Association Between Hospital Cardiac Catheter Laboratory Status, Use of an Invasive Strategy, and Outcomes After NSTEMI

Bleeding risk prediction after acute myocardial infarction-integrating cancer data: the updated PRECISE-DAPT cancer score

BACKGROUND AND AIMS

This study assessed the impact of incorporating cancer as a predictor on performance of the PRECISE-DAPT score.

METHODS

A nationally linked cohort of ST-elevation myocardial infarction patients between 1 January 2005 and 31 March 2019 was derived from the UK Myocardial Ischaemia National Audit Project and the UK Hospital Episode Statistics Admitted Patient Care registries. The primary outcome was major bleeding at 1 year. A new modified score was generated by adding cancer as a binary variable to the PRECISE-DAPT score using a Cox regression model and compared its performance to the original PRECISE-DAPT score.

RESULTS

A total of 216 709 ST-elevation myocardial infarction patients were included, of which 4569 had cancer. The original score showed moderate accuracy (C-statistic .60), and the modified score showed modestly higher discrimination (C-statistics .64; hazard ratio 1.03, 95% confidence interval 1.03-1.04) even in patients without cancer (C-statistics .63; hazard ratio 1.03, 95% confidence interval 1.03-1.04). The net reclassification index was .07. The bleeding rates of the modified score risk categories (high, moderate, low, and very low bleeding risk) were 6.3%, 3.8%, 2.9%, and 2.2%, respectively. According to the original score, 65.5% of cancer patients were classified as high bleeding risk (HBR) and 21.6% were low or very low bleeding risk. According to the modified score, 94.0% of cancer patients were HBR, 6.0% were moderate bleeding risk, and no cancer patient was classified as low or very low bleeding risk.

CONCLUSIONS

Adding cancer to the PRECISE-DAPT score identifies the majority of patients with cancer as HBR and can improve its discrimination ability without undermining its performance in patients without cancer.

Heart Failure Readmission in Patients With ST-Segment Elevation Myocardial Infarction and Active Cancer

Background

Although numerous studies have examined readmission with heart failure (HF) after acute myocardial infarction (AMI), limited data are available on HF readmission in cancer patients post-AMI.

Objectives

This study aimed to assess the rates and factors associated with HF readmission in cancer patients presenting with ST-segment elevation myocardial infarction (STEMI).

Methods

A nationally linked cohort of STEMI patients between January 2005 and March 2019 were obtained from the UK Myocardial Infarction National Audit Project registry and the UK national Hospital Episode Statistics Admitted Patient Care registry. Multivariable Fine-Gray competing risk models were used to evaluate HF readmission at 30 days and 1 year.

Results

A total of 326,551 STEMI indexed admissions were included, with 7,090 (2.2%) patients having active cancer. The cancer group was less likely to be admitted under the care of a cardiologist (74.5% vs 81.9%) and had lower rates of invasive coronary angiography (62.2% vs 72.7%; P < 0.001) and percutaneous coronary intervention (58.4% vs. 69.5%). There was a significant prescription gap in the administration of post-AMI medications upon discharge such as an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (49.5% vs 71.1%) and beta-blockers (58.4% vs 68.0%) in cancer patients. The cancer group had a higher rate of HF readmission at 30 days (3.2% vs 2.3%) and 1 year (9.4% vs 7.3%). However, after adjustment, cancer was not independently associated with HF readmission at 30 days (subdistribution HR: 1.05; 95% CI: 0.86-1.28) or 1 year (subdistribution HR: 1.03; 95% CI: 0.92-1.16). The opportunity-based quality indicator was associated with higher rates of HF readmission independent of cancer diagnosis.

Conclusions

Cancer patients receive care that differs in important ways from patients without cancer. Greater implementation of evidence-based care may reduce HF readmissions, including in cancer patients.

Outcomes of ST elevation myocardial infarction in patients with cancer: a nationwide study

AIMS

To assess processes of care and clinical outcomes in cancer patients with ST elevation myocardial infarction (STEMI) according to cancer type.

