Hospitalization For Myocardial Infarction Research Articles

Association of prior bariatric surgery with financial and clinical outcomes of acute myocardial infarction

BackgroundSuperior clinical outcomes after hospitalization for cardiovascular-related disease such as acute heart failure have been linked with prior history of bariatric surgery, but similar analyses in acute myocardial infarction (MI) are currently limited. ObjectiveThis work examines clinical outcomes and resource utilization in patients with acute MI hospitalizations with a prior history of bariatric surgery. SettingAcademic university-affiliated hospital in the United States. MethodsAll adult patients with hospitalizations with a primary diagnosis of acute MI were queried using the 2016–2020 Nationwide Readmissions Database. The study population was comprised of patients with an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code for obesity (body mass index ≥35 kg/m2) as well as those with a prior history of bariatric surgery regardless of their body mass index status. Comparison was made between those with a prior history of bariatric surgery and those without. Univariate analysis and multivariate regression models were used to examine the association between bariatric surgery and outcomes of interest, which included in-hospital mortality, medical complications, and resource utilization. ResultsOf an estimated 2,736,606 hospitalizations for acute MI, 296,902 patients (10.8%) had a diagnosis of obesity and/or a prior history of bariatric surgery. The bariatric cohort was more frequently female and had a lower prevalence of congestive heart failure, chronic lung disease, diabetes, and electrolyte derangements than the nonbariatric cohort. After risk adjustment, prior history of bariatric surgery was associated with significantly lower odds of in-hospital mortality, cardiogenic shock, and acute kidney injury. Additionally, prior history of bariatric surgery was linked to a decreased duration of hospital stay and lower hospitalization costs as well as lower odds of nonhome discharge. ConclusionAmong acute MI patients with obesity, prior history of bariatric surgery was associated with decreased odds of in-hospital mortality, improved clinical outcomes, and lower resource utilization. Expansion of bariatric surgery programs may provide improved access to a medical intervention that is intertwined with cardiovascular health.

Empagliflozin is associated with lower cardiovascular risk compared with dipeptidyl peptidase-4 inhibitors in adults with and without cardiovascular disease: EMPagliflozin compaRative effectIveness and SafEty (EMPRISE) study results from Europe and Asia

BackgroundStudies that have reported lower risk for cardiovascular outcomes in users of Sodium–Glucose Cotransporter-2 Inhibitors (SGLT-2i) are limited by residual cofounding and lack of information on prior cardiovascular disease (CVD). This study compared risk of cardiovascular events in patients within routine care settings in Europe and Asia with type 2 diabetes (T2D) initiating empagliflozin compared to dipeptidyl peptidase-4 inhibitors (DPP-4i) stratified by pre-existing CVD and history of heart failure (HF).Methods and resultsAdults initiating empagliflozin and DPP-4i in 2014–2018/19 from 11 countries in Europe and Asia were compared using propensity score matching and Cox proportional hazards regression to assess differences in rates of primary outcomes: hospitalisation for heart failure (HHF), myocardial infarction (MI), stroke; and secondary outcomes: cardiovascular mortality (CVM), coronary revascularisation procedure, composite outcome including HHF or CVM, and 3-point major adverse cardiovascular events (MACE: MI, stroke and CVM). Country-specific results were meta-analysed and pooled hazard ratios (HR) with 95% confidence intervals (CI) from random-effects models are presented.In total, 85,244 empagliflozin/DPP4i PS-matched patient pairs were included with overall mean follow-up of 0.7 years. Among those with pre-existing CVD, lower risk was observed for HHF (HR 0.74; 95% CI 0.64–0.86), CVM (HR 0.55; 95% CI 0.38–0.80), HHF or CVM (HR 0.57; 95% CI 0.48–0.67) and stroke (HR 0.79; 95% CI 0.67–0.94) in patients initiating empagliflozin vs DPP-4i. Similar patterns were observed among patients without pre-existing CVD and those with and without pre-existing HF.ConclusionThese results from diverse patient populations in routine care settings across Europe and Asia demonstrate that initiation of empagliflozin compared to DPP-4i results in favourable cardioprotective effects regardless of pre-existing CVD or HF status.

Association of prior outpatient diabetes screening with cardiovascular events and mortality among people with incident diabetes: a population-based cohort study

BackgroundOutcomes of diabetes screening in contemporary, multi-ethnic populations are unknown. We examined the association of prior outpatient diabetes screening with the risks of cardiovascular events and mortality in Ontario, Canada.MethodsWe conducted a population-based cohort study using administrative databases among adults aged ≥ 20 years with incident diabetes diagnosed during 2014–2016. The exposure was outpatient diabetes screening performed within 3 years prior to diabetes diagnosis. The co-primary outcomes were (1) a composite of all-cause mortality and hospitalization for myocardial infarction, stroke, coronary revascularization, and (2) all-cause mortality (followed up until 2018). We calculated standardized rates of each outcome and conducted cause-specific hazard modelling to determine the adjusted hazard ratio (HR) of the outcomes, adjusting for prespecified confounders and accounting for the competing risk of death.ResultsWe included 178,753 Ontarians with incident diabetes (70.2% previously screened). Individuals receiving prior screening were older (58.3 versus 53.4 years) and more likely to be women (49.6% versus 40.0%) than previously unscreened individuals. Individuals receiving prior screening had relatively lower standardized event rates than those without prior screening across all outcomes (composite: 12.8 versus 18.1, mortality: 8.2 versus 11.1 per 1000 patient-years). After multivariable adjustment, prior screening was associated with 34% and 32% lower risks of the composite (HR 0.66, 0.63–0.69) and mortality (0.68, 0.64–0.72) outcomes. Among those receiving prior screening, a result in the prediabetes range was associated with lower risks of the composite (0.82, 0.77–0.88) and mortality (0.71, 0.66–0.78) outcomes than a result in the normoglycemic range.ConclusionsPreviously screened individuals with diabetes had lower risks of cardiovascular events and mortality versus previously unscreened individuals. Better risk assessment tools are needed to support wider and more appropriate uptake of diabetes screening, especially among young adults.

