Readmission For Myocardial Infarction Research Articles

\u03b2-blockers after myocardial infarction and 1-year clinical outcome \u2013 a retrospective study

BackgroundLong term β-blocker therapy after myocardial infarction (MI) reduces mortality and recurrent MI but evidence for this treatment predates contemporary acute coronary care. β-blocker treatment is a key quality of care indicator in the Swedish national quality register for acute coronary care, Riks-HIA. Between 2011 and 2015 a declining number of MI-patients discharged with a β-blocker from the coronary care unit (CCU) at Helsingborg and other hospitals was reported. This retrospective observational study aimed to investigate the causes for discharge without a β-blocker and relate it to outcome, compared to patients discharged with a β-blocker.MethodsMI-patients registered in Riks-HIA discharged without β-blocker during 2011–2015 (no-β-group) and a control group (β-group) comprised of patients discharged with β-blocker treatment between January 1 to December 31, 2013, were matched by RIKS-HIA criteria for β-blocker use. Clinical characteristics, date of death, readmission for MI, other cardiovascular events were collected from Riks-HIA and medical records.ResultsThe no-β-group included 141 patients, where 65.2% had a justified reason for non-β-blocker use. The β-group included 206 patients. There was no difference in cardiovascular risk factor profile. There were a trend towards a higher number of readmissions for MI in the no-β-group was (n = 8 (5.7%) vs n = 2 (1.0%), p = 0.02), but not mortality (6 (4.3%) vs 2 (1.0%), p = 0.07) and combined readmission for angina pectoris, heart failure, arrhythmias or stroke/TIA (n = 23 (16.3%) vs n = 25 (12.1%), p = 0.27).ConclusionA majority of the patients in the no-β-group had a justified absence of a β-blocker. β-blocker treatment post-MI showed a trend towards fewer readmissions for MI. But important quality information is lacking to make a firm conclusion of the effect on outcome.

Association of Cardiac Rehabilitation With Survival Among US Veterans

Participation in cardiac rehabilitation (CR) programs at Veterans Affairs (VA) facilities is low. Most veterans receive CR through purchased care at non-VA programs. However, limited literature exists on the comparison of outcomes between VA and non-VA CR programs. To compare 1-year mortality and 1-year readmission rates for myocardial infarction or coronary revascularization between VA vs non-VA CR participants. This cohort study included 7320 patients hospitalized for myocardial infarction or coronary revascularization at the VA between 2010 and 2014 who did not die within 30 days of discharge and who participated in 2 or more CR sessions after discharge. The study excluded individuals hospitalized for ischemic heart disease after December 2014 when the VA Choice Act changed referral criteria for non-VA care. Data analysis was performed from November 2019 to January 2020. Participation in 2 or more CR sessions within 12 months of discharge at a VA or non-VA facility. The 1-year all-cause mortality and 1-year readmission rates for myocardial infarction or coronary revascularization from date of discharge were compared between VA vs non-VA CR participants using Cox proportional hazards models with inverse probability treatment weighting. The 7320 veterans with ischemic heart disease who participated in CR programs had a mean (SD) age of 65.13 (8.17) years and were predominantly white (6005 patients [82.0%]), non-Hispanic (6642 patients [91.0%]), and male (7191 patients [98.2%]). Among these 7320 veterans, 2921 (39.9%) attended a VA facility, and 4399 (60.1%) attended a non-VA CR facility. Black and Hispanic veterans were more likely to attend CR programs at VA facilities (509 patients [17.4%] and 378 patients [12.9%], respectively), whereas white veterans were more likely to attend CR programs at non-VA facilities (3759 patients [85.5%]). After inverse probability treatment weighting, rates of 1-year mortality were 1.7% among VA CR participants vs 1.3% among non-VA CR participants (hazard ratio, 1.32; 95% CI, 0.90-1.94; P = .15). Rates of readmission for myocardial infarction or revascularization during the 12 months after discharge were 4.9% among VA CR participants vs 4.4% among non-VA CR participants (hazard ratio, 1.06; 95% CI, 0.83-1.35; P = .62). These findings suggest that rates of 1-year mortality and 1-year readmission for myocardial infarction or revascularization did not differ for participants in VA vs non-VA cardiac rehabilitation programs. Eligible patients with ischemic heart disease should participate in CR programs regardless of where they are provided.

Heightened risk of cardiac events following percutaneous coronary intervention for cocaine-associated myocardial infarction.

