Primary Discharge Diagnosis Of Acute Myocardial Infarction Research Articles

Leveraging Clinical Digitized Data to Understand Temporal Characteristics and Outcomes of Acute Myocardial Infarctions at a Tertiary Care Medical Centre in Pakistan from 1988-2018 - Methods and Results.

Background and Objective:Few data exist on trends in acute myocardial infarction (AMI) patterns spanning recent epidemiological shifts in low middle-income countries (LMICs). To understand temporal disease patterns of AMI characteristics and outcomes between 1988–2018, we used digitized legacy clinical data at a large tertiary care centre in Pakistan.Methods:We reviewed digital health information capture systems maintained across the Aga Khan University Hospital and obtained structured elements to create a master dataset. We included index admissions of patients >18 years that were discharged between January 1, 1988, and December 31, 2018, with a primary discharge diagnosis of AMI (using ICD-9 diagnoses). The outcome evaluated was in-hospital mortality.Clinical characteristics derived from the electronic database were validated against chart review in a random sample of cases (k 0.53–1.00).Results:The final population consisted of 14,601 patients of which 30.6% (n = 4,470) were female, 52.4% (n = 7,651) had ST elevation MI and 47.6% (n = 6,950) had non-ST elevation MI. The median (IQR) age at presentation was 61 (52–70) years. Overall unadjusted in-hospital mortality was 10.3%. Across the time period, increasing trends were noted for the following characteristics: age, proportion of women, prevalence of hypertension, diabetes, proportion with NSTEMI (all ptrend < 0.001). In-hospital mortality rates declined significantly between 1988–1997 and 2008–2018 (13.8% to 9.2%, p < 0.001).Conclusions:The patterns of AMI have changed over the last three decades with a concomitant decline in in-hospital mortality at a tertiary care centre in Pakistan. Clinical digitized data presents a unique opportunity for gaining insights into disease patterns in LMICs.

Clinical and paraclinical characteristics of young patients with myocardial infarction from Northeast of Romania

The aim of this study was to evaluate the clinical and paraclinical features in young patients (18–40 years) with acute myocardial infarction (AMI) in the Northeast of Romania. We have considered all patients admitted between the 1st of January 2017 through the 31st of December 2019 at a tertiary care Cardiology Institute with the primary discharge diagnosis of AMI. These patients have been split into 2 groups depending on their age: the first group consisting of patients with an age equal to or lower than 40 years old and the second group consisting of patients with an age greater than 40 years old. After this, we have randomly selected a representative sample from each of the two groups. A total of 99 patients were ultimately enrolled in the study: 42 in the first group and 57 in the second group. Data collected included age, gender, medical history, laboratory tests, echocardiography parameters, coronarography study results, and case outcome. Most young patients with myocardial infarction were male, more likely to smoke (69% vs 35.1%, p = 0.001), and with a positive family history of cardiovascular diseases (35.7% vs 1.8%, p &lt; 0.001) in comparison to their older counterparts. Also, they had fewer comorbidities, such as diabetes mellitus, hypertension, or a positive history of stroke or atrial fibrillation. Mean ejection fraction was significantly higher in young patients (43.4 ± 10.65 vs 37.16 ± 10.77, p = 0.005) and both tricuspid and mitral valve regurgitations were less severe. Coronary lesions were more severe in the older patients (p = 0.009), usually with more coronary arteries involved. No significant difference was recorded in the number of hospitalization days or in the case outcome. Acute myocardial infarction in young patients typically occurs more in men who smoke, those who are more than 30 years old, and those who have a positive family history of cardiovascular diseases. Echocardiographic parameters seem to be better than in the case of older patients and the coronary involvement is usually less severe.