Population-level trends in asthma and chronic obstructive pulmonary disease emergency department visits and hospitalizations before and during the coronavirus disease 2019 pandemic in the United States

BackgroundPrevious studies have identified reductions in exacerbations of chronic lung disease in many locales after onset of the coronavirus disease 2019 (COVID-19) pandemic. ObjectiveTo evaluate the population-level impacts of COVID-19 on asthma and chronic obstructive pulmonary disease (COPD) exacerbations—with a focus on disadvantaged communities—in the United States. MethodsWe analyzed 2016 to 2020 county-level data on asthma and COPD acute care use, with myocardial infarction hospitalizations as a comparator condition. We linked this with county-level lower respiratory disease mortality data. We calculated rates of emergency department (ED) visits, hospitalizations, and deaths and evaluated changes using linear regressions adjusted for year and county-fixed effects.For a supplementary analysis, we calculated ED visit rates nationwide for asthma, COPD, or any diagnosis using the 2016 to 2020 National Hospital Ambulatory Medical Care Survey. ResultsOur county-level data included 685 counties in 13 states. Rates of each outcome fell in 2020. In adjusted analyses, we found large reductions in asthma and COPD ED visit rates (eg, a 21.5 per 10,000-person reduction in COPD ED visits; 95% confidence interval, −23.8 to −19.1), with smaller reductions in hospitalizations and chronic lower respiratory mortality. Disadvantaged communities had mostly higher baseline rates of respiratory morbidity and larger absolute reductions in some outcomes.Among 90,808 ED visits in the National Hospital Ambulatory Medical Care Survey, asthma ED visits/y fell 33% during the pandemic and COPD visits by 51%; overall ED visits fell by only 7%. ConclusionOnset of the COVID-19 pandemic coincided with reductions in acute care utilization for asthma and COPD. Understanding the mechanism of this reduction might inform future efforts to prevent exacerbations.

The role of insurance status in the association between short-term temperature exposure and myocardial infarction hospitalizations in New York State.

To evaluate effect modification of the relationship between short-term ambient temperature and MI, by individual-level insurance status (insured vs. uninsured). We identified MI hospitalizations and insurance status across New York State (NYS) hospitals from 1995 to 2015 in the New York Department of Health Statewide Planning and Research Cooperative System database, using International Classification of Diseases codes. We linked short-term ambient temperature (averaging the 6 hours preceding the event [MI hospitalization]) or nonevent control period in patient residential zip codes. We employed a time-stratified case-crossover study design for both insured and uninsured strata, and then compared the group-specific rate ratios. Over the study period, there were 1,095,051 primary MI admissions, 966,475 (88%) among insured patients. During extremely cold temperatures (<5.8 °C) insured patients experienced reduced rates of MI; this was not observed among the uninsured counterparts. At warmer temperatures starting at the 65th percentile (15.7 °C), uninsured patients had higher rates than insured patients (e.g., for a 6-hour pre-event average temperature increase from the median to the 75th percentile, the rate of MI increased was 2.0% [0.0%-4.0%] higher in uninsured group). Uninsured individuals may face disproportionate rates of MI hospitalization during extreme temperatures.

The Cardiovascular Safety of Five-Alpha-Reductase Inhibitors Among Men with Benign Prostatic Hyperplasia: A Population-Based Cohort Study

BackgroundFive-alpha reductase inhibitors (5αRIs) are used to treat benign prostatic hyperplasia (BPH). However, the cardiovascular effects of 5αRIs remain poorly understood. The study objective was to compare the rate of hospitalization for heart failure among men with BPH prescribed 5αRIs to that of men with BPH not prescribed BPH medications. MethodsUsing the Clinical Practice Research Datalink linked with hospitalization and vital statistics data, we conducted a population-based cohort study among patients newly diagnosed with BPH. We defined exposure as the current use of 5αRIs, current use of alpha-blockers, and no current use of BPH medications in a time-varying approach. The primary endpoint was hospitalization for heart failure, and secondary endpoints were myocardial infarction, stroke, and cardiovascular death. We used time-dependent Cox-proportional hazards models to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). ResultsOur cohort included 94,440 men with incident BPH. A total of 3893 hospitalizations for heart failure occurred over 527,660 person-years of follow-up (incidence rate 7.38; 95% CI, 7.15-7.61, per 1000 person-years). Compared with no current use of BPH medications, current use of 5αRIs was not associated with an increased risk of hospitalization for heart failure (HR 0.94; 95% CI, 0.86-1.03), myocardial infarction (HR 0.92; 95% CI, 0.81-1.05), stroke (HR 0.94; 95% CI, 0.85-1.05), or cardiovascular death (HR 0.89; 95% CI, 0.80-0.99). ConclusionsThe use of 5αRIs was not associated with an increased risk of hospitalization for heart failure, myocardial infarction, stroke, or cardiovascular death compared with non-use.

Prognostic Significance of Activated Monocytes in Patients with ST-Elevation Myocardial Infarction.