IntroductionSeveral works have suggested heightened risk for cardiac events in cocaine users following percutaneous coronary intervention (PCI). Such studies have generally been performed in small, poorly defined samples and have not utilised optimal control groups. We aimed to define the short-term risk for death or recurrent myocardial infarction (MI) when PCI was performed for myocardial infarction in subjects presenting with urine toxicology positive for cocaine in relation to subjects testing negative for cocaine use.Material and methodsOur institutional electronic health record (EHR) was queried for all subjects with urine toxicology performed for cocaine exposure within 5 days before or after having elevated troponin-T assay between 1/1/08 and 12/31/13. Query results were cross-referenced with our institutional cardiology database to identify the sample who had PCI on the same admission as the cocaine test. Subsequent readmission for MI was assessed from the EHR, and deaths were identified from the National Death Index.ResultsPCI had been performed in 380 subjects who tested negative for cocaine and 44 subjects who tested positive. In the cocaine-positive group, incidences of death or MI at 30 days and 1 year were 18% and 23%, respectively. Those who tested positive for cocaine had increased odds (odds ratio (OR) = 2.3, 95% confidence interval (CI): 1.0–5.1, p = 0.04) for death or MI at 30 days post PCI, after adjustment for age, sex, prior MI, and comorbidity index. Although the odds for events 1-year post PCI were not increased (OR = 2.0, 95% CI: 0.9–4.3), the p-value approached significance in this small sample (p = 0.09).ConclusionsThis retrospective study suggests that PCI performed in cocaine-associated myocardial infarction comes with a high 30-day and one-year risk. Further prospective studies are needed to better define this risk and to lend insight into better management strategies.

Reliability of the American Community Survey Estimates of Risk-Adjusted Readmission Rankings for Hospitals Before and After Peer Group Stratification

Since the transition to the American Community Survey, data uncertainty has complicated its use for policy making and research, despite the ongoing need to identify disparities in health care outcomes. The US Centers for Medicare & Medicaid Services' new, stratified payment adjustment method for its Hospital Readmissions Reduction Program may be able to reduce the reliance on data linkages to socioeconomic survey estimates. To determine whether there are differences in the reliability of socioeconomically risk-adjusted hospital readmission rates among hospitals that serve a disproportionate share of low-income populations after stratifying hospitals into peer group-based classification groups. This cross-sectional study uses data from the 2014 New York State Health Cost and Utilization Project State Inpatient Database for 96 278 hospital admissions for acute myocardial infarction, pneumonia, and congestive heart failure. The analysis included patients aged 18 years and older who were not transferred to another hospital, who were discharged alive, who did not leave the hospital against medical advice, and who were discharged before December 2014. The main outcomes were 30-day hospital readmissions after acute myocardial infarction, pneumonia, and congestive heart failure assessed using hierarchical logistic regression. The mean (SD) age of the patients was 69.6 (16.0) years for the safety-net hospitals and 74.9 (14.7) years for the non-safety-net hospitals; 9382 (48.8%) and 7003 (48.5%) patients, respectively, were female. For safety net designations, 20% (3 of 15) of all evaluations concealed and distorted differences in risk, with factors such as poverty failing to identify similar risk of acute myocardial infarction readmission until unreliable estimates were excluded from the analysis (OR, 1.23 [95% CI, 1.00-1.52], P = .02; vs OR, 1.17 [95% CI, 0.94-1.46], P = .15). By comparison, 2 of the 60 models (3%) for the peer group-based classification altered the association between socioeconomic status and readmission risk, concealing similarities in congestive heart failure readmission when adjusted using high school completion rates (OR, 1.27 [95% CI 1.02-1.58], P = .04; vs OR, 1.23 [95% CI, 0.98-1.53], P = .06) and distorting similarities in pneumonia readmissions when accounting for the proportion of lone-parent families (OR, 1.27 [95% CI, 0.98-1.66], P = .07; vs OR, 1.35 [95% CI, 1.02-1.80], P = .04) between the lowest and highest socioeconomic status hospitals in quartile 1. There was greater precision in socioeconomic adjusted readmission estimates when hospitals were stratified into the new payment adjustment criteria compared with safety net designations. A contributing factor for improved reliability of American Community Survey estimates under the new payment criteria was the merging of patients from low-income neighborhoods with greater homogeneity in survey estimates into groupings similar to those for higher-income patients, whose neighborhoods often exhibit greater estimate variability. Additional efforts are needed to explore the effect of measurement error on American Community Survey-adjusted readmissions using the new peer group-based classification methods.

