 percentage point (95% CI 1.09-1.44) increase in stroke and a 1.48 percentage point (95% CI 1.43-1.53%) increase in AMI hospitalizations and varied by climate region (figure). Daily temperature range had little influence on stroke or AMI mortality (both OR 1.00, 95% CI 1.00-1.00). Conclusions: Daily temperature fluctuations were associated with increased hospitalizations for stroke and AMI. Additional research is needed to understand meteorological effects on vascular events to inform prevention efforts for vulnerable populations.

Abstract 13670: Single versus Serial Measurements of Cardiac Troponin in the Evaluation of Emergency Department Patients With Suspected Acute Myocardial Infarction

Introduction: Chest pain is among the most common reasons for emergency department (ED) presentations. However, most patients are low risk for acute coronary syndrome (ACS) with low cardiac adverse outcomes. Biomarker testing with troponins is the mainstay of initial assessment for ACS. Although serial troponin testing can improve diagnosis of ACS, in clinical practice, some patients deemed to be low risk are discharged after a single negative troponin measurement. Our study evaluated the safety of single-troponin rule-out strategy using a conventional troponin assay. Hypothesis: We assessed the hypothesis that there is no significant difference in the clinical outcomes of patients deemed low-risk and discharged after a single negative troponin compared to patients discharged after serial troponin measurements. Methods: This is a retrospective study of ED encounters from January 2015 to December 2017 across 13 community emergency departments within an integrated healthcare system in Southern California. The study cohort includes adult ED encounters evaluated for suspected ACS with a HEART score and an initial conventional troponin-I below the level of detection (&lt;0.02). Multivariate logistic regression model was performed to evaluate the association between testing strategies and clinical outcomes. Results: Among 27,918 patients with an initial troponin measurement below the level of detection, 14,459 (51.8%) were discharged after a single measurement, and 13,459 patients (48.2%) had serial troponin orders. After adjusting for cardiac risk factors and comorbidities, there was no statistically significant difference in the primary outcome of AMI or cardiac mortality within 30 days between the two groups (single troponin 0.4% vs. serial troponin 0.4%, OR 1.41, 95% CI (0.96-2.07)). Single troponin was associated with a lower rate of CABG (OR 0.24, 95% CI: 0.11-0.48) and invasive coronary angiogram (OR 0.46, 95% CI: 0.38-0.56). Conclusions: When compared to serial troponin testing, discharge after a single negative troponin is routinely done among ED patients, and appears safe based on current physician decision making with no difference in rates of 30-day cardiac mortality and AMI.

305EMF Effective Nutritional Analyses as a Predictive Utility for 30-Day Cardiac Recovery

Persons consuming a micronutrient rich diet (eg, vitamins) have lower cardiovascular disease risk and there is interest in how the micronutrient environment might influence cardiac recovery post-acute myocardial infarction (AMI). Accordingly, we sought to investigate the relationship between nicotinamide specifically, and micro-nutritional profiles generally and AMI recovery with a goal of identifying plausible biologic targets to improve post-AMI outcomes. Since African Americans (AA) experience the highest rate of mortality and rehospitalization post-AMI, our study focuses on enrolling AA patients. Study will recruit 100 patients at emergency departments (EDs) of Detroit Receiving (DRH), Sinai Grace (SGH), and Harper University Hospitals (HUH) with age > 18 and primary diagnosis of AMI defined by 4th Universal Definition of MI. Comorbidities may alter micronutrient levels, excluding: active chronic alcohol/drug users, hepatic failure, renal failure, HIV; pregnant women, those with metabolic disorders except diabetes, and prisoners. We record 30-day post-AMI cardiac-related rehospitalization and mortality by chart review, phone follow-up, and social security death index. Procedures include collection of 2mL plasma stored at -80 C prior to micronutrient extraction and profiling. Liquid chromatography-mass spectrometry analysis of vitamins are performed using QTrap 6500 mass spectrometer (AB Sciex, Singapore) with multi-reaction monitoring to detect molecular ion-daughter combinations. Sample sizes (Table 1) calculation and power analysis (Table 2) were performed using G*Power software. With 100 patients, we anticipate 18 readmissions and 12 deaths, with 0.81 power to evaluate the association of nicotinamide deficiency and post-AMI outcomes with significance of 0.05 (one tail, normal distribution) with R2=0 and odds ratio=2 in the logistic regression adjusted for age, sex, biomarker data, clinical intervention, and medical history. Broad micronutrient profile and post-AMI outcomes assessed by principal component analysis (PCA). 15 individual micronutrients will be assayed. Patient records will be normalized (mean 0, unit variance within each analyte), and PCA will identify the set of micronutrients responsible for the majority of patient variation. Our study enrollment is on hold because of COVID-19 since February 2020. With publicly reported AMI readmission and mortality rates from DRH, HUH, and SGH, we estimate 18% AMI patients readmitted and 12% die 30 days post-discharge (prevalence 30%). We assume 50% patients with reduced nicotinamide plasma concentrations, which may make them two times more likely to die than those with greater concentrations. If their nicotinamide level increase one unit, adverse outcomes reduced by 5%. Micronutrients may contribute to post-AMI outcomes. Our study will be the first to evaluate this in an AA cohort of ED patients. Our hypothesis is that individual variation in micronutrient concentrations will partition study participants into groups. We will examine the prevalence of 30-day outcomes within groupings and identify which micronutrients contribute most robustly to the groupings.

