Data Registry Acute Coronary Treatment Research Articles

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.

Trends in Performance and Opportunities for Improvement on a Composite Measure of Acute Myocardial Infarction Care.

Background Despite improvements on individual process of care measures for acute myocardial infarction (AMI), little is known about performance on a composite measure of AMI care that assesses the delivery of many components of high-quality AMI care. We sought to examine trends in patient- and hospital-level performance on a composite defect-free care measure, identify disparities in the performance across sociodemographic groups, and identify opportunities to further improve quality and outcomes. Methods and Results We calculated the proportion of patients in the National Cardiovascular Data Registry-Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (now known as the Chest Pain - Myocardial Infarction Registry) between January 1, 2010, and December 31, 2017, receiving defect-free AMI care including guideline-recommended pharmacotherapy, timely provision of medical and reperfusion therapy, assessment of ventricular function, referral to cardiac rehabilitation, and smoking cessation counseling for patients with AMI. A total of 522 800 patients at 222 hospitals were included. Overall, the proportion of patients receiving defect-free care significantly increased from 66.0% in 2010 to 77.1% in 2017 ( P<0.001). Improvements in performance were observed across all sociodemographic subgroups, with the greatest absolute improvement observed for black and Hispanic patients ( P<0.001). However, absolute performance was consistently lower among older patients, women, black and Hispanic patients, and those with government insurance in 2017 ( P<0.001 for all). Improvements in care and reduced variation in performance were observed at the hospital level overall (2010, median [IQR] 67.2% [40.7%-76.3%]; 2017, median [IQR] 80.7% [73.1%-88.1%]; P<0.001) as well as across region, safety net status, teaching status, and proportion of patients who are nonwhite and have Medicaid insurance coverage ( P<0.001 for all). Conclusions Despite improvements in the proportion of patients with AMI receiving defect-free care overall and across sociodemographic groups, nearly 1 in 4 patients in 2017 still did not receive optimal care and absolute performance was consistently lower among older patients, women, black, and Hispanic patients. Composite measures of cardiovascular care, which assess the delivery of several evidence-based processes of care, can illuminate opportunities to improve the quality of care beyond that provided by conventional process measures.

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

BackgroundLittle is known about how differences in out of hospital cardiac arrest patient volume affect in‐hospital myocardial infarction (MI) mortality.HypothesisHospitals accepting cardiac arrest transfers will have increased hospital MI mortality.MethodsMI patients (ST elevation MI [STEMI] and non‐ST elevation MI [NSTEMI]) in the Acute Coronary Treatment Intervention Outcomes Network Registry were included. Hospital variation of cardiac arrest and temporal trend of the proportion of cardiac arrest MI patients were explored. Hospitals were divided into tertiles based on the proportion of cardiac arrest MI patients, and association between in‐hospital mortality and hospital tertiles of cardiac arrest was compared using logistic regression adjusting for case mix.ResultsA total of 252 882 patients from 224 hospitals were included, of whom 9682 (3.8%) had cardiac arrest (1.6% of NSTEMI and 7.5% of STEMI patients). The proportion of MI patients who had cardiac arrest admitted to each hospital was relatively low (median 3.7% [25th, 75th percentiles: 3.0%, 4.5%]).with a range of 4.2% to 12.4% in the high‐volume tertiles. Unadjusted in‐hospital mortality increased with tertile: low 3.8%, intermediate 4.6%, and high 4.7% (P < 0.001); this was no longer significantly different after adjustment (intermediate vs high tertile odds ratio (OR) = 1.02; 95% confidence interval [0.90‐1.16], low vs high tertile OR = 0.93 [0.83, 1.05]).ConclusionsThe proportion of MI patients who have cardiac arrest is low. In‐hospital mortality among all MI patients did not differ significantly between hospitals that had increased proportions of cardiac arrest MI patients. For most hospitals, overall MI mortality is unlikely to be adversely affected by treating cardiac arrest patients with MI.