P1885Cha2ds-2vasc score lacks of ability to predict mortality in patients attending the emergency department with atrial fibrillation in the presence of troponin i

Abstract Background CHA2DS2-VASc score has been used as a surrogate marker for predicting outcomes beyond thromboembolic risk in patients with atrial fibrillation (AF). Likewise, cardiac troponin I (cTnI) is a predictor of mortality in AF. Purpose This study aimed to investigate the association of cTnI and CHA2DS2-VASc score with long-term prognosis in patients admitted to the emergency department with AF. Methods A retrospective cohort study conducted between January 2012 and December 2013, enrolling patients admitted to the emergency department with AF and having documented cTnI measurements. CHA2DS2-VASc score was estimated. Primary endpoint was 5-year all-cause mortality, readmission for heart failure (HF), readmission for myocardial infarction (MI) and the composite end point of major adverse cardiac events defined as death, readmission for HF or readmission for MI (MACE). Results A total of 578 patients with AF were studied, of whom 252 patients had elevated levels of cTnI (43.6%) and 334 patients had CHA2DS2-VASc score >3 (57.8%). Patients with elevated cTnI tended to be oldercompared with those who did not have cTnI elevation and were more frequently comorbid and of higher ischemic risk, including hypertension, prior MI, prior HF, chronic renal failure and peripheral artery disease. The overall median CHA2DS2-VASc score was higher in those with cTnI elevation compared to those patients elevated cTnI levels (4.2 vs 3.3 points, p<0.001). Main diagnoses at hospital discharge were tachyarrhythmia 30.3%, followed by heart failure 17.7%, respiratory infections 9.5% and acute coronary syndrome 7.3%. At 5-year follow-up, all-cause death was significantly higher for patients with cTnI elevation compared with those who did not have cTnI elevation (56.4% vs. 27%; logrank test p<0.001). Specifically, for readmissions for HF and readmissions for MI there were no differences in between patients with or without cTnI elevation. In addition, MACE was reached in 165 patients (65.5%) with cTnI elevation, compare to 126 patients (38.7%) without cTnI elevation (p<0.001). On multivariable Cox regression analysis, cTnI elevation was an independent predictor of all-cause death (hazard ratio, 1.67, 95% confidence interval [CI]: 1.24–2.26, p=0.001) and of MACE (hazard ratio 1.47, 95% confidence interval 1.15–1.88; P=0.002), but it did not reach statistical significance for readmissions for MI and readmissions for HF. CHA2DS2-VASc score was a predictor on univariate Cox regression analysis for each endpoint, but it did not reach significance on multivariable Cox regression analysis for any endpoint. Conclusions cTnI is independently associated with long-term all-cause mortality in patients attending the emergency department with AF. cTnI compared to CHA2DS2-VASc score is thus a biomarker with predictive capacity for mortality in late follow-up, conferring utility in the risk stratification of patients with atrial fibrillation.

An Economic Evaluation of the All New Zealand Acute Coronary Syndrome Quality Improvement Registry Program (ANZACS-QI 28)

The All New Zealand Acute Coronary Syndrome Quality Improvement (ANZACS-QI) program comprises a clinical quality registry of acute coronary syndrome patients admitted to hospitals across New Zealand. Its primary purpose is to improve quality of care by promoting evidence- and guidelines-based practice, and benchmarking against performance targets. Few studies have examined the cost-effectiveness attributed to clinical quality registries. We aimed to evaluate the clinical and cost impacts of the ANZACS-QI program in New Zealand from both a societal and health care system perspective. Using decision analytic Markov models, we estimated the effectiveness and costs of the ANZACS-QI program in each year over 4 years (2013-2016), against a hypothetical scenario where the registry did not exist. We assumed that the ANZACS-QI contributed to 15% of the temporal changes to patient mortality and hospital readmissions for myocardial infarction observed in the study period. Marginal costs of the registry and years of life saved were estimated. Over a one-year period, the return on investment (ROI) ratio for the ANZACS-QI program was 1.53; thus, every dollar spent on the program resulted in a return of NZD $1.53. (All dollars are in 2017 New Zealand dollars [NZD] unless otherwise stated). The estimated incremental cost-effectiveness ratio (ICER) was $113,327 per year of life saved (YoLS). Extending the time horizon to 5 years, reduced the ICER to $19,684 per YoLS. The ANZACS-QI program represents a sound investment for New Zealand. Even based on highly conservative assumptions, the program is cost saving for society, at a ROI ratio of about 1.5 each year.

β-Blocker treatment and prognosis in acute coronary syndrome associated with cocaine consumption: The RUTI-Cocaine Study