Evaluating quality variation of emergency departments

Abstract Background Germany introduced a graduated system of emergency levels (0 non-participation; 1 for basic up to 3 for comprehensive infrastructure) to overcome various inefficiencies of hospital emergency care. For each level, detailed requirements must be met, however, the case volume of conditions treated in the levels is unclear. Moreover, the relationship between emergency level and outcomes needs evaluation to analyse if patients are directed to the most appropriate hospital. Methods We selected three major emergency conditions - Stroke, AMI and Hip fracture - and matched risk-adjusted outcome and process indicators on hospital level to the hospital respective emergency level. Descriptive statistics such as distribution and correlation are used to examine the allocation of cases to emergency levels and to analyse the effect of structural differences on health outcomes. Results We saw large variations in quality for all clinical conditions regardless of the emergency level. Hospitals with a small case number showed greater fragmentation; hospitals that did not meet the requirements nevertheless performed interventions for AMI and stroke. In detail, 30-day mortality of AMI shows high variation of quality results in level 1; for stroke it is underperformed with almost 10% in hospitals with level 0. Pre-operative LOS for hip fracture is above the acceptable average in any level (tolerance range ≤ 15%), and the ratio O/E in mortality is noticeable for 40% of hospitals with level 0. Conclusions Many cases are treated in low volume hospitals with wide quality variation and subpar results. Therefore, the definition of emergency levels should be integrated to emergency pathways which might help to direct patients to the most appropriate hospital. Moreover, many emergency symptoms are not captured by available quality metrics and current classification systems which shows that emergency service provision is to a large extent not covered by current measurement initiatives. Key messages Emergency service provision is fragmented and not related to emergency levels. Development of emergency quality indicators is needed.

Building Perspective‐Taking as an Organizational Capability: An Exploratory Study

Research ObjectivePerspective‐taking, or understanding the viewpoints of others, is associated with greater trust, cooperation, and creative problem‐solving within high‐functioning teams. High‐functioning teams have been associated with a range of positive quality, safety, and clinical outcomes. Perspective‐taking has largely been understood as an individual and interpersonal phenomenon, primarily based on laboratory studies outside of health care. Despite its potential for improving outcomes in health care, little is known about whether and how perspective‐taking might build from the interpersonal to a wider, shared capability within and across organizations. We present novel empirical data to describe perspective‐taking across teams and organizations and suggest hypothesis for future exploration.Study DesignLeadership Saves Lives was a 2‐year, mixed‐methods intervention study in 10 U.S. hospitals to achieve reductions in AMI mortality by supporting the implementation of evidence‐based strategies and fostering improvements in domains of organizational culture related to hospital performance. The qualitative component included in‐depth interviews at baseline, 6, and 18 months (n = 393 interviews with 197 staff) and observations (56 hours). We performed a secondary exploratory analysis of the longitudinal qualitative data using the constant comparative method, focusing on selected codes most potentially relevant to perspective‐taking.Population StudiedParticipants included members of the guiding coalitions in 10 hospitals in the Mayo Clinic Care Network. Coalitions included approximately 15 key staff involved in care of patients with AMI, from multiple departments (ie, cardiology, emergency medicine, pharmacy, quality improvement, cardiac rehabilitation), professions (ie, physicians, nurses, technologists, administrators), and levels of the organization (ie, senior executives to front‐line staff).Principal FindingsStaff described improved collective perspective‐taking at both the group and system levels over the intervention period. Perspective‐taking behaviors were reported by members from diverse departments, professions, and levels of the organization. Behaviors were apparent in each of the core dimensions of perspective‐taking: 1) affective empathic concern (eg, bonding over a common purpose, solidarity, 2) cognitive attributional understanding (eg, concrete, specific insights and knowledge about facts, roles, processes, and 3) motivational efforts to improve understanding (eg, structural conditions, psychological safety of the perspectives inherent to other organizational targets). Participants described these behaviors as new and attributed them to structural and cultural changes developed through the intervention.ConclusionsThe LSL intervention included training for intentionally diverse teams in engaging conflict productively, using levels of analysis to diagnose organizational challenges, fostering psychological safety, ensuring role clarity, and working with power and hierarchy. Organizations may foster perspective‐taking by building ecological structures and processes that build team capacity in these areas.Implications for Policy or PracticePerspective‐taking has implications for productively spanning boundaries and distances across teams and organizations. Such boundary spanning is becoming increasingly important given contemporary efforts to integrate health and social care.Primary Funding SourceThe medicines company.