Association of State Medicaid Expansion With Quality of Care and Outcomes for Low-Income Patients Hospitalized With Acute Myocardial Infarction

Lack of insurance is associated with worse care and outcomes among adults hospitalized for acute myocardial infarction (AMI). It is unclear whether states' decision to expand Medicaid eligibility under the Patient Protection and Affordable Care Act in 2014 were associated with improved quality of care and outcomes among low-income patients hospitalized with AMI. To investigate whether rates of uninsurance, quality of care, and outcomes changed among patients hospitalized for AMI 3 years after states elected to expand Medicaid compared with nonexpansion states. Retrospective cohort study completed at hospitals participating in National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry. Participants were patients younger than 65 years hospitalized for AMI from January 1, 2012, to December 31, 2016. State Medicaid expansion in 2014. Rates of uninsured and Medicaid-insured hospitalizations for AMI in states that expanded Medicaid vs those that did not. Comparison of in-hospital care quality, procedure use, and mortality between expansion and nonexpansion states for the years prior to and after Medicaid expansion. Hierarchical logistic regressions models were used to assess the association between Medicaid expansion and outcomes. The initial cohort included 325 343 patients. Uninsured AMI hospitalizations declined in expansion states (18.0% [4395 of 24 358 hospitalizations] to 8.4% [2638 of 31 382 hospitalizations]) and more modestly in nonexpansion states (25.6% [7963 of 31 137 hospitalizations] to 21.1% [8668 of 41 120 hospitalizations]) from 2012 to 2016 (P < .001 difference in trend expansion vs nonexpansion). Medicaid coverage increased from 7.5% (1818 of 24 358 hospitalizations) to 14.4% (4502 of 31 382 hospitalizations) in expansion states and 6.2% (1924 of 31 137 hospitalizations) to 6.6% (2717 of 41 120 hospitalizations) in nonexpansion states (P < .001). The low-income cohort included 55 737 patients across 765 sites. In expansion states, low-income adults' odds of receipt of defect-free care increased (76.3% to 75.9%, adjusted odds ratio 1.11; 95% CI, 1.02-1.21) but to a lesser degree than in nonexpansion states (72.8% to 74.5%, adjusted odds ratio, 1.38; 95% CI, 1.30-1.47; P for interaction < .001). There was no change in use of most procedures (ie, percutaneous coronary intervention for non-ST-segment elevation myocardial infarction) in expansion compared with nonexpansion states. Improvement in in-hospital mortality was similar between expansion and nonexpansion states (3.2% to 2.8%, adjusted odds ratio, 0.93; 95% CI, 0.77-1.12 vs 3.3% to 3.0%, adjusted odds ratio, 0.85; 95% CI, 0.73-0.99; P for interaction = .48). Medicaid expansion was associated with a significant reduction in rates of uninsurance among patients hospitalized with AMI. Quality of care and outcomes did not improve among low-income adults in expansion compared with nonexpansion states. Hospital care for AMI may be less sensitive to insurance than has been recognized in the past.

Improving Care of STEMI in the United States 2008 to 2012.

BackgroundWe aimed to determine the change in treatment strategies and times to treatment over the first 5 years of the Mission: Lifeline program.Methods and ResultsWe assessed pre‐ and in‐hospital care and outcomes from 2008 to 2012 for patients with ST‐segment–elevation myocardial infarction at US hospitals, using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With The Guidelines Registry. In‐hospital adjusted mortality was calculated including and excluding cardiac arrest as a reason for primary percutaneous coronary intervention delay. A total of 147 466 patients from 485 hospitals were analyzed. There was a decrease in the proportion of eligible patients not treated with reperfusion (6.2% versus 3.3%) and treated with fibrinolytic therapy (13.4% versus 7.0%). Median time from symptom onset to first medical contact was unchanged (≈50 minutes). Use of prehospital ECGs increased (45% versus 71%). All major reperfusion times improved: median first medical contact‐to‐device for emergency medical systems transport to percutaneous coronary intervention–capable hospitals (93 to 84 minutes), first door‐to‐device for transfers for primary percutaneous coronary intervention (130 to 112 minutes), and door‐in–door‐out at non–percutaneous coronary intervention–capable hospitals (76 to 62 minutes) (all P<0.001 over 5 years). Rates of cardiogenic shock and cardiac arrest, and overall in‐hospital mortality increased (5.7% to 6.3%). Adjusted mortality excluding patients with known cardiac arrest decreased by 14% at 3 years and 25% at 5 years (P<0.001).ConclusionsQuality of care for patients with ST‐segment–elevation myocardial infarction improved over time in Mission: Lifeline, including increased use of reperfusion therapy and faster times‐to‐treatment. In‐hospital mortality improved for patients without cardiac arrest but did not appear to improve overall as the number of these high‐risk patients increased.