Circulating monocytes have different subsets, including classical (CD14++CD16-), intermediate (CD14++CD16+), and nonclassical (CD14+CD16++), which play different roles in cardiovascular physiology and disease progression. The predictive value of each subset for adverse clinical outcomes in patients with coronary artery disease is not fully understood. We sought to evaluate the prognostic efficacy of each monocyte subset in patients with ST-elevation myocardial infarction (STEMI). We recruited 100 patients with STEMI who underwent primary percutaneous coronary intervention (PCI). Blood samples were collected at the time of presentation to the hospital (within 6 h from onset of symptoms, baseline (BL)) and then at 3, 6, 12, and 24 h after presentation. Monocytes were defined as CD45+/HLA-DR+ and then subdivided based on the expression of CD14, CD16, CCR2, CD11b, and CD42. The primary endpoint was a composite of all-cause death, hospitalization for heart failure, stent thrombosis, in-stent restenosis, and recurrent myocardial infarction. Univariate and multivariate Cox proportional hazards models, including baseline comorbidities, were performed. The mean age of our cohort was 58.9 years and 25% of our patients were females. Patients with high levels (above the median) of CD14+CD16++ monocytes showed an increased risk for the primary endpoint in comparison to patients with low levels; adjusted hazard ratio (aHR) for CD14+/CD16++ cells was 4.3 (95% confidence interval (95% CI) 1.2-14.8, p = 0.02), for CD14+/CD16++/CCR2+ cells was 3.82 (95% CI 1.06-13.7, p = 0.04), for CD14+/CD16++/CD42b+ cells was 3.37 (95% CI 1.07-10.6, p = 0.03), for CD14+/CD16++/CD11b+ was 5.17 (95% CI 1.4-18.0, p = 0.009), and for CD14+ HLA-DR+ was 7.5 (95% CI 2.0-28.5, p = 0.002). CD14++CD16-, CD14++CD16+, and their CD11b+, CCR2+, and CD42b+ aggregates were not significantly predictive for our composite endpoint. Our study shows that CD14+ CD16++ monocytes and their subsets expressing CCR2, CD42, and CD11b could be important predictors of clinical outcomes in patients with STEMI. Further studies with a larger sample size and different coronary artery disease phenotypes are needed to verify the findings.

Can traffic-related air pollution trigger myocardial infarction within a few hours of exposure? Identifying hourly hazard periods

IntroductionTraffic-related air pollution can trigger myocardial infarction (MI). However, the hourly hazard period of exposure to nitrogen dioxide (NO2), a common traffic tracer, for incident MI has not been fully evaluated. Thus, the current hourly US national air quality standard (100 ppb) is based on limited hourly-level effect estimates, which may not adequately protect cardiovascular health. ObjectivesWe characterized the hourly hazard period of NO2 exposure for MI in New York state (NYS), USA, from 2000 to 2015. MethodsFor nine cities in NYS, we obtained data on MI hospitalizations from the NYS Department of Health Statewide Planning and Research Cooperative System and hourly NO2 concentrations from the US Environmental Protection Agency’s Air Quality System database. We used city-wide exposures and a case-crossover study design with distributed lag non-linear terms to assess the relationship between hourly NO2 concentrations over 24 h and MI, adjusting for hourly temperature and relative humidity. ResultsThe mean NO2 concentration was 23.2 ppb (standard deviation: 12.6 ppb). In the six hours preceding MI, we found linearly increased risk with increasing NO2 concentrations. At lag hour 0, a 10 ppb increase in NO2 was associated with 0.2 % increased risk of MI (Rate Ratio [RR]: 1.002; 95 % Confidence Interval [CI]: 1.000, 1.004). We estimated a cumulative RR of 1.015 (95 % CI: 1.008, 1.021) for all 24 lag hours per 10 ppb increase in NO2. Lag hours 2–3 had consistently elevated risk ratios in sensitivity analyses. ConclusionsWe found robust associations between hourly NO2 exposure and MI risk at concentrations far lower than current hourly NO2 national standards. Risk of MI was most elevated in the six hours after exposure, consistent with prior studies and experimental work evaluating physiologic responses after acute traffic exposure. Our findings suggest that current hourly standards may be insufficient to protect cardiovascular health.

Internet Versus Noninternet Participation in a Decentralized Clinical Trial: Lessons From the ADAPTABLE Study.

Background Internet-based participation has the potential to enhance pragmatic and decentralized trials, where representative study populations and generalizability to clinical practice are key. We aimed to study the differences between internet and noninternet/telephone participants in a large remote, pragmatic trial. Methods and Results In a subanalysis of the ADAPTABLE (Aspirin Dosing: A Patient-Centric Trial Assessing Benefits and Long-Term Effectiveness) study, we compared internet participants with those who opted for noninternet participation. Study process measures examined included participant characteristics at consent, study medication adherence, and study retention. The clinical outcome examined was a composite of all-cause mortality, hospitalization for myocardial infarction, or hospitalization for stroke. Noninternet participants were older (mean 69.4 versus 67.4 years), more likely to be female (38.9% versus 30.2%), more likely to be Black (27.3% versus 6.0%) or Hispanic (11.1% versus 2.0%), and had a higher number of comorbid conditions. The composite clinical outcome was more than twice as high in noninternet participants. The hazard of nonadherence to the assigned aspirin dosage was 46% higher in noninternet participants than internet participants. Conclusions Noninternet participants differed from internet participants in notable demographic characteristics while having poorer baseline health. Over the course of ADAPTABLE, they also had worse clinical outcomes and greater likelihood of study drug nonadherence. These results suggest that trials focused on internet participation select for younger, healthier participants with a higher proportion of traditionally overrepresented patients. Allowing noninternet participation enhances diversity; however, additional steps may be needed to promote study retention and study medication adherence. Registration Information clinicaltrials.gov. Identifier: NCT02697916.