BackgroundThe use of β-blocker therapy in the setting of acute coronary syndrome (ACS) associated with cocaine consumption (ACS-ACC) is discouraged due to the risk of coronary vasoconstriction. We examined the prognostic value of β-blocker therapy in a contemporary ACS cohort. Methods and resultsProspective, single-center study conducted between January 2001 and December 2014 that examined cocaine use among young (≤50-year-old) consecutive patients admitted with an ACS. During the study period, 1002 patients were admitted; of these, 57 (5.7%) had a positive cocaine urine test We collected data on clinical characteristics and major adverse cardiovascular events (MACE) during follow-up. Among ACS-ACC patients, 33 (57.9%) received β-blocker therapy during hospital admission and after discharge. During a median follow-up of 4.0 (IQR: 2.4–6.5) years after the index event, 2 (6.1%) patients treated with β-blocker therapy died and 6 (18.2%) experienced hospital re-admission for myocardial infarction (MI); in contrast, there were 5 (20.8%) deaths and 5 (20.8%) readmissions due to MI in patients without β-blocker therapy. Lower rates of MACE were observed in patients treated with β-blocker therapy (30.3%) than those without β-blocker therapy (41.7%). The 90-day survival was higher in patients treated with β-blocker therapy (87.5% vs. 100%; Log rank test p = 0.035). ConclusionsIn patients with ACS-ACC, β-blocker treatment was associated with a significantly better clinical outcome, with lower rates of death and MI. Our findings support the evidence for long-term β-blocker administration in high-risk patients and highlight the need for large prospective multicenter studies of β-blocker treatment in ACS-ACC.

The Impact of a Transition of Care Program on Acute Myocardial Infarction Readmission Rates.

Hospital discharge is a high-risk time period, and acute myocardial infarction (AMI) patients often have early readmissions. The authors hypothesized that a multifaceted AMI care coordination program would reduce early hospital readmission rates. The outcomes of patients receiving care coordination (n = 304) were compared to patients receiving standard care (n = 192). Multivariable analyses of the outcomes were conducted by conditional logistic regression of propensity score matched sets. The primary outcome-hospital readmission within 30 days of discharge-occurred in 18% of standard care patients and 11.8% of care coordination patients. Patients receiving care coordination demonstrated a 48% reduction in odds of readmission within 30 days (odds ratio = 0.52; P = .04; 95% CI = 0.28-0.97). These results are the first to demonstrate that inclusion in an AMI-specific care coordination program is associated with a significantly lower risk of 30-day hospital readmission.

Association Between Energy Prices and US Hospital Patient Outcomes.

To evaluate associations between changing energy prices and US hospital patient outcomes. Generalized estimating equations were used to analyze relationships between changes in energy prices and subsequent changes in hospital patient outcomes measures for the years 2008 through 2014. Patient outcomes measures included 30-day acute myocardial infarction, heart failure, and pneumonia mortality rates, and 30-day acute myocardial infarction, heart failure, and pneumonia readmission rates. Energy price data included state average distillate fuel, electricity and natural gas prices, and the US average coal price. All of the price data were converted to 2014 dollars using Consumer Price Index multipliers. There was a significant positive association between changes in coal price and both short-term (P = 0.029) and long-term (P = 0.017) changes in the 30-day heart failure mortality rate. There was a similar significant positive association between changes in coal price and both short-term (P <0.001) and long-term (P = 0.002) changes in the 30-day pneumonia mortality rate. Changes in coal prices also were positively associated with long-term changes in the 30-day myocardial infarction readmission rate (P < 0.001). Changes in coal prices (P = 0.20), natural gas prices (P = 0.040), and electricity prices (P = 0.040) were positively associated with long-term changes in the 30-day heart failure readmission rate. Changing energy prices are associated with subsequent changes in hospital mortality and readmission measures. In light of these data, we encourage hospital, health system, and health policy leaders to pursue patient-support initiatives, energy conservation programs, and reimbursement policy strategies aimed at mitigating those effects.

Change in Angina Symptom Status After Acute Myocardial Infarction and Its Association With Readmission Risk: An Analysis of the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) Registry.

BackgroundAngina is common both before and after myocardial infarction (MI). Whether the change in angina status within the first 30 days after MI is associated with subsequent readmission and angina persistence is unknown.Methods and ResultsWe studied 2915 MI patients enrolled at 24 hospitals in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status (TRIUMPH) registry. Angina before and 30 days after MI was assessed with the Seattle Angina Questionnaire. Patients were divided into angina‐free pre‐ and post‐MI (−/−), resolved angina (+/−), new angina (−/+), and persistent angina (+/+) groups. Multivariable proportional hazards and hierarchical modified Poisson models were performed to assess the association of each group with all‐cause readmission, readmission for MI or unplanned revascularization, and angina persistence at 1 year. Overall, 1293 patients (44%) had angina before their MI and 849 (29%) reported angina within 30 days of discharge. Patients with post‐MI angina were more likely to be younger, nonwhite, and uninsured. Compared with patients who were angina‐free pre‐ and post‐MI, 1‐year all‐cause readmission risks were significantly higher for patients with persistent angina (hazard ratio [HR], 1.35; 95% CI 1.06–1.71) or new angina (HR, 1.40; 95% CI, 1.08–1.82). At 1 year, angina was present in 22% of patients and was more likely if angina was persistent (HR, 3.55; 95% CI, 3.05–4.13) or new (HR, 3.38; 95% CI, 2.59–4.42) at 30 days compared with patients who were angina‐free pre‐ and post‐MI.ConclusionsPost‐MI angina, whether new or persistent, is associated with higher likelihood of readmission. Prioritizing post‐MI angina management is a potential means of improving 1‐year outcomes.