Seasonal and circadian patterns of myocardial infarction by coronary artery disease status and sex in the ACTION Registry-GWTG

BackgroundMyocardial infarction (MI) presentations are more common during winter months and morning hours. However, it is unknown whether MI with obstructive coronary artery disease (MI-CAD) and non-obstructive CAD (MINOCA) display similar patterns. MethodsWe evaluated seasonal and circadian patterns of MI presentation by coronary artery disease (CAD) status and sex in patients with MI from 2007 to 2014 in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines. Adult patients who underwent coronary angiography for MI were included. Patients with missing age, sex, or angiographic data, cocaine use, thrombolytic therapy prior to catheterization, or prior revascularization were excluded. Baseline demographics and characteristics of symptom onset, including season and time of day of presentation, were compared by CAD status and sex. ResultsAmong 322,523 patients, 112,547 were female (35%); 18,918 had MINOCA (5.9%). There was no seasonal pattern of MI overall. However, both men and women with MINOCA presented more often in the summer and fall while MI-CAD presentations were equally distributed across seasons. The most common time of presentation was 8 am–2 pm regardless of CAD status or sex. A secondary peak in women with MINOCA during late afternoon hours was also identified. ConclusionsSeasonal variation of MI differed between MINOCA and MI-CAD, with a small increase in MINOCA incidence in the summer and fall. MINOCA and MI-CAD most commonly occurred in the morning, with a secondary peak in late afternoon in women with MINOCA. These differences in presentation may relate to underlying MI pathophysiology.

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.

Abstract 19724: Renoprotective Effect of Remote Ischemic Peri-conditioning During Air Medical Transport of Patients With ST-segment Elevation Myocardial Infarction

Background: Acute kidney injury (AKI) manifesting as acute increase in serum creatinine is a recognized complication to cardiac catheterization. Patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) have a markedly increased risk of developing AKI. At present, there is no universally accepted strategy for prevention of AKI in the setting of primary PCI. We assessed whether remote ischemic peri-conditioning (RIPC) stimulus during ambulance transport of STEMI patient would reduce the rate of creatinine rise post primary PCI. Method: We evaluated STEMI patients transferred to two hospitals participating in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) between March, 2013 and March, 2015. Patients were transferred by an air medical critical care service utilizing RIPC as part of a standard protocol and compared to controls matched by referring location/facility. Patient demographics, clinical characteristics, treatments, cardiac biomarkers, left ventricular function, serum creatinine and rate of any increase in creatinine post PCI were compared by the presence or absence of RIPC during transport. Results: Out of the 221 STEMI patients (Age, 63±12.7 yrs; 32.6% female) in this analysis, 107 received RIPC and 114 did not. Baseline characteristics were similar between the two groups. RIPC group had significantly lower rate of creatinine rise post PCI (38.6% vs 55.2%; OR, 1.40; CI, 1.03-1.90; p=0.03) despite having similar baseline serum creatinine (median (IQR), 1.0(0.36) mg/dl vs. median (IQR), 1.0(0.4) mg/dl; p=0.46). In multivariable logistic regression analysis adjusting for demographic factors and clinical characteristics, RIPC (OR, 1.62; CI, 1.12-2.35; p=0.01) was independently associated with lower rate of creatinine rise post PCI. Conclusion: Among patients with STEMI undergoing primary PCI, RIPC before hospital arrival compared with no RIPC was associated with significantly lower rate of creatinine rise post PCI. The use of RIPC as a potential renoprotective strategy for STEMI patients warrants further investigation.