Trends in Short-, Intermediate-, and Long-Term Mortality Following Hospitalization for Myocardial Infarction Among Medicare Beneficiaries, 2008 to 2018.

Background Advances in technology and care quality have transformed the care of acute myocardial infarction (AMI), but little is known about trends in mortality rates across separate time periods after hospitalization. Methods and Results We identified all Medicare fee-for-service beneficiaries hospitalized with incident AMI from 2008 to 2018. We calculated unadjusted mortality rates by dividing the number of all-cause deaths by the number of patients with incident AMI for the following time periods: acute (in hospital), post acute (0-30 days after hospital discharge), short term (31 days to 1 year after discharge), intermediate term (1-2 years after discharge), and long term (2-3 years after discharge). Each period was considered separately (ie, patients who died during one period were not counted in subsequent periods). Using logistic regression to account for differences in patient characteristics, we calculated annual risk standardized mortality ratios defined as observed over expected mortality based on 2008 rates. Among 768 084 patients with incident AMI (mean age 81 years, 48% male, 87% White), declines in observed-to-expected mortality ratios were observed for each time period: acute (0.68 [95% CI, 0.66-0.71]), postacute (0.72 [95% CI, 0.71-0.75]), short term (0.77 [95% CI, 0.75-0.78]), intermediate term (0.79 [95% CI, 0.77-0.81]), and long term (0.77 [95% CI, 0.75-0.79]). Declines were observed both for patients with and without ST-segment-elevation AMI. Conclusions For patients with incident AMI, there have been improvements in mortality rates across periods spanning the hospital stay through 3 years after discharge, reflecting advances in AMI care from hospitalization through long-term outpatient follow-up.

#5749 RATES OF SELECTED CARDIOVASCULAR AND NON-CARDIOVASCULAR EVENTS AMONG DIALYSIS PATIENTS WITH ANEMIA IN THE US MEDICARE POPULATION

Abstract Background and Aims The safety and efficacy of daprodustat in patients on dialysis were reported in ASCEND-D/ID trials [1,2]. Trials impose strict criteria for enrollment, making participants more narrowly selected than a broader population with disease who might benefit from treatment. We describe events, of which most were noted as safety events in ASCEND-D/ID trials, among general anemia “treatment eligible” (TE) patients on dialysis and patients similar to those in ASCEND-D/ID trials (“clinical trial-like” [CTL]) in the US. Method Using United States Renal Data System data, we conducted a retrospective cohort study of incident dialysis-dependent (IDD) patients from 2017–2019 and, separately, point prevalent dialysis-dependent (PDD) patients as of Jan 1 2018. Dialysis initiation date was the index date for IDD patients and Jan 1 2018 for PDD patients. We also required patients to have ≥6 months of continuous Medicare coverage before, and be aged ≥18 years on, index date. Patients with a history of kidney transplant or who had cancer during the year prior, and those who had a hospitalization for heart failure (HF), myocardial infarction (MI), or stroke in the 4 weeks before, the index date were excluded. For IDD patients, we required use of ESAs at the index date to support comparability to the PDD patients. The CTL cohort was a subset of the TE cohort, approximating eligibility in the ASCEND-D/ID trials. Patients were followed from index date to the earliest date of death, loss of Medicare coverage, kidney transplantation, or Dec 31 2019. We assessed cardiovascular (CV: all-cause death, HF, MI, stroke, thromboembolic events [TEEs], major cardiovascular events [MACE: death, MI, stroke] and MACE+HF) and non-CV (cancer, gastric erosions, ocular events, seizures, serious infections) events, derived from medical claims in the follow-up period using ICD-10 diagnosis, Healthcare Common Procedure Coding System, and Current Procedural Terminology codes. HF, MI, stroke, and serious infections were defined as inpatient events. First event rates for TE and CTL cohorts were calculated separately for IDD and PDD patients and expressed as number of events per 100 patient-years (PYs). Results Of IDD patients, 23,909 were in the TE and 6,962 in the CTL cohorts; corresponding numbers were 230,055 and 41,980 for PDD patients. Median follow-up was 12.6 and 13.8 months for the TE and CTL cohorts, respectively, in IDD patients; and 24 months for both TE and CTL cohorts in PDD patients. Mean ages were 70.3 and 71.0 years for the TE and CTL cohorts in IDD patients; and 63.3 and 64.1 years for the TE and CTL cohorts in PDD patients. For both IDD and PDD patients, the TE and CTL cohorts had similar demographics, but the TE cohorts had a slightly higher proportion of patients with comorbidities. First event rates are shown in the Table. TE cohorts had higher rates than CTL cohorts for most CV events (mortality, 17.3 vs 14.0 per 100 PYs in IDD and 16.8 vs 15.1 in PDD; MACE; 20.9 vs 17.5 in IDD and 20.3 vs 18.6 in PDD; MACE+HF, 25.6 vs 21.8 in IDD, 26.9 vs 25.1 in PDD). In IDD patients, HF was more common in the TE than the CTL cohort (7.1 vs 6.1) but was similar in PDD patients. MI, stroke, and TEEs (vascular access thrombosis [in hemodialysis patients only], deep venous thrombosis, and pulmonary embolism) had similar rates in the TE and CTL cohorts for both IDD and PDD patients. Serious infections were higher in the TE than the CTL cohort in both IDD and PDD patients. In PDD patients, gastric erosions were higher in the TE than the CTL cohort (40.0 vs 38.5) while ocular events and retinal hemorrhage were lower in the TE cohort. Conclusion Rates for most CV events were higher in TE cohorts, comprised of patients eligible for anemia treatment, compared with CTL cohorts mimicking trial participants. Rates of non-CV events did not show a consistent pattern. As expected, rates of VAT were higher in IDD than PDD patients. These findings further contextualize real-world event rates of interest in dialysis populations. Reported rates were crude (unadjusted) and should be interpreted with caution. Funding: GSK (study 217316).