Influenza vaccination and in-hospital mortality in patients with acute myocardial infarction with history of prior PCI or CABG: a nationwide cohort analysis

Abstract Introduction Influenza vaccination is associated with lower risk of death as well as major adverse cardiovascular events, including acute myocardial infarction (AMI), heart failure and stroke. Purpose The impact of Influenza vaccination on in-hospital mortality in patients with AMI with a prior history of percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG) is largely unknown. We hypothesize that such individuals who develop AMI have better outcomes if they had received influenza vaccine. Methods We analyzed the United States National Inpatient Sample Database from 2010–2014 to identify patients with primary discharge diagnosis of AMI (STEMI, NSTEMI) with a history of prior PCI or CABG. In this cohort, patients with influenza vaccination were identified using ICD-9 code V04.81. The primary outcome was in-hospital mortality. Chi-square test and multivariate regression model controlling for age, gender, race, type of AMI and co-morbidities were employed for statistical analysis. Results A total of 495,619 patients with ACS were identified who had prior PCI or CABG and 6525 had positive influenza vaccination status. Influenza vaccination was independently associated with lower risk of in-hospital mortality in patients with AMI (aOR = 0.253, 95% CI: 0.196–0.328; p&amp;lt;0.001). Conclusion Vaccination against influenza was associated with lower risk of in-hospital mortality in patients with prior PCI or CABG who developed AMI. Figure 1 Funding Acknowledgement Type of funding source: None

Management strategies and clinical outcomes of acute myocardial infarction in leukaemia patients: Nationwide insights from United Stateshospitalisations.

Patients with leukaemia are at increased risk of cardiovascular events. There are limited outcomes data for patients with a history of leukaemia who present with an acute myocardial infarction (AMI). We queried the Nationwide Inpatient Sample (2004-2014) for patients with a primary discharge diagnosis of AMI, and a concomitant diagnosis of leukaemia, and further stratified according to the subtype of leukaemia. Multivariable logistic regression was conducted to identify the association between leukaemia and major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, stroke and cardiac complications) and bleeding. Out of 6750878 AMI admissions, a total of 21694 patients had a leukaemia diagnosis. The leukaemia group experienced higher rates of MACCE (11.8% vs 7.8%), mortality (10.3% vs 5.8%) and bleeding (5.6% vs 5.3%). Following adjustments, leukaemia was independently associated with increased odds of MACCE (OR 1.26 [1.20, 1.31]) and mortality (OR 1.43 [1.37, 1.50]) without an increased risk of bleeding (OR 0.86 [0.81, 0.92]). Acute myeloid leukaemia (AML) was associated with approximately threefold risk of MACCE (OR 2.81 [2.51, 3.13]) and a fourfold risk of mortality (OR 3.75 [3.34, 4.22]). Patients with leukaemia were less likely to undergo coronary angiography (CA) (48.5% vs 64.5%) and percutaneous coronary intervention (PCI) (28.2% vs 42.9%) compared with those without leukaemia. Patients with leukaemia, especially those with AML, are associated with poor clinical outcomes after AMI, and are less likely to receive CA and PCI compared with those without leukaemia. A multi-disciplinary approach between cardiologists and haematology oncologists may improve the outcomes of patients with leukaemia after AMI.

P681Acute Myocardial Infarction in patients with Leukaemia: A national analysis of prevalence, predictors and outcomes in United States hospitalisations (2004 to 2014)