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

In 2009, national legislation promoted wide-spread adoption of electronic health records (EHRs) across US hospitals; however, the association of EHR use with quality of care and outcomes after acute myocardial infarction (AMI) remains unclear. Data on EHR use were collected from the American Hospital Association Annual Surveys (2007-2010) and data on AMI care and outcomes from the National Cardiovascular Data Registry Acute Coronary Treatment and Interventions Outcomes Network Registry-Get With The Guidelines. Comparisons were made between patients treated at hospitals with fully implemented EHR (n=43 527), partially implemented EHR (n=72 029), and no EHR (n=9270). Overall EHR use increased from 82.1% (183/223) hospitals in 2007 to 99.3% (275/277) hospitals in 2010. Patients treated at hospitals with fully implemented EHRs had fewer heparin overdosing errors (45.7% versus 72.8%; P<0.01) and a higher likelihood of guideline-recommended care (adjusted odds ratio, 1.40 [confidence interval, 1.07-1.84]) compared with patients treated at hospitals with no EHR. In non-ST-segment-elevation AMI, fully implemented EHR use was associated with lower risk of major bleeding (adjusted odds ratio, 0.78 [confidence interval, 0.67-0.91]) and mortality (adjusted odds ratio, 0.82 [confidence interval, 0.69-0.97]) compared with no EHR. In ST-segment-elevation MI, outcomes did not significantly differ by EHR status. EHR use has risen to high levels among hospitals in the National Cardiovascular Data Registry. EHR use was associated with less frequent heparin overdosing and modestly greater adherence to acute MI guideline-recommended therapies. In non-ST-segment-elevation MI, slightly lower adjusted risk of major bleeding and mortality were seen in hospitals implemented with full EHRs; however, in ST-segment-elevation MI, differences in outcomes were not seen.

Risk factor burden and control at the time of admission in patients with acute myocardial infarction: Results from the NCDR

Understanding risk factor burden and control as well as perceived risk prior to acute myocardial infarction (MI) presentation may identify gaps in contemporary systems of care. Patients presenting with MI in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry--Get With the Guidelines between January 2007 and November 2013 (N = 443,117) were stratified into 5 mutually exclusive risk categories: Framingham Risk Score (FRS) <10% 74,990 (16.9%), FRS 10% to 20% 90,429 (20.4%), FRS >20% 25,701 (5.8%), diabetes without cardiovascular disease (CVD) 67,779 (15.3%), and prior CVD 184,218 (41.6%). Low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol (non-HDL-C) goals and statin eligibility were determined based on the Third Adult Treatment Panel. At presentation, 66.3% met the low-density lipoprotein cholesterol goal, 66.8% met the non-HDL-C goal, 63.7% were nonsmokers, and 65.1% of patients with prior CVD were on aspirin. Only 36.1% of patients met all assessed risk factor control metrics. Overall statin eligibility prior to MI was 60.8%, and 61.1% of statin-eligible patients reported statin use. Risk factor control prior to MI was suboptimal, with the majority of individuals failing to meet at least 1 risk factor control metric. More effective system-based interventions are needed to promote adherence to prevention targets.

Nationwide Analysis of Patients With ST-Segment-Elevation Myocardial Infarction Transferred for Primary Percutaneous Intervention: Findings From the American Heart Association Mission: Lifeline Program.

Current American College of Cardiology/American Heart Association guidelines recommend transfer and primary percutaneous coronary intervention (PCI) for ST-segment-elevation myocardial infarction (STEMI) patients within the time limit of first contact to device ≤ 120 minutes. We determined the hospital-level, patient-level, and process characteristics of timely versus delayed primary PCI for a diverse national sample of transfer patients confined to a travel distance that facilitates the process. We studied 14,518 patients transferred from non-PCI-capable hospitals for primary PCI to 398 National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines hospitals between July 2008 and December 2012. Patients with estimated transfer times > 60 minutes (by Google Maps driving times) were excluded from the analysis. Patients achieving first door-to-device time ≤ 120 minutes were compared with patients with delayed treatment; independent predictors of timely treatment were determined using generalized estimating equations logistic regression models. The median estimated transfer distance was 26.5 miles. First door-to-device ≤ 120 minutes was achieved in 65% of patients (n = 9380); only 37% of the hospitals were high-performing hospitals (defined as risk-adjusted rate, ≥ 75% of transfer STEMI patients with ≤ 120-minute first door-to-device time). In addition to known predictors of delay (cardiogenic shock, cardiac arrest, and prolonged door-in door-out time), STEMI referral hospitals' rural location and longer estimated transfer time were identified as predictors of delay. In this diverse national sample, regional and racial variations in care were observed. Finally, lower PCI hospital annual STEMI volume was a potent predictor of delay. More than one third of US STEMI patients transferred for primary PCI fail to achieve first door-to-device time ≤ 120 minutes, despite estimated transfer times <60 minutes. Delays are related to process variables, comorbidities, and lower annual PCI hospital STEMI volumes.

Fibrinolysis Use Among Patients Requiring Interhospital Transfer for St-Segment Elevation Myocardial Infarction Care: A Report from The US National Cardiovascular Data Registry: Vora AN, Holmes DN, Rokos I, et al. JAMA Intern Med 2014. doi: 10.1001/jamainternmed.2014.6573. Published online December 8, 2014.