#5810 SELECTED CARDIOVASCULAR (CV)/NON-CV EVENT RATES IN NON-DIALYSIS-DEPENDENT PATIENTS TREATED WITH ESAS IN US MEDICARE (2017–2019), BY CKD STAGE

Abstract Background and Aims The safety and efficacy of daprodustat in non-dialysis-dependent chronic kidney disease (CKD) patients have been reported in the ASCEND-ND trial [1]. However, CKD stage may affect both the need for anemia treatment as well as outcomes, including potential safety events for anemia treatment. This study describes cardiovascular (CV) and non-CV event rates by CKD stage among patients treated with erythropoietin-stimulating agents (ESAs) in the US Medicare population. Method Using Medicare data for all fee-for-service enrollees, we conducted a retrospective cohort study of patients who had diagnosis of CKD stages 3, 4, or 5 and a first use of ESA in 2017–2019. CKD stage was identified by ICD-10 codes; ESA use was derived using Healthcare Common Procedure Coding System (HCPCS) codes. The date of first ESA use was the index date and CKD stage was defined as the most recent diagnosis on or before index date. We further required patients to have at least 12 continuous months of Medicare Parts A and B coverage (also used as a washout period to identify new ESA users) prior to, and be aged ≥66 years on, the index date. Patients with a history of kidney transplant or who had cancer during the year prior, and those who had a hospitalization for heart failure (HF), myocardial infarction (MI), or stroke in the 4 weeks before, the index date were excluded. Patients were followed from index date to the earliest date of death, loss of Medicare coverage, kidney transplantation or dialysis, or December 31, 2019. Both CV (all-cause death, HF, MI, stroke, thromboembolic events [TEEs], MACE [death, stroke, MI], and MACE+HF) and non-CV (cancer, gastric erosions, ocular events, seizures, and serious infections) events were ascertained, derived from Medical claims using ICD-10 diagnosis, HCPCS, and Current Procedural Terminology codes in the follow-up period. HF, MI, stroke, and serious infection were defined as inpatient events. First event rates were calculated separately by CKD stage, expressed as number of events per 100 patient-years during the follow-up period. Results This study cohort included 50,206 patients; 22,332 had stage 3, 19,177 stage 4, and 8,697 stage 5 CKD at the index date. Median follow-up time was 11.5 months for patients with CKD stage 3, 8.9 months for patients with stage 4, and 3.7 months for patients with stage 5 CKD. Patients with higher (worse) CKD stages were slightly younger (mean ages for stages 3, 4, and 5 were 79.7, 79.1, and 76.8 years); with increasingly more males (42.9%, 45.1%, and 48.5%), increasingly more individuals of non-Hispanic Black race (14.2%, 15.7%, and 19.6%), with lower income (indicated by Medicare/Medicaid dual enrolment and Medicare Part D low-income subsidy), and lower proportion of comorbidities. Rates were higher for most CV events in patients with higher (worse) CKD stages (Table): death rates were 19.5, 22.1, and 28.1 per 100 patient-years for stages 3, 4, and 5, respectively; MI rates were 2.2, 2.9, and 3.2; HF rates were 12.5, 17.2, and 19.0; MACE rates were 22.0, 25.4, and 31.8; and MACE+HF rates were 31.0, 38.7 and 47.8, respectively. Rates of stroke were similar across CKD stages; but no pattern for TEE. For non-CV events, higher (worse) CKD stage had higher rates of first ocular events (17.2, 23.3, and 27.1) and seizures (2.3, 2.7, and 3.4), but lower rates of cancer (21.8, 14.2, and 10.2) and, within this, hematological malignancies (10.4, 4.11 and 2.3). Conclusion Medicare-covered ESA-treated patients with higher CKD stage had higher rates for most events assessed, while malignancy rates were lower. These findings may provide important context when assessing US event rates in non-dialysis-dependent CKD patients. Further investigation could clarify some of the differences between stages, such as rates of malignancy. Rates were reported as crude (unadjusted) and so should be interpreted with caution. Limiting the analysis to ESA-treated patients may have resulted in different event rates than would be expected to occur in the general CKD population. Funding: GSK (study 217316).