METHODS AND RESULTS

This is a national population-based study of patients admitted with STEMI in the UK between January 2005 and March 2019. Data were obtained from the National Heart Attack Myocardial Infarction National Audit Project (MINAP) registry and the Hospital Episode Statistics registry. We identified 353 448 STEMI-indexed admissions between 2005 and 2019. Of those, 8581 (2.4%) had active cancer. Prostate cancer (29% of STEMI patients with cancer) was the most common cancer followed by haematologic malignancies (14%) and lung cancer (13%). Cancer patients were less likely to receive invasive coronary revascularization (60.0% vs. 71.6%, P < 0.001] and had higher in-hospital death [odd ratio (OR) 1.39, 95% confidence interval (CI) 1.25-1.54] and bleeding (OR 1.23, 95% CI 1.03-1.46). Cancer patients had higher mortality at 30 days (HR 2.39, 95% CI 2.19-2.62) and 1 year (HR 3.73, 95% CI 3.58-3.89). Lung cancer was the cancer associated with the highest risk of death in the hospital (OR 1.75, 95% CI 1.39-2.22) and at 1 year (OR 8.08, 95% CI 7.44-8.78). Colon cancer (OR 1.98, 95% CI 1.24-3.14) was the main cancer associated with major bleeding. All common cancer types were associated with higher mortality at 1 year. Cardiovascular death (62%) was the main cause of death in the first 30 days, while cancer (52%) was the main cause of death within 1 year.

CONCLUSION

STEMI patients with cancer have a higher risk of short- and long-term mortality, particularly lung cancer. Colon cancer is the main cancer associated with major bleeding. Cardiovascular disease was the main cause of death in the first month, whereas cancer was the main cause of death within 1 year.

Women Are Less Likely to Survive AMI Presenting With Out-of-Hospital Cardiac Arrest: A Nationwide Study

OBJECTIVE

To assess the impact of patient's sex on outcomes and management of acute myocardial infarction (AMI) patients presenting with out-of-hospital cardiac arrest (OHCA).

PATIENTS AND METHODS

We conducted a population-based retrospective cohort study in AMI patients admitted with OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) registry. We used multivariable logistic regression models to evaluate the role of sex as a predictor of clinical outcomes and treatment strategy.

RESULTS

Of 16,278 patients, women constituted almost one-quarter of the population (n=3710 [22.7%]). Women were older (median age 69 [IQR, 57-79] years vs 63 [IQR, 54-72] years, P<.001), experienced longer call-to-hospital-arrival time (median, 1.2 hours vs 1.1 hours; P=.008), were less likely to present with shockable rhythm (86.8% vs 91.5%, P<.001), and less likely to receive dual antiplatelet therapy (73.8% vs 78.6%, P<.001), beta blockers (64.7% vs 72.3%, P<.001), angiotensin-converting enzyme inhibitors (49.0% vs 55.3%, P<.001), coronary angiography (73.7% vs 83.3%, P<.001), and percutaneous coronary intervention (37.5% vs. 40.7%, p 0.004). After adjusting for patient characteristics and management, women had significantly higher odds of in-hospital death compared with men (odds ratio [OR], 1.3; 95% CI, 1.1 to 1.5) and lower odds of receiving coronary angiography (OR, 0.67; 95% CI, 0.59 to 0.75) and coronary artery bypass graft (OR, 0.28; 95% CI, 0.19 to 0.40).

CONCLUSION

Women were less likely to survive following OHCA secondary to AMI. Hospital protocols that minimize physician bias and improve women-physician communication are needed to close this gap.

Association of admitting physician specialty and care quality and outcomes in non-ST-segment elevation myocardial infarction (NSTEMI): insights from a national registry

AIM

Little is known about the association between admitting physician specialty and care quality and outcomes for non-ST-segment elevation myocardial infarction (NSTEMI).

METHODS AND RESULTS

We identified 288 420 patients hospitalized with NSTEMI between 2010 and 2017 in the UK Myocardial Infarction National Audit Project database. The cohort was dichotomized according to care under a non-cardiologist (n = 146 722) and care under a cardiologist (n = 141 698) within the first 24 h of admission to hospital. Patients admitted under a cardiologist were significantly younger (70 vs. 75 years, P < 0.001), and less likely to be female (32% vs. 39%, P < 0.001). Independent factors associated with admission under a cardiologist included prior history of percutaneous coronary intervention (PCI) [odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07; P = 0.04], hypercholesterolaemia (OR 1.17, 95% CI 1.15-1.20; P < 0.001), hypertension (OR 1.03, 95% CI 1.01-1.04; P = 0.01), and admission to an interventional centre (OR 3.90, 95% CI 3.79-4.00; P < 0.001). Patients admitted under cardiology were more likely to receive optimal pharmacotherapy, undergo invasive coronary angiography (79% vs. 60%, P < 0.001), and receive revascularization in the form of PCI (52% vs. 36%, P < 0.001). Following propensity score matching, odds of in-hospital all-cause mortality (OR 0.81, 95% CI 0.79-0.85; P < 0.001), re-infarction (OR 0.78, 95% CI 0.66-0.91; P = 0.001), and major adverse cardiovascular events (OR 0.81, 95% CI 0.78-0.84; P < 0.001) were lower in patients admitted under a cardiologist.