Unmet Nursing Care Linked to Rehospitalizations Among Older Black AMI Patients: A Cross-Sectional Study of US Hospitals.

Recent studies suggest that nurses may be unable to complete all aspects of necessary care due to a lack of time. Research is needed to determine whether unmet nursing care contributes to disparities in readmissions for vulnerable populations. To examine differences in the relationship between nursing care left undone and acute myocardial infarction readmissions among older black patients compared with older white patients. Cross-sectional analysis of multiple datasets, including: 2006 to 2007 administrative discharge data, a survey of registered nurses, and the American Hospital Association Annual Survey. Risk-adjusted logistic regression models were used to estimate the association between care left undone and 30-day readmission. Interactions were used to examine the moderating effect of care left undone on readmission by race. The sample included 69,065 patients in 253 hospitals in California, New Jersey, and Pennsylvania. Older black patients were 18% more likely to experience a readmission after adjusting for patient and hospital characteristics and more likely to be in hospitals where nursing care was often left undone. Black patients were more likely to be readmitted when nurses were unable to talk/comfort patients [odds ratio (OR), 1.09; 95% confidence interval (CI), 1.01-1.19], complete documentation (OR, 1.16; 95% CI, 1.01-1.32), or administer medications in a timely manner (OR, 1.26; 95% CI, 1.09-1.46). Unmet nursing care is associated with readmissions for older black patients following acute myocardial infarction. Investment in nursing resources to improve the delivery of nursing care may decrease disparities in readmission.

Outcomes According to Cardiac Catheterization Referral and Clopidogrel Use Among Medicare Patients With Non-ST-Segment Elevation Myocardial Infarction Discharged Without In-hospital Revascularization.

BackgroundWhile use of P2Y12 receptor inhibitor is recommended by guidelines, few studies have examined its effectiveness among older non–ST‐segment elevation myocardial infarction patients who did not undergo coronary revascularization.Methods and ResultsWe included unrevascularized non–ST‐segment elevation myocardial infarction patients ≥65 years discharged home from 463 ACTION Registry‐GWTG hospitals from 2007 to 2010. Rates of discharge clopidogrel use were described for patients with no angiography, angiography without obstructive coronary artery disease (CAD; ≥50% stenosis in ≥1 vessel), and angiography with obstructive CAD. Two‐year outcomes were ascertained from linked Medicare data and included composite major adverse cardiac events (defined as all‐cause death, myocardial infarction readmission, or revascularization), and individual components. Outcomes associated with clopidogrel use were adjusted using inverse probability‐weighted propensity modeling. Of 14 154 unrevascularized patients, 54.7% (n=7745) did not undergo angiography, 10.6% (n=1494) had angiography without CAD, and 34.7% (n=4915) had angiography with CAD. Discharge clopidogrel was prescribed for 42.2% of all unrevascularized patients: 37.8% without angiography, 34.1% without obstructive CAD at angiography, and 51.6% with obstructive CAD at angiography. Discharge clopidogrel use was not associated with major adverse cardiac events in any group: without angiography (adjusted hazard ratio [95% CI]: 0.99 [0.93–1.06]), angiography without CAD (1.04 [0.74–1.47]), and angiography with CAD (1.12 [1.00–1.25], P interaction=0.20).ConclusionsWe found no association between discharge clopidogrel use and long‐term risk of major adverse cardiac events among older, unrevascularized non–ST‐segment elevation myocardial infarction patients. Clopidogrel use in this population requires further prospective evaluation.

Percutaneous coronary intervention for older adults who present with syncope and coronary artery disease? Insights from the National Cardiovascular Data Registry

We explored the risks/benefits of revascularization versus medical management in syncope patients with obstructive coronary artery disease (CAD). We retrospectively examined Medicare patients ≥65 years undergoing percutaneous coronary intervention (PCI) for syncope at 539 CathPCI Registry hospitals with ≥70% stenosis in at least 1 coronary artery, excluding those with ST-segment elevation myocardial infarction (MI), cardiogenic shock, left main disease, and coronary artery bypass grafting. In a propensity-matched population, we compared short-term (90-day) all-cause readmission risk and long-term (3-year) risks of readmission for syncope and MI, as well as mortality in those receiving PCI versus medical management. Among 14,674 syncope patients, 9,549 (65%) had at least 1-vessel obstructive CAD. After exclusions, 3,196 of 7,338 patients (44%) underwent PCI. In the propensity-matched cohort, there was no significant difference in 90-day all-cause readmission risk (28.2% vs 30.3%, adjusted hazard ratio [HR] 0.92, 95% CI 0.83-1.02) or long-term risks of readmission for syncope (7.0% vs 6.1%, adjusted HR 1.06, 95% CI 0.83-1.35). PCI-treated patients had significantly higher risk of readmission for MI (5.6% vs 4.0%, adjusted HR 1.56, 95% CI 1.18-2.06) but lower risk of long-term mortality (27.0% vs 30.3%, adjusted HR 0.86, 95% CI 0.77-0.97) than medically managed patients. In patients presenting with syncope and obstructive CAD, PCI was not associated with significant improvements in the risk of readmission but was associated with lower long-term mortality compared with medical therapy, suggesting the need to more definitively assess the benefit of PCI among elderly syncope patients.