Abstract Background Patients with leukaemia are at increased risk of cardiovascular events. There is limited outcomes data for patients with a history of leukaemia who present with an acute myocardial infarction (AMI). Purpose To examine the prevalence and clinical characteristics of patients with leukaemia presenting with AMI, and evaluate differences in clinical outcomes according to the subtype of leukaemia in comparison to patients without leukaemia. Methods We analysed the Nationwide Inpatient Sample (2004–2014) for patients with a primary discharge diagnosis of AMI and concomitant leukaemia, and further stratified according to the subtype of leukaemia into 4 groups; AML; ALL; CML; and CLL. Multiple logistic regression was conducted to identify the association between leukaemia and major acute cardiovascular and cerebrovascular events (MACCE; composite of mortality, stroke and cardiac complications) and bleeding. Results Out of 6,750,927 AMI admissions, a total of 21,694 patients had a leukaemia diagnosis. The leukaemia group experienced higher rates of MACCE (11.8% vs. 7.8%), mortality (10.3% vs. 5.8%) and bleeding (5.6% vs. 5.3%). Following adjustments, leukaemia was independently associated with increased odds of MACCE (OR 1.26 [1.20,1.31]) and mortality (OR 1.43 [1.37,1.50]) without an increased risk of bleeding (OR 0.86 [0.81,0.92]). Acute myeloid leukaemia (AML) was associated with approximately three-fold risk of MACCE (RR 2.81 [2.51, 3.13]) and a four-fold risk of mortality (RR 3.75 [3.34, 4.22]) (Figure 1). Patients with leukaemia were less likely to undergo coronary angiography (CA) (48.5% vs. 64.5%) and percutaneous coronary intervention (PCI) (28.2% vs. 42.9%) compared to those without leukaemia. Figure 1.Relative risk of adverse events Conclusion Patients with leukaemia, especially those with AML, are associated with poor clinical outcomes after AMI, and are less likely to receive CA and PCI compared to those without leukaemia. A multi-disciplinary approach between cardiologists and haematology oncologists may improve the outcomes of patients with leukaemia after AMI.

Inferior Outcomes of Patients With Acute Myocardial Infarction and Comorbid Protein-Energy Malnutrition.

Protein-energy malnutrition (PEM) diminishes amino acid and energy availability, impairing the body's healing capability after injury, such as in myocardial damage following acute myocardial infarction (AMI). We sought to investigate the influence of PEM on clinical outcomes of AMI. We identified records with a primary discharge diagnosis of AMI from the Nationwide Inpatient Sample (2012-2014), stratified by concomitant PEM. We matched PEM to no-PEM (1:1) using a greedy algorithm-based propensity methodology and estimated the impact of PEM on health outcomes (SAS 9.4). Of the 332,644 hospitalizations for AMI, 11,675 had concomitant PEM accounting for roughly $US 1.5 billion and over 119,792 hospital days. PEM was associated with older age (74.43- vs. 66.90-years; P<0.0001), female sex (49.19% vs. 38.44%; P<0.0001), black race (12.78% vs. 10.46%; P<0.0001), and higher comorbidity burden (Deyo > 3: 32.77% vs. 16.69%; P<0.0001). After propensity matching, PEM was associated with higher mortality (Adjusted odds ratio [AOR]: 1.59 [1.46-1.73]), cardiogenic shock (AOR: 2.26 [2.08-2.44]), discharge to secondary facilities (AOR: 2.21 [2.10-2.33]), charges ($135,500 [$131,956-139,139] vs. $81,084 [$79,241-82,970]), cardiac artery bypass surgery (AOR:1.81 [1.66-1.97]), intra-aortic balloon pump placement (AOR: 1.83 [1.65-2.04]) and longer length of stay (10.15- vs. 5.52-days). PEM is a predisposing factor for devastating clinical outcomes among AMI hospitalizations. Higher prevention, identification and management of PEM among high-risk individuals (older age, female sex, and black race) residing in the community are needed.

Abstract 16644: Independent Predictors of 30-Day Readmission After Acute Myocardial Infarction at a Large, Inner City Medical Center