CONCLUSION

Patients with NSTEMI admitted under a cardiologist within 24 h of hospital admission were more likely to receive guideline-directed management and had better clinical outcomes.

Racial Disparities in Management and Outcomes of Out-of-Hospital Cardiac Arrest Complicating Myocardial Infarction: A National Study From England and Wales

BACKGROUND

Studies of racial disparities in care of patients admitted with an out-of-hospital cardiac arrest (OHCA) in the setting of acute myocardial infarction (AMI) have shown inconsistent results. Whether these differences in care exist in the universal healthcare system in United Kingdom is unknown.

METHODS

Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. All patients were stratified based on ethnicity into a Black, Asian, or minority ethnicity (BAME) group vs a White group. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy.

RESULTS

From 14,287 patients admitted with AMI complicated by OHCA, BAME patients constituted a minority of patients (1185 [8.3%]), compared with a White group (13,102 [91.7%]). BAME patients were younger (median age [interquartile range]) for BAME group, 58 [50-70] years; for White group, 65 [55-74] years). Cardiogenic shock (BAME group, 33%; White group, 20.7%; P < 0.001) and severe left ventricular impairment (BAME group, 21%; White group, 16.5%; P < 0.003) were more frequent among BAME patients. BAME patients were more likely to be seen by a cardiologist (BAME group, 95.9%; White group, 92.5%; P < 0.001) and were more likely to receive coronary angiography than the White group (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.2-1.88). The BAME group had significantly higher in-hospital mortality (OR 1.26, 95% CI 1.04-1.52) and re-infarction (OR 1.52, 95% CI 1.06-2.18) than the White group.

CONCLUSIONS

BAME patients were more likely to be seen by a cardiologist and receive coronary angiography than White patients. Despite this difference, the in-hospital mortality of BAME patients, particularly in the Asian population, was significantly higher.

Impact of availability of catheter laboratory facilities on management and outcomes of acute myocardial infarction presenting with out of hospital cardiac arrest

OBJECTIVES

We aimed to identify whether the availability of catheter laboratory affects clinical outcomes of out-of-hospital cardiac arrest (OHCA) complicating myocardial infarction (AMI).

METHODS

Patients admitted with a diagnosis of AMI and OHCA from the Myocardial Ischaemia National Audit Project (MINAP) between 2010 to 2017 were stratified into three groups based on initial hospital's catheter laboratory status: hospitals without a catheter laboratory (No-catheter lab hospitals), hospitals with diagnostic catheter laboratory (Diagnostic hospitals), and hospitals with PCI facilities (PCI hospitals). We used multivariable logistic regression to evaluate factors associated with clinical outcomes.

RESULTS

We included 12,303 patients of which 9,798 were admitted to PCI hospitals, 1,595 to no-catheter lab hospitals, and 910 to diagnostic hospitals. Patients admitted to PCI hospitals were more frequently reviewed by a cardiologist (96%, p < 0.001) than no-catheter lab hospitals (80%) and diagnostic hospitals (74%), and more likely to receive coronary angiography (PCI hospitals (87%), diagnostic hospitals (31%), no-catheter lab hospitals (54%), p < 0.001). They also were more likely to undergo PCI (PCI hospitals (42%), diagnostic hospitals (17%), no-catheter lab hospitals (17%), p < 0.001). After adjustment, there was no significant difference in the in-hospital mortality (OR 0.76, 95% CI 0.55-1.06) or re-infarction (OR 1.28, 95% CI 0.72-2.26) in patients admitted to PCI hospitals nor in patients admitted to diagnostic hospitals (mortality (OR 1.28, 95% CI 0.72-2.26), re-infarction (OR 1.38, 95% CI 0.68-2.82)).

CONCLUSION

There is variation in coronary angiography use between hospitals without a catheter laboratory and PCI centres, which was not associated with better in-hospital survival.