Sex and Ethnic Differences in Outcomes of Acute Coronary Syndrome and Stable Angina Patients With Obstructive Coronary Artery Disease.

The joint contribution of sex, ethnicity, and initial clinical presentation to the long-term outcomes of patients undergoing coronary angiography for acute coronary syndrome (ACS) or stable angina, in whom there is angiographic evidence for obstructive coronary artery disease, remains unknown. We conducted a population-based cohort study on 49 556 adult ACS or stable angina patients with angiographic evidence of obstructive coronary artery disease (≥ 50% stenosis) in British Columbia. The 2-year composite outcome was all-cause death and hospital readmissions for myocardial infarction, heart failure, cerebrovascular accident, or angina after the index angiography. Sex and ethnic differences in the composite outcome were examined by clinical presentation using the Cox proportional-hazards and logistic regression models. Overall, 25.6% were women, 9.5% were South Asians, 3.0% were Chinese, and 65.9% presented with ACS. Regardless of ethnicity, women were more likely than men to have adverse outcomes, but the magnitude of the sex difference was greater in the ACS patients (P(interaction) for sex and clinical presentation=0.03). Angina readmission accounted for 45% of the composite outcome and was the main component for all groups with the exception of Chinese women with ACS. Furthermore, women were more likely than men to be readmitted for angina (odds ratio [95% confidence interval], 1.13 [1.04-1.22]). Higher rates of adverse events among women with obstructive coronary artery disease, regardless of ethnicity, as well as high rates of angina readmission, highlight the need for more targeted interventions to reduce the burden of angina because this presentation is clearly not benign.

Prolonged Clopidogrel Use is Associated with Improved Clinical Outcomes Following Drug-Eluting But Not Bare Metal Stent Implantation.

Guidelines recommend clopidogrel use for 6-12 months following drug-eluting stent (DES) implantation and 1-12 months following bare metal stent (BMS) implantation. The role of clopidogrel beyond 12 months is unclear. We linked hospital administrative, community pharmacy and cardiac revascularization data to determine clopidogrel use and outcomes for all patients (those with acute presentations and those with stable angina) receiving a coronary stent in British Columbia 2004-2006, with follow-up until the end of 2008. Cox proportional hazard regression was performed to evaluate the effect of clopidogrel duration (≤12 vs. >12 months) on outcomes following BMS or DES implantation. Patients who died ≤12 months from index stent placement were excluded. A total of 15,629 patients were included in the study. Of 3599 patients who received at least one DES and 12,030 patients who received only BMS, 1326 (37 %) and 2121 (18 %), respectively, filled a prescription for clopidogrel >12 months from the index procedure. The mean duration of clopidogrel was 406 ± 35 days and 407 ± 37 days in the prolonged use (>12 months) DES and BMS cohorts, respectively, compared with 224 ± 112 days (p < 0.001) and 122 ± 117 days (p < 0.001), respectively, for patients receiving clopidogrel ≤12 months. Clopidogrel use beyond 12 months was associated with a reduction in mortality [hazard ratio (HR) 0.66, 95 % confidence interval (CI) 0.45-0.97] and the composite of mortality and readmission for myocardial infarction (HR 0.72, 95 % CI 0.55-0.94) in patients treated with DES, but not BMS alone. Prolonged clopidogrel use was not associated with bleeding-related mortality. Clopidogrel use beyond 12 months was associated with a reduction in death and hospitalization for myocardial infarction following DES, but not BMS, implantation. Our findings support a longer duration of clopidogrel therapy for patients treated with DES.