Clinical and Financial Performance of Hospitals with Physician CEOs vs. Nonphysician CEOs

Leaders impact organizational behavior and performance, and CEOs may have a greater impact via numerous mechanisms. Because of this, organizations expend considerable resources recruiting and selecting CEOs and may benefit from information suggesting a positive impact on organizational performance based upon measurable CEO characteristics. With this said, little work has been done comparing the performance of hospitals with physician CEOs versus non-physician CEOs, in spite of the ease of identification of this characteristic and extant leadership theories suggesting a relationship between technical expertise and success in leading highly technical organizations. We examined physician CEOs versus non-physician CEOs led hospitals in respect to various clinical and financial performance measures and found no statistically significant differences between the two groups. The 30-day AMI mortality rate showed a positive statistically significant difference in bivariate analysis (p-value<0.001), but the effect was nullified in the multivariable regression analysis.

Impact of left ventricular assist devices and heart transplants on acute myocardial infarction and heart failure mortality and readmission measures.

Concern has been raised about consequences of including patients with left ventricular assist device (LVAD) or heart transplantation in readmission and mortality measures. We calculated unadjusted and hospital-specific 30-day risk-standardized mortality (RSMR) and readmission (RSRR) rates for all Medicare fee-for-service beneficiaries with a primary diagnosis of AMI or HF discharged between July 2010 and June 2013. Hospitals were compared before and after excluding LVAD and heart transplantation patients. LVAD indication was measured. In the AMI mortality (n = 506,543) and readmission (n = 526,309) cohorts, 1,166 and 1,016 patients received an LVAD while 3 and 2 had a heart transplantation, respectively. In the HF mortality (n = 1,015,335) and readmission (n = 1,254,124) cohorts, 789 and 931 received an LVAD, while 212 and 202 received a heart transplantation, respectively. Less than 2% of hospitals had either ≥6 patients who received an LVAD or, independently, had ≥1 heart transplantation. The AMI mortality and readmission cohorts used 1.8% and 2.8% of LVADs for semi-permanent/permanent indications, versus 73.8% and 78.0% for HF patients, respectively. The rest were for temporary/external indications. In the AMI cohort, RSMR for hospitals without LVAD patients versus hospitals with ≥6 LVADs was 14.8% and 14.3%, and RSRR was 17.8% and 18.3%, respectively; the HF cohort RSMR was 11.9% and 9.7% and RSRR was 22.6% and 23.4%, respectively. In the AMI cohort, RSMR for hospitals without versus with heart transplantation patients was 14.7% and 13.9% and RSRR was 17.8% and 17.7%, respectively; in the HF cohort, RSMR was 11.9% and 11.0%, and RSRR was 22.6% and 22.6%, respectively. Estimations changed ≤0.1% after excluding LVAD or heart transplantation patients. Hospitals caring for ≥6 patients with LVAD or ≥1 heart transplantation typically had a trend toward lower RSMRs but higher RSRRs. Rates were insignificantly changed when these patients were excluded. LVADs were primarily for acute-care in the AMI cohort and chronic support in the HF cohort. LVAD and heart transplantation patients are a distinct group with differential care requirements and outcomes, thus should be considered separately from the rest of the HF cohort.

Mortality of Cardiovascular Events in Patients With COPD and Preceding Hospitalization for Acute Exacerbation

Acute exacerbation (AE) of COPD may be accompanied by the deterioration of cardiovascular comorbidities, as evidenced by the increased incidence of acute cardiovascular events. The goal of this study was to determine whether preceding AE might be associated with mortality of cardiovascular events. Using a health insurance research database in Taiwan, patients with COPD were identified who experienced first-time acute myocardial infarction (AMI; n= 26,442), ischemic stroke (n= 54,959), and intracranial hemorrhage (ICH; n= 14,893) over a 13-year period. In each cohort, 4,356, 6,655, and 1,727 patients, respectively, had been hospitalized for AE within the previous year prior to the index cardiovascular events, and patients with COPD but without hospitalization for AEs constituted the control subjects. ORs of 90-day mortality and hazard ratios (HRs) of overall mortality during follow-up in relation to hospitalization for an AE and the frequency of hospitalization for AEs (ie, 1 and≥ 2 hospitalizations for AEs) were estimated with adjustment for potential confounders. Hospitalization for an AE was independently associated with 90-day mortality of AMI (OR, 1.33; 95%CI, 1.24-1.43), ischemic stroke (OR, 1.46; 95%CI, 1.36-1.56), and ICH (OR, 1.19; 95%CI, 1.06-1.32). Hospitalization for an AE was associated with overall mortality of AMI (HR, 1.23; 95%CI, 1.19-1.27), ischemic stroke (HR, 1.29; 95%CI, 1.26-1.33), and ICH (HR, 1.19; 95%CI, 1.13-1.26). In addition, compared with control subjects, patients with more frequent hospitalizations for AEs exhibited significant trends at higher risk of 90-day and overall mortality of AMI, ischemic stroke, and ICH. Finally, these results were consistent with propensity score matching-based estimates. Preceding hospitalization for AEs is associated with 90-day and overall mortality of cardiovascular events in COPD.