Background: Acute myocardial infarction (AMI) accounts for one of the most common reasons for cardiovascular disease admission in the United States. Despite modern therapeutics, 15-20% of index admissions for AMI result in unplanned readmission within 30 days of discharge. In tailoring efforts to decrease AMI 30 day readmissions we sought to identify independent predictors for readmission. Methods: All 1771 patient discharges from Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center in fiscal years 2016 and 2017 with a primary discharge diagnosis of AMI were included. The age, sex, race, insurance status, aggregated AHRQ comorbidity count, concomitant diagnosis of specific comorbidities, discharging hospital, discharging service, destination at discharge, diagnosis (NSTEMI vs. STEMI), procedures during index admission and length of index admission for each discharge were recorded and odds ratios with 95% confidence intervals for 30 day readmission to a Maryland hospital were calculated. If a patient was readmitted to a Hopkins hospital the reason for readmission was recorded. Results: Of the 1771 patient discharges over the study period, 273 were excluded because the patient was not eligible for readmission in CMS reporting algorithms (i.e. same or next day transfer, death), had a planned readmission, or was &lt;18 years old. Of the remaining 1498 discharges, 264 (17.6%) were readmitted within 30 days. In a multivariable model, major independent predictors of 30 day readmission risk were high comorbidity burden (OR for 4-5 vs. 0-1 comorbidities: 3.27, 95% CI 1.55 - 6.88; OR for &amp;gt; 5 vs. 0-1 comorbidities: 6.86, 95% CI 3.2 -14.71) and leaving the hospital AMA (OR 3.77, 95% CI 1.63-8.72). In a separate model considering specific comorbidities, a concomitant diagnosis of CHF (OR 1.94, 95% CI 1.4-2.67), renal failure (OR 1.76, 95% CI 1.27-2.45), or depression (OR 1.61, 95% CI 1.12-2.33) were independent predictors of readmission risk. Of patients whose readmission diagnoses were known (n=143), the majority (n=75, 52.4%) were readmitted with cardiac diagnoses. The most prevalent cardiac readmission diagnoses were CHF (n=28), NSTEMI (n=25), and chest pain (n=15). Conclusions: In our large, inner city hospital system, patients with a greater number of comorbidities, in particular CHF, renal failure, or depression, were at significantly greater risk for 30 day readmission after AMI. Identifying high risk patient characteristics is an important first step in designing tailored, system-wide initiatives to reduce AMI readmissions.

Abstract 18092: Statin Use After an Acute In-Hospital Myocardial Infarction Among Medicare Beneficiaries

Background: American Heart Association (AHA) guidelines recommend all patients are discharged on a statin following a coronary heart disease (CHD) event. Many patients have an acute myocardial infarction (AMI) while hospitalized for another reason but the use of statins upon discharge in this population has not been well studied. Methods: Using the Medicare 5% national random sample, we identified beneficiaries who had a hospital discharge diagnosis for AMI or who underwent coronary artery bypass graft (CABG) surgery or percutaneous coronary intervention (PCI) in 2007-2009. Medicare requires the primary diagnosis code to represent the initial reason for hospitalization; secondary discharge diagnosis codes capture complications including in-hospital AMI. Beneficiaries taking and not taking statins prior to their hospitalization were analyzed separately. Filling a statin prescription within 90 days after hospital discharge was identified using Medicare Part D claims. Results: Of 5,810 and 8,517 Medicare beneficiaries taking and not taking statins prior to their CHD-related hospitalization, 84% and 55% filled a statin within 90 days of discharge, respectively. The proportion of beneficiaries filling a statin following discharge was substantially lower among those with a secondary versus primary discharge diagnosis of AMI, or PCI or CABG (Table). After multivariable adjustment, beneficiaries with a secondary discharge diagnosis of AMI were 41% (risk ratio = 0.59, 95% CI: 0.54 - 0.65) and 11% (risk ratio = 0.89; 95% CI: 0.82 - 0.97) less likely to fill a statin compared to those with a primary discharge diagnosis of AMI. Conclusion: A high percentage of Medicare beneficiaries with in-hospital AMIs do not fill statins following hospital discharge. Reasons why patients with in-hospital AMIs do fill statins following discharge need to be identified.

Acute Myocardial Infarction Rehospitalization of the Medicare Fee-for-Service Patient