Abstract 14638: Stent-type at Percutaneous Coronary Intervention and Long-term Outcomes in Relation to Renal Function: Data From 103.747 Patients in the SCAAR-registry

Objective: To evaluate the risk of hard clinical endpoints of different types of PCI stents in relation to renal function. Methods: During 2007 and 2013, 103.747 patients enrolled in the Swedish Coronary Angiography &amp; Angioplasty Registry (SCAAR) with a known serum creatinine were treated with PCI using new generation drug eluting stents (n-DES) (n=32.440), old generation drug eluting stents (o-DES) (n=17.363) or bare metal stents (BMS) (n=53.974). Renal function groups were derived from creatinine estimated glomerular filtration rate (eGFR) and expressed in ml/min/1.73 m2. The hazard risk (HR) of the combined endpoint (all-cause mortality or myocardial infarction readmission) was estimated using Cox landmark analyses (≤1 year and &gt;1 year to 3 years). Adjustments were made for year, hospital, extent of coronary artery disease, indication for PCI, use of multiple stents, periprocedural antithrombotic treatment, number of stents, stent dimensions, diabetes, age, gender, risk factors and history of cardiovascular disease. Results: N-DES was associated with a significantly lower up-to 1 year risk compared to BMS in patients with eGFR &gt;60. These associations were attenuated and not significant in patients with eGFR &lt;60. Adjusted HR comparing o-DES and BMS were not statistically different (≤1 year). There was no significant difference between n-DES and BMS after 1 year. Compared to BMS, o-DES had significantly higher risks in patients with eGFR ≥60 and in patients with eGFR 30-59 HR was similarly but not significantly elevated. Conclusion: In this large national registry we found that in patients with normal renal function, n-DES was associated with a lower up to 1-year risk of MI readmission or all-cause mortality, whereas o-DES was associated with a higher risk after 1 year. A similar trend was seen for patients with moderately reduced renal function but not for patients with severely reduced renal function.

Long-term traffic air and noise pollution in relation to mortality and hospital readmission among myocardial infarction survivors.

There is relatively little evidence of health effects of long-term exposure to traffic-related pollution in susceptible populations. We investigated whether long-term exposure to traffic air and noise pollution was associated with all-cause mortality or hospital readmission for myocardial infarction (MI) among survivors of hospital admission for MI. Patients from the Myocardial Ischaemia National Audit Project database resident in Greater London (n = 1 8,138) were followed for death or readmission for MI. High spatially-resolved annual average air pollution (11 metrics of primary traffic, regional or urban background) derived from a dispersion model (resolution 20 m × 20 m) and road traffic noise for the years 2003-2010 were used to assign exposure at residence. Hazard ratios (HR, 95% confidence interval (CI)) were estimated using Cox proportional hazards models. Most air pollutants were positively associated with all-cause mortality alone and in combination with hospital readmission. The largest associations with mortality per interquartile range (IQR) increase of pollutant were observed for non-exhaust particulate matter (PM(10)) (HR = 1.05 (95% CI 1.00, 1.10), IQR = 1.1 μg/m(3)); oxidant gases (HR = 1.05 (95% CI 1.00, 1.09), IQR = 3.2 μg/m(3)); and the coarse fraction of PM (HR = 1.05 (95% CI 1.00, 1.10), IQR = 0.9 μg/m(3)). Adjustment for traffic noise only slightly attenuated these associations. The association for a 5 dB increase in road-traffic noise with mortality was HR = 1.02 (95% CI 0.99, 1.06) independent of air pollution. These data support a relationship of primary traffic and regional/urban background air pollution with poor prognosis among MI survivors. Although imprecise, traffic noise appeared to have a modest association with prognosis independent of air pollution.

Use and Outcomes of Triple Therapy Among Older Patients With Acute Myocardial Infarction and Atrial Fibrillation

BackgroundAntithrombotic therapy for acute myocardial infarction (MI) with atrial fibrillation (AF) among higher risk older patients treated with percutaneous coronary intervention (PCI) remains unclear. ObjectivesThis study sought to determine appropriate antithrombotic therapy for acute MI patients with AF treated with PCI. MethodsWe examined 4,959 patients ≥65 years of age with acute MI and AF who underwent coronary stenting (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With the Guidelines). The primary effectiveness outcome was 2-year major adverse cardiac events (MACE) comprising death, readmission for MI, or stroke; the primary safety outcome was bleeding readmission. Outcomes with dual antiplatelet therapy (DAPT) or triple therapy (DAPT plus warfarin) were compared using Cox proportional hazard modeling with inverse probability-weighted propensity adjustment. ResultsAmong 4,959 patients, 27.6% (n = 1,370) were discharged on triple therapy. Relative to DAPT, patients on triple therapy had a similar risk of MACE (adjusted hazard ratio [HR]: 0.99 [95% confidence interval (CI): 0.86 to 1.16]) but significantly greater risk of bleeding requiring hospitalization (adjusted HR: 1.61 [95% CI: 1.31 to 1.97]) and greater risk of intracranial hemorrhage (adjusted HR: 2.04 [95% CI: 1.25 to 3.34]). Of 1,591 Medicare Part D patients, 90-day post-discharge warfarin persistence among patients discharged on warfarin was 93.2% (n = 412). Results of 90-day landmark analyses comparing triple therapy versus DAPT in patients persistently on warfarin versus those not discharged on warfarin who had not filled a warfarin prescription were similar to our primary findings. ConclusionsApproximately 1 in 4 older AF patients undergoing PCI for MI were discharged on triple therapy. Those receiving triple therapy versus DAPT had higher rates of major bleeding without a measurable difference in composite MI, death, or stroke.