#2569 HEART FAILURE AND DIABETES IN CHRONIC KIDNEY DISEASE

Abstract Background and Aims Few studies have investigated the prognosis in chronic kidney disease (CKD) patients with heart failure (HF) and diabetes (DM). In the clinical setting, treating a combination of these conditions is challenging but novel treatments such as SGLT2-inhibitors are now emerging. The aim of this study is to investigate the prevalence and outcomes of survival and major cardiovascular events (MACE) in CKD patients with HF and/or DM before these new treatments were commonly used. Method In this retrospective observational study, we extracted data from 26647 nephrology-referred patients ≥18 years old with eGFR 60 ≤ ml/min/1,73 m2 from the Swedish Renal Registry – Chronic Kidney Disease (SRR-CKD) and health registers at the National Board of Health and Welfare in Sweden during an observational period of January 2005 – June 2017. HF and DM was categorized based on International Classification of Disease 10 (ICD-10) diagnostic codes prior to inclusion in the SRR-CKD. Outcomes were death by any cause and MACE, defined as a composite of hospitalization for nonfatal myocardial infarction, coronary heart disease, congestive heart failure, nonfatal stroke or cardiovascular death. Secondary outcome was start of kidney replacement therapy (KRT) defined as start of dialysis or kidney transplantation. Results There were 12910 (47.7%) patients with CKD, 3458 (12.5%) with CKD+HF, 7595 (27.3%) with CKD+DM and 3684 (13.3%) with CKD+HF+DM. Median age was higher in the cohorts with heart failure (CKD+HF and CKD+HF+DM), 77 and 74 years vs 67 and 69 years (CKD and CKD+DM). Most patients were men in all four groups (62-66%). The use of evidence based therapies such as ACE-inhibitors/ARBs, varied across the groups between 62.9, 66.6, 78.5 and 78.7% (CKD, CKD+HF, CKD+DM, CKD+HF+DM). Statins were used in 42.0, 50.7, 71.1 and 73.7% and betablockers in 53.9, 83.7, 65.9, and 86.1%. Survival data is presented in a Kaplan-Meier curve (Figure 1). Adjusted hazard ratio (HR) for all cause-death was highest in the cohorts with heart failure CKD+HF (2.54 [95% CI 2.40–2.68]) and CKD+DM+HF (3.22 [3.05–3.39]) followed by CKD+DM (HR 1.53 [1.45–1.60]) compared to patients with only CKD. The cumulative incidence of MACE is illustrated below (Figure 2). Adjusted HR for MACE was substantially higher in patients with heart failure, 3.82 (3.62–4.03) and 4.82 (4.59–5.08) for CKD+HF and CKD+HF+DM respectively while it was 1.63 (1.56–1.72) for CKD+DM. The risk of initiation of KRT was similar in all four groups, but risk of death before start of KRT was higher in patients with HF. Conclusion In CKD-patients, a heart failure diagnosis comprises approximately three to four times greater risk of death and MACE compared to patients with only CKD. The combination of CKD+HF+DM is the most severe. In all patient groups the use of evidence-based therapies was surprisingly low. This may reflect both deviation from guidelines for CKD-patients and the clinical challenge in treating comorbidities in CKD-patients. The results underlie the importance of identifying CKD-patients with HF and DM early to optimize treatment.

Trends in ST-elevation myocardial infarction hospitalization among young adults: a binational analysis.

ST-segment myocardial infarction (STEMI) is typically associated with increased age, but there is an important group of patients who suffer from STEMI under the age of 50 who are not well characterized in studies. We analysed results from Myocardial Ischemia National Audit Project (MINAP) from the United Kingdom (UK) between 2010 and 2017 and the National Inpatient Sample (NIS) from the United States of America (USA) between 2010 and 2018. After exclusion criteria, there were 32 719 STEMI patients aged≤50 from MINAP, and 238 952 patients' ≤50 from the NIS. We analysed temporal trends in demographics, management, and mortality. The proportion of females increased, 15.6% (2010-2012) to 17.6% (2016-2017) (UK) and 22.8% (2010-2012) to 23.1% (2016-2018) (USA). The proportion of white patients decreased, from 86.7% (2010) to 79.1% (2017) (UK) and 72.1% (2010) to 67.1% (2017) (USA). Invasive coronary angiography (ICA) rates increased in UK (2010-2012: 89.0%, 2016-2017: 94.3%), while decreased in USA (2010-2012: 88.9%, 2016-2018: 86.2% (USA). After adjusting for baseline characteristics and management strategies, there was no difference in all-cause mortality in the UK in 2016-2017 compared to 2010-2012 (OR:1.21, 95% CI:0.60-2.40), but there was a decrease in the USA in 2016-2018 compared to 2010-2012 (OR: 0.84, 95% CI: 0.79-0.90). The demographics of young STEMI patients have temporally changed in the UK and USA, with increased proportions of females and ethnic minorities. There was a significant increase in the frequency of diabetes mellitus over the respective time periods in both countries.

Body Weight in Adolescent Men in Sweden and Risk of an Early Acute Coronary Event: A Prospective Population-Based Study.

Background Coronary heart disease remains the dominant cause of death worldwide. To improve cardiovascular disease prevention, knowledge of early key risk factors, especially those that are modifiable, is essential. The ongoing global obesity epidemic is of particular concern. We aimed to determine whether body mass index at conscription predicts early acute coronary events among men in Sweden. Methods and Results This was a population-based Swedish cohort study of conscripts (n=1 668 921; mean age, 18.3 years; 1968-2005), with follow-up through linkage to the nationwide Swedish patient and death registries. Risk of a first acute coronary event (hospitalization for acute myocardial infarction or coronary death) during follow-up (1-48 years) was calculated with generalized additive models. Objective baseline measures of fitness and cognition were included in the models in secondary analyses. During follow-up, there were 51 779 acute coronary events, of which 6457 (12.5%) were fatal within 30 days. Compared with men at the lowest end of the normal body mass index spectrum (body mass index, 18.5 kg/m2), an increasing risk for a first acute coronary event was observed, with hazard ratios (HRs) peaking at 40 years of age. After multivariable adjustments, men with a body mass index of 35 kg/m2 had an HR of 4.84 (95% CI, 4.29-5.46) for an event before the age of 40 years. Conclusions An increased risk of an early acute coronary event was detectable within normal levels of body weight at the age of 18 years, increasing to almost 5-fold in the highest weight category at 40 years of age. Given increasing levels of body weight and prevalence of overweight and obesity in young adults, the current decrease in coronary heart disease incidence in Sweden may flatten or even reverse in the near future.