Acute myocardial infarction (AMI) readmission among the older adults is frequent and costly to the Medicare Trust Fund and to the patient in preventable suffering. In this study, we explore factors that are associated with states having AMI readmission rates that are higher than the U.S. national rate. Acute inpatient hospital settings. Multivariate regression analysis of 50 state-level data is used. The dependent variable AMI 30-day readmission worse than U.S. rate is based on adult Medicare fee-for-service patients hospitalized with a primary discharge diagnosis of AMI and for which a subsequent all-cause readmission occurred within 30 days of their last discharge. We find one key variable--states with more β-blocker prescription given at discharge--that is significantly associated with a decrease in probability in states ranking "worse" on AMI 30-day readmission. Whereas, states with more total days of care per 1,000 Medicare enrollees, more community hospital outpatient visits per 1,000 population, and greater aspirin prescription given at discharge have a greater probability for AMI 30-day readmission to be "worse" than the U.S. national rate. Case management programs targeting efficient medication reconciliation from the hospital setting to the transfer setting can potentially help minimize readmission for patients highly dependent on β-blockers for improved clinical outcomes. This intervention may be more effective than other factors to improve state-level hospital status on AMI 30-day readmission. Factors such as total days of care per 1,000 Medicare enrollees, more community hospital outpatient visits per 1,000 populations, and greater aspirin prescription given at discharge may not be as important as β-blocker prescription given at discharge.

Abstract 17019: Age-Specific Trends in Acute Myocardial Infarction Hospitalization in Minneapolis/St. Paul

Background: Hospitalizations for acute myocardial infarction (AMI) declined during the past 40 years. However, some studies suggest rising rates of AMI in young adults associated with the increasing prevalence of obesity and diabetes, but there are few data in this group. We hypothesized an increase in the rate of AMI hospitalizations among young and middle-aged adults (&lt;50 years) and a decline among older adults. Methods: Data from the Minnesota Hospital Association (MHA) were utilized to identify patients hospitalized with a primary discharge diagnosis of AMI (ICD-9 410) at the 20 acute care hospitals within the Minneapolis-St. Paul metropolitan area (2.85 million) between 1999-2008. Results: From 1999 to 2008, there were 42,850 AMI hospitalizations (4507 in 1999, 3904 in 2008; 13.4% decline) among those aged ≥ 30 years. Among women, the age-standardized rate of AMI hospitalization declined from 239 in 1999 to 169 in 2008, representing an annual proportionate decline of 3.2% (p=0.01) [Table]. Despite the overall decline, the rates of hospitalization among women 30-39 and 40-49 increased during this period (by 1.9% and 2.3%, respectively). In 1999, women aged 30-49 accounted for 5.5% of AMI hospitalizations in all women. By 2008, this age group accounted for 9.2% of hospitalizations. Among men, the age-standardized rate of AMI hospitalizations declined from 506 to 351 during this period (annual proportionate decline of 4.8%, p=0.003). The proportionate decline was lowest among men aged 30-39 (2.7%). Conclusion: In an era of decreasing hospitalization for AMI, differences in trends exist by sex and age. AMI hospitalizations rates increased among young and middle-aged women between 1999 and 2008, potentially due to increased attention paid to heart disease among women, the use of more sensitive biomarkers or actual increase in risk. Despite the aging population, the overall AMI hospitalization case burden decreased by 13% between 1999 and 2008.

Smoke-Free Laws, Gender, and Reduction in Hospitalizations for Acute Myocardial Infarction

We examined gender differences in the incidence of acute myocardial infarction (AMI) after the passage of a smoke-free law in Lexington, Kentucky. The initial legislation had exemptions not covering manufacturing facilities and government buildings, which may have put men at greater risk for AMI. We examined the effect of Lexington's smoke-free public places law on hospitalizations for AMI (i.e., heart attack) among men and women 40 months prior to and 32 months after enactment of the law. We used the statewide administrative database (Comp Data) for all hospital billing records for the four health-care systems in Lexington-Fayette County. Cases were included in the analysis if (1) the patient was $35 years of age; (2) the patient had a primary discharge diagnosis of AMI, with an International Classification of Diseases, Ninth Revision code in the range of 410.00 to 410.99; and (3) the date of service was between January 1, 2001, and December 31, 2006. Among women, AMI hospitalizations declined 23% after the law took effect. The rate of AMI events among men did not change significantly. There was an overrepresentation of women in the hospitality industry and a disproportionate number of men working in manufacturing facilities and government worksites not mandated by the law. We found gender differences in the reduction of AMI hospitalizations following implementation of a smoke-free law that covered only some sectors of the workforce. Enacting smoke-free laws that cover all places of employment and strengthening existing partial laws may extend protection against AMIs to female and male workers.