Condition-specific Streaming versus an Acuity-based Model of Cardiovascular Care: A Historically-controlled Quality Improvement Study Evaluating the Association with Early Clinical Events

Ensuring optimal evidence translation is challenging when health-service design has not kept pace with developments in care. Differences in patient outcomes were evident when specific cardiac conditions were discordant with the subspecialty of the cardiologists managing their care. We prospectively explored the clinical and health service implications of a "condition-based" redesign in cardiac care delivery, rather than acuity-based, within a tertiary hospital. Prospective evaluation of a disease-specific streaming model of care compared to propensity-matched historical controls, among cardiac patients admitted to a tertiary hospital cardiology unit was undertaken. The outcome measures of 30-day death, and readmission for myocardial infarction, cardiac arrhythmia, and heart failure were explored. In total, 2018 patients admitted subsequent to the implementation of the streaming model were compared with 1830 patients admitted prior. The median age was 68.9 years, and 39.5% were female. There was no significant difference in the overall proportion of patients admitted with an acute coronary syndrome, arrthythmia or heart failure, nor their Charlson index before and after streaming. Subsequent to the implementation, there was a reduction in the use of angiography (pre: 35.4% vs. post: 31.2%, p=0.007) and echocardiography (pre: 59.4% vs. post: 55.6%, p=0.007). A reduction in length of length-of-stay was observed in the entire cohort (pre: 2.7 (range: 1.2-5.0) days vs. post: 2.3 (range 1.0-4.5) days, p=0.0003). By 30 days, the propensity-adjusted hazard ratio for major adverse cardiac events and death or any cardiovascular admission was 0.76 (95% C.I. 0.59-0.97, p=0.026). Cardiac service redesign that streams cardiac patients by presenting diagnosis into teams designed to treat that condition may provide capacity and productivity gains for health services striving to improve outcome and efficiency.

Abstract 218: Impact of Electronic Health Record Components on Hospitals’ Performance in Heart Failure and Myocardial Infarction Mortality and Readmission Rates

Background: Cross-sectional studies have identified an association between the use of electronic health records (EHRs) and the quality of cardiovascular care; however, there is little longitudinal data to support this association. The objective of this study was to assess the impact of EHR implementation on heart failure (HF) and myocardial infarction (MI) 30-day mortality and 30-day readmission rates in the following two years. Methods: To measure hospitals’ implementation of EHR and its specific components, we used national data from the American Hospital Association (AHA) Health IT survey representing data for years 2009 and 2010. Hospitals which did not use EHRs in 2009 but did in 2010 were considered newly implemented. Hospitals which did not use an EHR system in either 2009 or 2010 were considered as not yet implemented and hospitals which were using EHRs in both 2009 and 2010 had already implemented EHRs. We examined the use of specific EHR components including clinical decision support tools, electronic clinical documentation, computerized provider order entry, the ability to generate quality data and the ability to electronically share patient data with outside hospitals. To assess hospital performance in HF and MI 30-day mortality/readmission rates, we used data from CMS Hospital Quality Initiative, Hospital Compare. We used baseline performance in 2010 and tracked change to 2012. We used a difference-of-difference statistical analysis to compare the change over time between hospitals with EHR components newly implemented to ones who had not yet implemented EHRs. We adjusted for hospital characteristics including bed size, region, profit-status and their baseline performance. Results: This study included 3300 hospitals that responded to both 2009 and 2010 surveys. In general, large, not-for-profit, and southern hospitals were significantly more likely to have implemented the different EHR components. For HF, implementation of two EHR components, ‘Clinical Discharge Summaries’ and ‘Electronic Exchange of Patient Data’ were significantly associated with slower increase in 30-day mortality as compared to hospitals who had not yet implemented them (p=0.01 and 0.002 respectively). Only the EHR component ‘Computerized Provider Order Entry of Lab Tests’ was significantly associated with a faster decrease in HF readmissions (p=0.03). For MI, none of the EHR components’ implementation was associated with changes in 30-day mortality. ‘Clinical Provider Order Entry for Radiology and Lab Tests’ were significantly associated with a slower increase in 30-day MI readmissions (p=0.03). Conclusion: Select components of EHRs have positive impact on heart failure 30-day mortality and myocardial infarction 30-day readmission rates. As hospitals and physician practices continue to adopt and expand their EHR systems these components and their potential benefits should be considered.