Short-term effects of individual exposure to PM2.5 on hospital admissions for myocardial infarction and stroke: a population-based case-crossover study in Guangzhou, China.

Some studies have investigated the effects of PM2.5 on cardiovascular diseases based on the population-average exposure data from several monitoring stations. No one has explored the short-term effect of PM2.5 on cardiovascular hospitalizations using individual-level exposure data. We assessed the short-term effects of individual exposure to PM2.5 on hospitalizations for myocardial infarction (MI) and stroke in Guangzhou, China, during 2014-2019. The population-based data on cardio-cerebrovascular events were provided by Guangzhou Center for Disease Control and Prevention. Average annual percent changes (AAPCs) were used to describe trends in the hospitalization rates of MI and stroke. The conditional logistic regression model with a time-stratified case-crossover design was applied to estimate the effects of satellite-retrieved PM2.5 with 1-km resolution as individual-level exposure. Furthermore, we performed stratified analyses by demographic characteristics and season. There were 28,346 cases of MI, 188,611, and 36,850 cases of ischemic stroke (IS) and hemorrhagic stroke (HS), respectively, with an annual average hospitalization rate of 37.2, 247, and 48.4 per 100,000 people. Over the six-year study period, significant increasing trends in the hospitalization rates were observed with AAPCs of 12.3% (95% confidence interval [CI]: 7.24%, 17.6%), 13.1% (95% CI: 9.54%, 16.7%), and 9.57% (95% CI: 6.27%, 13.0%) for MI, IS, and HS, respectively. A 10μg/m3 increase in PM2.5 was associated with an increase of 1.15% (95% CI: 0.308%, 1.99%) in MI hospitalization and 1.29% (95% CI: 0.882%, 1.70%) in IS hospitalization. A PM2.5-associated reduction of 1.17% (95% CI: 0.298%, 2.03%) was found for HS hospitalization. The impact of PM2.5 was greater in males than in females for MI hospitalization, and greater effects were observed in the elderly (≥ 65years) and in cold seasons for IS hospitalization. Our study added important evidence on the adverse effect of PM2.5 based on satellite-retrieved individual-level exposure data.

Association of Beta-Blocker Therapy With Cardiovascular Outcomes in Patients With Stable Ischemic Heart Disease

BackgroundPrevious studies have failed to show a cardioprotective benefit of beta-blockers in patients with stable coronary artery disease (CAD). ObjectivesThis study sought to determine the association between beta-blockers and cardiovascular events in patients with stable CAD using a new user design. MethodsAll patients aged >66 years undergoing elective coronary angiography in Ontario, Canada, from 2009 to 2019 with diagnosed obstructive CAD were included. Exclusion criteria included heart failure or a recent myocardial infarction, as well as having a beta-blocker prescription claim in the previous year. Beta-blocker use was defined as having at least 1 beta-blocker prescription claim in the 90 days preceding or after the index coronary angiography. The main outcome was a composite of all-cause mortality and hospitalization for heart failure or myocardial infarction. Inverse probability of treatment weighting using the propensity score was used to account for confounding. ResultsThis study included 28,039 patients (mean age: 73.0 ± 5.6 years; 66.2% male), and 12,695 of those (45.3%) were newly prescribed beta-blockers. The 5-year risks of the primary outcome were 14.3% in the beta-blocker group and 16.1% in the no beta-blocker group (absolute risk reduction: −1.8%; 95% CI: −2.8 to −0.8; HR: 0.92; 95% CI: 0.86-0.98; P = 0.006). This result was driven by reductions in myocardial infarction hospitalization (cause-specific HR: 0.87; 95% CI: 0.77-0.99; P = 0.031), whereas no differences were observed in all-cause death or heart failure hospitalization. ConclusionsIn patients with angiographically documented stable CAD without heart failure or a recent myocardial infarction, beta-blockers were associated with a small but significant reduction in cardiovascular events at 5 years.

Characteristics and outcomes of 795 patients with renal cell cancer following hospitalization for acute myocardial infarction.

e16516 Background: Renal cell cancer (RCC), as with many cancers, is associated with a hypercoagulable state as well as the potential risk of anemia that can lead to various cardio/cerebrovascular complications. Some of the treatments used in RCC like vascular endothelial growth factor (VEGF) inhibitors increase the thrombotic risk. Thus, the management of RCC patients following an episode of Acute Myocardial Infarction (AMI) can be more complex than that of the general population. We, therefore, conducted an in-depth analysis to study the characteristics and outcomes of AMI among RCC patients in the United States. Methods: We used the 2019 National Inpatient Sample (NIS), a yearly set of hospitalization records from the United States. Patients with a primary diagnosis of AMI and a diagnosis of RCC were identified. We excluded all patients below the age of 18 and those with other malignancies. Multiple patient characteristics were compared via Chi-Square tests. We also compared the odds of requiring Coronary artery bypass graft surgery (CABG) and Percutaneous coronary intervention (PCI) among the two groups. The overall mortality rate and adjusted odds ratios were estimated. Results: Our study found 633410 cases of AMI among adults in the United States in 2019. Among them, 795 (0.1%) had a diagnosis of RCC. A higher number of RCC patients were Male (75.5% vs. 62.7%, p &lt; 0.01), racially classified as White (77.1% vs. 73.0%, p &lt; 0.01), aged 60 or more (88.7% vs. 69.8%, p &lt; 0.01), covered by Medicare (72.3% vs. 56.1%, p &lt; 0.01), had hypertension (66.7% vs. 82.7%, p &lt; 0.01), were diabetics (45.9% vs. 41.4%, p &lt; 0.01) or had anemia (42.1% vs. 22.1%, p &lt; 0.01). A lower percentage of RCC patients underwent various procedures following their AMI, as only 6.3% underwent CABG (vs. 7.5% in the non-RCC group), and 27.6% (vs. 45.8% in the non-RCC group) underwent PCI. Patients with RCC were also older (71.62 years vs. 66.64 years, p &lt; 0.01), had a longer hospitalization (5.51 days vs.4.34 days, p &lt; 0.01), which was also associated with a more expensive mean hospital charge ($114572.98 vs. $106241.24). Unfortunately, we also found that the presence of RCC among AMI patients was also linked with a higher odds ratio of mortality (7.5% vs. 4.4%, aOR 1.643, 95% CI 1.249- 2.160, p &lt; 0.01). Conclusions: Our study confirms various differences in patient characteristics among AMI cases with and without RCC. While fewer RCC patients underwent procedures such as CABG or PCI, they experienced a less favorable outcome, including a longer and more costly stay and higher odds of in-hospital death. It is thus vital to screen RCC patients for potential risk factors for AMI, promote primary and secondary prevention measures, and improve hospitalization protocols to identify potential complications.