Effect of the Timing of Admission of Out of Hospital Cardiac Arrest Complicating Acute Myocardial Infarction on Management and Outcome

There is limited data regarding the impact of time of admission on clinical outcomes of out of hospital cardiac arrest (OHCA) complicating acute myocardial infarction (AMI). We investigated the patient characteristics, management, and outcomes of OHCA complicating AMI according to the time of admission. Patients admitted with a diagnosis of AMI and OHCA between 2010 and 2017 from the Myocardial Ischemia National Audit Project (MINAP) were studied. All patients were stratified into out-of-hours (OOH) and working hours (WH) cohort according to the time of hospital admission. We used multivariable logistic regression models to evaluate the predictors of clinical outcomes and treatment strategy. 16,118 patients were admitted with AMI and OHCA. The WH cohort consisted of 5,780 patients (35.9%) and OOH cohort consisted of 10,338 patients (64.1%). The OOH cohort was younger (OOH 64 vs WH 66 years, p <0.001). A significantly higher proportion of patients had a final diagnosis of STEMI in OOH cohort (OOH 78.3% vs WH 76.6%, p = 0.012). Whilst the use of coronary angiography was lower in OOH (OOH 80.7% vs WH 82.5%, p = 0.005), PCI rates were similar (OOH 39.7% vs WH 40.5%, p = 0.4). Adjusted in-hospital mortality (OR 0.96, 95%CI 0.86 to 1.07), re-infarction (OR 0.90, 95% CI 0.72 to 1.12) and bleeding (OR 0.93, 95% CI 0.76 to 1.12) were similar in the 2 groups. In conclusion, the majority of OHCA occurred out of working hours. However, the time of hospital admission didn't affect the rate of revascularization by PCI or clinical outcomes.

Effect of Location on Treatment and Outcomes of Cardiac Arrest Complicating Acute Myocardial Infarction in England & Wales

We investigated the incidence, management, and outcomes of acute myocardial infarction (AMI) patients according to cardiac arrest location. Patients admitted with a diagnosis of AMI between January 1, 2010 to March 31, 2017 from the Myocardial Ischaemia National Audit Project (MINAP) were studied. We used logistic regression models to evaluate predictors of the clinical outcomes and treatment strategy. The study population consisted of 580,796 patients admitted with AMI stratified into three groups: out of hospital cardiac arrest (OOHCA) (16,278[2.8%]), in-hospital cardiac arrest (IHCA) (21,073[3.7%]), plus a reference group consisting of those without cardiac arrest (non-cardiac arrest (543,418[93.5%]). IHCA declined steadily (from 666 per 1000 in 2010 to 477 per 1000 AMI with cardiac arrest admissions in 2017) with a commensurate rise in OOHCA (from 344 per 1000 to 533 per 1000 AMI with cardiac arrest admissions). Coronary angiography utilization (OOHCA 81.1% vs IHCA 60.3% vs non-cardiac arrest 70.4%, p < 0.001) and PCI (OOHCA 40% vs IHCA 32.8% vs non-cardiac arrest 45.2%, p < 0.001) were higher in OOHCA. In-hospital mortality odds were greatest for IHCA (OR 35.3, 95% CI 33.4-37.2) compared to OOHCA (OR 12.7, 95% CI 11.9-13.6), with the worse outcomes seen in patients on medical wards (OR 97.37, 95% CI 87.02-108.95) and the best outcomes seen in the emergency department (OR 8.35, 95% CI 7.32-9.53). In conclusion, outcomes of AMI complicated by cardiac arrest depended on cardiac arrest location, especially the outcomes of the IHCA.

Outcomes of COVID-19-positive acute coronary syndrome patients: A multisource electronic healthcare records study from England

BACKGROUND

Patients with underlying cardiovascular disease and coronavirus disease 2019 (COVID-19) infection are at increased risk of morbidity and mortality.

OBJECTIVES

This study was designed to characterize the presenting profile and outcomes of patients hospitalized with acute coronary syndrome (ACS) and COVID-19 infection.

METHODS

This observational cohort study was conducted using multisource data from all acute NHS hospitals in England. All consecutive patients hospitalized with diagnosis of ACS with or without COVID-19 infection between 1 March and 31 May 2020 were included. The primary outcome was in-hospital and 30-day mortality.

RESULTS

A total of 12 958 patients were hospitalized with ACS during the study period, of which 517 (4.0%) were COVID-19-positive and were more likely to present with non-ST-elevation acute myocardial infarction. The COVID-19 ACS group were generally older, Black Asian and Minority ethnicity, more comorbid and had unfavourable presenting clinical characteristics such as elevated cardiac troponin, pulmonary oedema, cardiogenic shock and poor left ventricular systolic function compared with the non-COVID-19 ACS group. They were less likely to receive an invasive coronary angiography (67.7% vs 81.0%), percutaneous coronary intervention (PCI) (30.2% vs 53.9%) and dual antiplatelet medication (76.3% vs 88.0%). After adjusting for all the baseline differences, patients with COVID-19 ACS had higher in-hospital (adjusted odds ratio (aOR): 3.27; 95% confidence interval (CI): 2.41-4.42) and 30-day mortality (aOR: 6.53; 95% CI: 5.1-8.36) compared to patients with the non-COVID-19 ACS.