This study used the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry—Get With the Guidelines, to examine ST-segment elevation myocardial infarction (STEMI) treatments and outcomes. The objectives of the study were to 1) determine how drive times between referring and receiving centers determined choice of fibrinolysis vs. primary percutaneous coronary intervention (pPCI) and 2) evaluate outcomes for those patients eligible for either fibrinolysis or pPCI based on inter-hospital transfer times.

Cardiac arrest and clinical characteristics, treatments and outcomes among patients hospitalized with ST-elevation myocardial infarction in contemporary practice: A report from the National Cardiovascular Data Registry

Cardiac arrest (CA) is a major complication of patients with ST-elevation myocardial infarction (STEMI). Its prevalence and prognostic impact in contemporary US practice has not been well assessed. We evaluated STEMI patients included in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) from 4/1/11 to 6/30/12. Patient clinical characteristics, treatments, and inhospital outcomes were compared by the presence or absence of CA on first medical contact-either before hospital arrival or upon presentation to the ACTION hospital. Of the 49,279 STEMI patients included, 3,716 (7.5%) had CA. Cardiac arrest patients were more likely to have heart failure (15.5% vs 6.9%) and shock (42.9% vs 4.9%) on presentation and higher median (25th and 75th percentiles) ACTION Registry-GWTG mortality risk scores (42 [32, 54] vs 32 [26, 38]) than non-CA patients (all P < .001). Primary percutaneous coronary intervention was performed in most patients with and without CA (76.7% vs 79.1%). Inhospital mortality was significantly higher in patients with than without CA (28.8% vs 4.0%; P < .001), both in patients who presented with cardiogenic shock (46.9% vs 27.1%; P < .001) and those without shock (15.4% vs 2.9%; P < .001). The ACTION Registry-GWTG inhospital mortality model underestimated mortality risk in CA patients; however, prediction significantly improved after adding CA to the model. Almost 8% of STEMI patients present with CA. More than 25% die during the hospitalization, despite high use of primary percutaneous coronary intervention. Cardiogenic shock and CA frequently coexist. Our results suggest that development of systems of care and treatments for both STEMI and CA is needed to reduce the high mortality in these patients.

Impact of Diabetes Mellitus on Clinical Characteristics, Management, and In-hospital Outcomes in Patients With Acute Myocardial Infarction (from the NCDR)

Patients with diabetes mellitus (DM) presenting with acute myocardial infarction (AMI) have worse outcomes versus those without DM. Comparative contemporary data in patients presenting with AMI with insulin-requiring diabetes mellitus (IRDM), noninsulin-requiring diabetes mellitus (NIRDM), and newly identified DM (hemoglobin A1C level >6.5%) versus patients without DM are limited. This observational study from the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network-Get with the Guidelines (ACTION Registry-GWTG consisted of 243,861 patients with AMI from 462 US sites identified from January 2007 to March 2011 entered into the registry. Clinical characteristics, management, and in-hospital outcomes were analyzed. Patients with DM with non-ST-segment elevation myocardial infarction (NSTEMI; n = 53,094, 35%) were less likely to undergo diagnostic angiography or revascularization, whereas those with ST-segment elevation myocardial infarction (STEMI) (n = 21,507, 23%) were less likely to undergo reperfusion therapy compared with patients without DM. There was an increased adjusted risk of in-hospital mortality in the DM group in both the NSTEMI (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.06 to 1.22) and STEMI (OR 1.17, 95% CI 1.07 to 1.27) population. In patients with DM, the risk-adjusted in-hospital mortality was higher in patients with IRDM than those with NIRDM in the NSTEMI group (OR 1.12, 95% CI 1.01 to 1.24) but not in the STEMI group (OR 1.12, 95% CI 0.95 to 1.32). Newly diagnosed patients with DM presenting with AMI had similar unadjusted in-hospital outcomes compared with patients without DM. In conclusion, patients with DM presenting with AMI have a higher mortality risk than patients without DM. In patients with DM, those with IRDM presenting with NSTEMI had an increased mortality than those with NIRDM.