ВЗАИМОСВЯЗЬ ТИПА ЛИЧНОСТИ D И НАРУШЕНИЯ ФУНКЦИИ ЭНДОТЕЛИЯ У ПАЦИЕНТОВ С ОСТРЫМ ИНФАРКТОМ МИОКАРДА

Introduction. Major psychosocial risk factors for acute myocardial infarction include depression, anxiety (various anxiety syndromes and disorders), pessimistic D personality type, work and family stress, anger/hostility, lack of social support, and low socioeconomic status. There are few studies evaluating the association between psychological factors and myocardial infarction. Aim. The aim of the study was to study the relationship of personality type D with the development of endothelial dysfunction in patients with acute myocardial infarction. Material and methods. The study included 158 patients, mean age 58.2±2.5 years, who were admitted to the hospital for ST-segment elevation myocardial infarction. The diagnosis was established according to the clinical guidelines of the Russian Society of Cardiology, 2020. In addition to the traditional clinical and instrumental examination, on the 3rd–7th day after the development of myocardial infarction, patients underwent an assessment of plasma concentrations of inflammatory biomarkers and psychological testing using anxiety and depression rating scales. In the group of patients, individuals with and without personality type D were identified. Results and discussion. Personality type D was found in 29.1% of patients with acute myocardial infarction. Patients with personality type D were significantly younger, employed and married, had a higher body mass index and a significantly greater hereditary burden of arterial hypertension. In patients with personality type D, the values of pro-inflammatory markers were statistically significantly different from the comparison group, which indicates the intensity of subclinical inflammation and cytokine imbalance. Personality type D was significantly associated with total inflammation score and total endothelial dysfunction score. Significant differences were found in the ratio of patients with depressive conditions in subgroups of patients with personality type D. The values of echocardiographic parameters were also associated with the presence of personality type D. Conclusion. Personality type D was associated with impaired endothelial function in men with acute myocardial infarction, they were more likely to have depressive disorders. An adverse effect of personality type D on the cardiovascular system in patients with myocardial infarction was revealed.

Generalizability of an EHR-network dataset to the United States for cardiovascular disease conditions: Comparison of Cerner real world data with the national inpatient sample

Electronic Health Record (EHR) data from health systems are increasingly being combined for clinical research purposes. Yet, it remains unclear whether these large EHR data sources provide a representative assessment of national disease prevalence and treatment. To evaluate this, we compared Cerner RealWorldData (CRWD), a large EHR data source, to those seen in the National Inpatient Sample (NIS) for three cardiovascular conditions (myocardial infarction (MI), congestive heart failure (CHF), and stroke. Adult patients (age ≥18 years) hospitalized with MI, CHF, and stroke were identified in both CRWD (86 health systems) and the NIS (4,782 hospitals). Patient demographics, comorbidities, procedures, outcomes (length of stay and in-hospital mortality) and hospital type (teaching or non-teaching) were compared between NIS and CRWD patients. Of 86 health systems participating in CRWD, 33 were excluded for potential data quality issues which accounted for about 11% of hospitalizations in the dataset, leaving 53 for inclusion in analysis which accounted for about 89% of hospitalizations in the dataset. Between January 1st 2017 and December 31st 2018, 116,956 MI, 188,107 CHF, and 93,968 stroke hospitalizations were identified in CRWD versus 2,245,300 MI, 4,310,745 CHF, and 1,333,480 stroke hospitalizations in the NIS. Patient demographics were similar among patients in CWRD and the NIS for all three cardiovascular groups except for ethnicity, with underrepresentation of Hispanic individuals in CRWD vs the NIS. Patients hospitalized in CRWD had a slightly higher proportion of coded co-morbidities compared with NIS hospitalizations due to a longer potential look-back period. For patients with MI, hospital mortality, length of stay, coronary artery bypass graft (CABG) rates, and percutaneous coronary intervention (PCI) rates were similar between CRWD and NIS. Additionally, there was similar in hospital mortality and length of stay for those with CHF and stroke hospitalizations between CRWD and NIS. On aggregate, characteristics of hospitalizations for MI, CHF, and stroke using EHR data from one nationwide EHR-derived database, CRWD, appears similar to characteristics of hospitalizations in the nationally representative NIS. Important limitations of CRWD include lack of geographic representativeness, under-representation of Hispanic adults, and the need to exclude health systems for missing data.