CONCLUSION

COVID-19 infection was present in 4% of patients hospitalized with an ACS in England and is associated with lower rates of guideline-recommended treatment and significant mortality hazard.

Patient response, treatments, and mortality for acute myocardial infarction during the COVID-19 pandemic

Aim

COVID-19 might have affected the care and outcomes of hospitalised acute myocardial infarction (AMI). We aimed to determine whether the COVID-19 pandemic changed patient response, hospital treatment and mortality from AMI.

Methods and Results

Admission were classified as non ST-elevation myocardial infarction (NSTEMI) or STEMI at 99 hospitals in England through live feeding from the Myocardial Ischaemia National Audit Project between 1^st January, 2019 and 22^nd May, 2020. Time series plots were estimated using a 7-day simple moving average, adjusted for seasonality. From 23^rd March, 2020 (UK lockdown) median daily hospitalisations decreased more for NSTEMI (69 to 35; IRR 0.51, 95% CI 0.47-0.54) than STEMI (35 to 25; IRR 0.74, 95% CI 0.69-0.80) to a nadir on 19th April, 2020. During lockdown, patients were younger (mean age 68.7 years vs. 66.9 years), less frequently diabetic (24.6% vs. 28.1%) or had cerebrovascular disease (7.0% vs. 8.6%). STEMI more frequently received primary PCI (81.8% vs 78.8%%), thrombolysis was negligible (0.5% vs. 0.3%), median admission-to-coronary angiography duration for NSTEMI decreased (26.2 vs. 64.0 hours), median duration of hospitalisation decreased (4 to 2 days), secondary prevention pharmacotherapy prescription remained unchanged (each >94.7%). Mortality at 30 days increased for NSTEMI (from 5.4% to 7.5%; OR 1.41, 95% CI 1.08-1.80), but decreased for STEMI (from 10.2% to 7.7%; OR 0.73, 95% CI 0.54-0.97).

Conclusions

During COVID-19, there was a substantial decline in admissions with AMI. Those who presented to hospital were younger, less co-morbid and, for NSTEMI, had higher 30-day mortality.

Impact of Coronavirus Disease 2019 Pandemic on the Incidence and Management of Out-of-Hospital Cardiac Arrest in Patients Presenting With Acute Myocardial Infarction in England

Background Studies have reported significant reduction in acute myocardial infarction-related hospitalizations during the coronavirus disease 2019 (COVID-19) pandemic. However, whether these trends are associated with increased incidence of out-of-hospital cardiac arrest (OHCA) in this population is unknown. Methods and Results Acute myocardial infarction hospitalizations with OHCA during the COVID-19 period (February 1-May 14, 2020) from the Myocardial Ischaemia National Audit Project and British Cardiovascular Intervention Society data sets were analyzed. Temporal trends were assessed using Poisson models with equivalent pre-COVID-19 period (February 1-May 14, 2019) as reference. Acute myocardial infarction hospitalizations during COVID-19 period were reduced by >50% (n=20 310 versus n=9325). OHCA was more prevalent during the COVID-19 period compared with the pre-COVID-19 period (5.6% versus 3.6%), with a 56% increase in the incidence of OHCA (incidence rate ratio, 1.56; 95% CI, 1.39-1.74). Patients experiencing OHCA during COVID-19 period were likely to be older, likely to be women, likely to be of Asian ethnicity, and more likely to present with ST-segment-elevation myocardial infarction. The overall rates of invasive coronary angiography (58.4% versus 71.6%; P<0.001) were significantly lower among the OHCA group during COVID-19 period with increased time to reperfusion (mean, 2.1 versus 1.1 hours; P=0.05) in those with ST-segment-elevation myocardial infarction. The adjusted in-hospital mortality probability increased from 27.7% in February 2020 to 35.8% in May 2020 in the COVID-19 group (P<.001). Conclusions In this national cohort of hospitalized patients with acute myocardial infarction, we observed a significant increase in incidence of OHCA during COVID-19 period paralleled with reduced access to guideline-recommended care and increased in-hospital mortality.