Implications of prior myocardial infarction for patients presenting with an acute myocardial infarction

Prior myocardial infarction (MI) is a known risk factor for long-term mortality among acute MI patients; but its prevalence and implications for the short-term outcomes of patients with a new, acute MI remain uncertain. We studied a total of 319,152 consecutively enrolled ST-segment elevation MI (STEMI) and non-STEMI (NSTEMI) patients in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines (01/2007-03/2012). Baseline characteristics, home and in-hospital treatments, mortality rates, and major bleeding were compared separately for STEMI and NSTEMI by prior MI status, with adjustment for mortality and major bleeding. Prior MI was documented in 19% of STEMI (n = 124,535) and 29% of NSTEMI (n = 194,617) patients, who were older, were more likely to have comorbidities or prior revascularization, and were more commonly taking secondary prevention medications at home. Guideline-recommended treatments in-hospital and at discharge did not differ in prior-MI STEMI patients, but invasive management was lower for prior-MI NSTEMI patients. The frequency of in-hospital mortality was higher for prior-MI STEMI (5.9% vs. 5.2%) and NSTEMI patients (4.3% vs. 3.4%). After adjustment, the excess mortality risk associated with prior MI was no longer present for STEMI (odds ratio = 1.06, 95% CI 0.97-1.15), with only modest excess risk for NSTEMI (odds ratio = 1.10, 95% CI 1.04-1.15). The risk of in-hospital major bleeding was marginally lower for prior-MI NSTEMI. More than 20% of patients with acute MI treated in contemporary practice have a history of a prior MI; despite differences in the baseline risk profile, there was little difference in the adjusted risk of in-hospital mortality by prior-MI status.

Sources of Hospital-Level Variation in Major Bleeding Among Patients With Non–ST-Segment Elevation Myocardial Infarction

Major bleeding has received increasing attention as a target for quality improvement in care of patients with acute myocardial infarction. However, little is known about variation in bleeding across hospitals and whether variation is attributable to quality of hospital care, treatments, or case mix. We characterized hospital variation in major bleeding events (an absolute hemoglobin drop ≥4 g/dL, intracranial hemorrhage, retroperitoneal bleed, or transfusion) among 99 200 patients with non-ST-segment elevation myocardial infarction in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTIOM Registry-GWTG) between January 2007 and June 2010. A total of 9566 (9.6%) patients experienced a major bleeding event during hospitalization. The median of the estimated distribution of major bleeding rates across hospitals was 9.4% (interquartile range, 7.5%-11.7%), with some hospitals having bleeding rates >2.3 times higher than others (10th-90th percentile, 6.1%-14.2%). Multivariable hierarchical models revealed that differences in case mix explained 19.2% of the hospital variation in bleeding complications, where anticoagulation and antiplatelet strategies explained an incremental 9.9% and 6.8%, respectively. Together, 32.3% of hospital variation in major bleeding rates was attributable to differences in patient case mix and identifiable differences in treatment strategies in patients with non-ST-segment elevation myocardial infarction. In-hospital major bleeding rates varied widely across hospitals. Although patient factors and treatments explained less than one third of hospital-level variation, ≈70% of bleeding variation remains after adjustment. A better understanding of causes for substantial hospital-level bleeding variations is needed to help target high-risk patients or practices and to optimize care.

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

Aldosterone antagonists (AldA) improve survival after myocardial infarction (MI) in patients with left ventricular systolic dysfunction (ejection fraction [EF] <40%) concomitant with either clinical heart failure (HF) or diabetes mellitus (DM). Although current American College of Cardiology/American Heart Association guidelines provide a class I recommendation for AldA therapy in such patients, how US practice reflects these recommendations is unclear. Using data from the National Cardiovascular Data Registry ACTION Registry-GWTG, we describe contemporary discharge AldA prescription patterns among 202,213 patients discharged after acute MI from 526 US sites participating in ACTION Registry-GWTG between January 2007 and March 2011. Overall, 10.0% of patients were eligible for AldA without documented contraindication, with only 14.5% of eligible patients receiving AldA at discharge. Among the subset of AldA-eligible patients discharged on otherwise optimal medical therapy (68.9%), AldAs were prescribed to 16.1%. Aldosterone antagonist use was higher in patients with EF <40% and clinical HF with or without DM (17.7% and 16.6%, respectively), compared with patients with EF <40% and DM without clinical HF (7.8%, P < .001 for each). Fewer than 2% of participating centers used AldA in ≥50% of eligible patients. Despite clinical outcome evidence and class I guideline recommendations, AldAs are underused in the United States, with only 1 in 7 eligible patients prescribed AldA at discharge after MI. This contrasts with high use of other evidence-based post-MI medications and identifies a specific gap in translation of evidence into clinical practice.