Recent US Patterns and Predictors of Prevalent Diabetes among Acute Myocardial Infarction Patients

Background. Diabetes mellitus (DM) confers high vascular risk and is a growing national epidemic. We assessed clinical characteristics and prevalence of diagnosed DM among patients hospitalized with acute myocardial infarction (AMI) in the US over the last decade. Methods. Data were obtained from all states within the US that contributed to the Nationwide Inpatient Sample. All patients admitted to hospitals between 1997 and 2006 with a primary discharge diagnosis of AMI were included. Time trends in the proportion of these patients with DM diagnosis were computed. Results. The portion of patients with comorbid diabetes among AMI hospitalizations increased substantially from 18% in 1997 to 30% in 2006 (P < .0001). Absolute numbers of AMI hospitalizations in the US decreased 8% (from 729, 412 to 672, 243), while absolute numbers of AMI hospitalizations with coexisting DM rose 51% ((131, 189 to 198, 044), both (P < .0001). Women with AMI were significantly more likely to have DM than similarly aged men, but these differences diminished with increasing age. Conclusion. Although overall hospitalizations for AMI in the US diminished over the last decade, prevalence of diabetes rose substantially. This may have important consequences for the future societal vascular disease burden.

Association of Troponin Status With Guideline-Based Management of Acute Myocardial Infarction in Older Persons

Over the past decade, a large body of evidence has emerged demonstrating the prognostic significance of troponin as well as its use in tailoring therapeutic interventions. Little is known, however, regarding the association of troponin status with guideline-based therapies in older patients with acute myocardial infarction (AMI). A nationwide sample of eligible Medicare beneficiaries 65 years or older, who were hospitalized with a primary discharge diagnosis of AMI from April 1998 to March 1999 or from July 2000 to June 2001, was evaluated. The analysis was restricted to patients with clinically confirmed AMI who underwent testing for both creatine kinase-myocardial band (CK-MB) and troponin. Results were assessed in 3 groups of patients based on biomarker status: those whose findings were positive for troponin only (hereinafter, troponin-only patients), those whose findings were positive for CK-MB only (hereinafter, CK-MB-only patients), and those whose findings were positive for both troponin and CK-MB (hereinafter, troponin/CK-MB patients). Then, the use of guideline-recommended care was compared for patients without contraindications to treatment across the 3 groups. The final study sample included 33 096 patients (mean age, 77.6 years [range, 65-105 years]). The crude in-hospital mortality rate was highest for troponin-only patients (14%) and lowest for CK-MB-only patients (10%, P<.001). After adjusting for demographics, physician specialty, and hospital characteristics, CK-MB-only patients were more likely to receive aspirin (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.28-1.65) and beta-blocker (OR, 1.21; 95% CI, 1.08-1.34) within 24 hours of hospital arrival and aspirin on discharge (OR, 1.27; 95% CI, 1.08-1.49) compared with troponin-only patients. In addition, troponin/CK-MB patients were more likely to receive aspirin (OR, 1.55; 95% CI, 1.42-1.69) and beta-blocker (OR, 1.22; 95% CI, 1.12-1.31) within 24 hours of arrival and on discharge compared with troponin-only patients (ORs, 1.31 [95% CI, 1.17-1.46] and 1.33 [95% CI, 1.15-1.52] for aspirin and beta-blocker, respectively) . Despite the known poor prognosis associated with troponin elevations in AMI, we demonstrate that guideline-based therapies are underused in older patients with AMI. Therefore, national efforts should focus on the unique characteristics of this high-risk patient population to improve the quality of care for older patients with AMI.