Circulation : Clinical Summaries

<i>Circulation</i> : Clinical Summaries

Limitations of using cardiac catheterization rates to assess the quality of care for patients with non–ST-segment elevation myocardial infarction

An early invasive management strategy is recommended for patients with non-ST-segment elevation myocardial infarction (NSTEMI) who do not have a contraindication to cardiac catheterization (CCC). However, the frequency of CCC reporting has not been delineated, and the relationship of CCC reporting to hospital-level guidelines adherence for NSTEMI has not been investigated. We used the American College of Cardiology National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines database to evaluate variations in hospital-level reporting of CCC for 111,320 patients with NSTEMI admitted to 370 hospitals with revascularization capabilities in the United States from 2007 to 2010 and how these variations were associated with guideline adherence and in-hospital mortality. Hospitals were grouped into tertiles based on rates of reported CCCs. Treatment patterns and in-hospital mortality rates were evaluated across hospital tertiles separately for patients with and without a reported CCC. A total of 18,290 (16.4%) of 111,320 patients with NSTEMI had a reported CCC, but hospital-level CCC reporting varied considerably (low tertile 0%-8.2%, intermediate tertile >8.2%-18.8%, and high tertile >18.8%-75.6%). Patients with a reported CCC had more comorbidities and high-risk features compared with patients without a CCC. The use of most guideline-recommended medications and in-hospital mortality rates were similar across hospital tertiles-both for patients with and without a reported CCC. The reporting of CCC among patients with NSTEMI varies widely across US hospitals and does not appear to be related to guidelines adherence or in-hospital mortality rates. These findings suggest that it will be a challenge to standardize the reporting of CCC and thus use invasive management to assess the quality of NSTEMI care.

Admission International Normalized Ratio Levels, Early Treatment Strategies, and Major Bleeding Risk Among Non–ST-Segment–Elevation Myocardial Infarction Patients on Home Warfarin Therapy

Background— Non–ST-segment–elevation myocardial infarction patients on home warfarin pose treatment concerns because of their potential increased risk of bleeding. Expert opinion from the American College of Cardiology/American Heart Association guidelines suggest holding anticoagulants and initiating antiplatelet therapy among therapeutically anticoagulated non–ST-segment–elevation myocardial infarction patients. Yet, little is known about contemporary treatment patterns and bleeding risks in this population. Methods and Results— We stratified 5787 non–ST-segment–elevation myocardial infarction patients on home warfarin therapy using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines by admission international normalized ratio (INR) levels: subtherapeutic (INR &lt;2), therapeutic (INR, 2–3), and supratherapeutic (INR &gt;3). Multivariable logistic generalized estimating equations models were constructed to examine the associations between admission INR level, early antithrombotic treatment and invasive therapy, and risk of in-hospital major bleeding. Among these patients, 46%, 35%, and 19% had subtherapeutic, therapeutic, and supratherapeutic admission INR levels, respectively. Risk of major bleeding was higher among patients with therapeutic (15%; adjusted odds ratio, 1.25; 95% confidence interval [CI], 1.03–1.50) and supratherapeutic (22%; odds ratio, 1.60; 95% CI, 1.30–1.97) anticoagulation compared with the subtherapeutic group (12%). Among patients with admission INR ≥2, 45% were treated with early (within 24 hours) heparin, 35% with early clopidogrel, 14% with early glycoprotein IIb/IIIa inhibitor, and 36% with early invasive strategy. Early antithrombotic treatment was associated with increased bleeding risk (odds ratio, 1.40 [95% CI, 1.14–1.72] for heparin; 1.50 [95% CI, 1.22–1.84] for clopidogrel; and 1.82 [95% CI, 1.43–2.32] for glycoprotein IIb/IIIa inhibitor); however, an early invasive strategy was not (odds ratio, 1.09; 95% CI, 0.86–1.37). No significant interactions were observed between INR level and use of each early treatment in its association with bleeding. Conclusions— National patterns of early antithrombotic treatment for non–ST-segment–elevation myocardial infarction patients on home warfarin diverge from expert opinion provided by current practice guidelines. Early antithrombotic treatment was associated with increased bleeding risk regardless of admission INR level.