Sex and Racial Differences in Outcomes and Guideline‐Based Management of Troponin‐Only‐Positive Acute Myocardial Infarction in Older Persons

Multiple studies have shown sex and racial differences in the management and outcomes of ischemic heart disease, but whether these sex and racial disparities persist in patients with troponin-only-positive acute myocardial infarction (AMI) is unknown. The authors evaluated a nationwide sample of eligible Medicare beneficiaries, 65 years or older, who were hospitalized (N=71,120) with a primary discharge diagnosis of AMI. Analysis was restricted to patients with troponin-only-positive AMI (n=5897) and was substratified into 4 groups: white men, white women, nonwhite men, and nonwhite women. The authors found that the traditional sex and racial disparities in the evidence-based medication prescriptions for ischemic heart diseases resolved in this cohort of older patients. Similarly, in settings of equal care, sex and race seem to have no impact on the outcomes for older patients with troponin-only-positive AM.

Trends in Acute Myocardial Infarction in 4 US States Between 1992 and 2001

Because of the health impact of acute myocardial infarction (AMI), substantial resources have been dedicated to improving AMI care and outcomes. Long-term trends in the clinical characteristics, quality of care, and outcomes for AMI over time from the health system perspective in geographically diverse populations are not well known. The present study included 20,550 Medicare patients aged > or = 65 years hospitalized in 4 US states (Alabama, Connecticut, Iowa, Wisconsin) with the confirmed primary discharge diagnosis of AMI in 4 periods: 1992-1993 (n=10,292), 1995 (n=5566), 1998-1999 (n=2413), and 2000-2001 (n=2279). With the use of standard quality indicator definitions, treatment of ideal candidates with aspirin and beta-blockers within 24 hours after presentation, beta-blockers, and angiotensin-converting enzyme inhibitors at discharge was assessed. Multivariable models were constructed to calculate adjusted 1-year mortality. The hospitalized Medicare population with AMI changed substantially during 1992-2001, with increasing age, more comorbidity, and fewer meeting ideal treatment criteria. Although treatment rates increased significantly for all medications, aspirin, beta-blockers, and angiotensin-converting enzyme inhibitors were not provided at discharge to 12.6%, 19.7%, and 25.2% of ideal candidates, respectively, in 2000-2001. Crude 1-year mortality increased (27.6%, 28.3%, 30.6%, and 31.0%; P=0.003 for trend, but adjusted mortality declined (compared with 1992-1993, relative risk in 1995=0.94 [95% CI, 0.88 to 1.01]; relative risk in 1998-1999=0.91 [95% CI, 0.85 to 0.98]; relative risk in 2000-2001=0.87 [95% CI, 0.81 to 0.94]). The quality of care and adjusted 1-year mortality improved significantly for Medicare beneficiaries with AMI during 1992-2001. Nevertheless, fewer were ideal for guideline-based therapy, and absolute mortality remains high, suggesting the need for treatment strategies applicable to a broader range of older patients.

National Impact of the Troponin Diagnostic Standard on the Prevalence and Prognosis of Acute Myocardial Infarction in Older Persons

Consensus guidelines from the American College of Cardiology, the American Heart Association, and the European Society of Cardiology have made cardiac troponin central to the diagnosis of acute myocardial infarction (AMI). Although multiple studies have shown that the troponin diagnostic standard facilitates the identification of new AMI cases in the general population, and that elevations of troponin are associated with poor prognosis, questions remain regarding the impact of the troponin diagnostic standard on the prevalence and prognosis of AMI in older persons. Nationwide samples of eligible Medicare beneficiaries aged > or =65 years who were hospitalized (n = 71,120) with a primary discharge diagnosis of AMI between April 1998 and March 1999 (baseline cohort) or July 2000 and June 2001 (remeasurement cohort) were evaluated. The analysis was restricted to patients with clinically confirmed AMI who underwent testing for both CK-MB and troponin. The majority of these patients (71.0%) were both CK-MB- and troponin-positive, but 17.8% were diagnosed with AMI based solely on positive troponin levels. Combining the CK-MB or both groups as a reference and troponin as a design variable to fit Cox proportional hazards models, troponin-only-positive patients had an unadjusted risk ratio (RR) of 1.14 (95% confidence interval [CI], 1.07-1.22) for the 30-day mortality and RR of 1.09 (95% CI, 1.03-1.15) for the 3-year mortality. However, after adjusting for patient demographics, clinical characteristics, physician specialties, and hospitals characteristics, troponin-only-positive patients had similar risk for early- and long-term mortality as the other 2 groups; the risk-adjusted RR for 30-day mortality was 0.96 (95% CI, 0.89-1.02) and for 3-year mortality was 0.95 (95% CI, 0.90-1.00). The widespread application of cardiac troponins results in a substantial increase in AMI diagnoses in older patients. Contrary to the prevailing wisdom that troponin-only-positive AMIs are smaller "infarctlets" and likely to have better prognosis, older persons with troponin-only AMIs are at similar risk for early and long-term mortality compared with those with CK-MB-positive AMIs. Therefore, nationwide efforts should focus on the unique characteristics of this emerging patient population so as to improve quality of care provided to this high-risk cohort of patients with AMI.

Impact of managed care on the treatment, costs, and outcomes of fee-for-service Medicare patients with acute myocardial infarction.

To examine the effects of market-level managed care activity on the treatment, cost, and outcomes of care for Medicare fee-for-service acute myocardial infarction (AMI) patients. Patients from the Cooperative Cardiovascular Project (CCP), a sample of Medicare beneficiaries discharged from nonfederal acute-care hospitals with a primary discharge diagnosis of AMI from January 1994 to February 1996. We estimated models of patient treatment, costs, and outcomes using ordinary least squares and logistic regression. The independent variables of primary interest were market-area managed care penetration and competition. The models included controls for patient, hospital, and other market area characteristics. We merged the CCP data with Medicare claims and other data sources. The study sample included CCP patients aged 65 and older who were admitted during 1994 and 1995 with a confirmed AMI to a nonrural hospital. Rates of revascularization and cardiac catheterization for Medicare fee-for-service patients with AMI are lower in high-HMO penetration markets than in low-penetration ones. Patients admitted in high-HMO-competition markets, in contrast, are more likely to receive cardiac catheterization for treatment of their AMI and had higher treatment costs than those admitted in low-competition markets. The level of managed care activity in the health care market affects the process of care for Medicare fee-for-service AMI patients. Spillovers from managed care activity to patients with other types of insurance are more likely when managed care organizations have greater market power.

The risk of hospitalization for acute myocardial infarction among older adults.

The purpose of this study was to prospectively examine the risk of hospitalization for acute myocardial infarction (AMI) in a large, nationally representative sample of very old men and women. We utilized secondary analysis of the Longitudinal Study of Aging. Baseline (1984) in-person interview data were linked to Medicare hospitalization records for 1984-1991. Subjects were 6,071 noninstitutionalized adults 70 years old or older at baseline. Hospitalization for AMI was defined as having primary discharge diagnoses containing ICD9-CM 410 codes. Multivariable proportional hazards regression was used to evaluate the epidemiologic risks for all persons, and separately for women, men, self-respondents, those with no previous AMIs, and those with no history of coronary heart disease. Of the sample, 357 persons (5.9%; 172 women and 185 men) had at least one primary discharge diagnosis of AMI. Significant (p<.05) risk factors for being hospitalized with an AMI (adjusted hazards ratios in parentheses) from the pooled analysis were male gender (1.86), having no more than a grade school education (1.35), atherosclerosis (1.43), hypertension (1.29), coronary heart disease (1.63), angina (1.60), previous AMI (1.52), diabetes (1.89), and four or more lower body limitations (1.43). The gender-specific analyses, however, revealed that hypertension, angina, diabetes, and lower body limitations were risk factors only for women, and that having no more than a grade school education was a risk factor only for men. Men, especially those with low education, women with diabetes, angina, hypertension, or lower body limitations, and either men or women with previous AMIs, coronary heart disease, or atherosclerosis have elevated risks for AMI resulting in hospitalization, and they should be considered for evaluation and monitoring. Current protocols for therapeutic management should be adopted, and compliance should be encouraged.