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Assaf M, Costa D, Efremov L, Holland K, Mikolajczyk R. Comparison between Invasive Intervention and Conservative Treatment in Patients with In-Hospital Myocardial Infarctions: Results from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA) Study. J Clin Med 2024; 13:2194. [PMID: 38673467 PMCID: PMC11050707 DOI: 10.3390/jcm13082194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 04/28/2024] Open
Abstract
Background/Objectives: In-hospital myocardial infarctions (AMIs) are less often treated with invasive intervention, compared to out-of-hospital AMIs. We aimed to identify the determinants of invasive intervention in patients with in-hospital AMIs and assess its association with mortality, compared to conservative treatment. Methods: This was a cross-sectional study of in-hospital AMIs in The Regional Myocardial Infarction Registry of Saxony-Anhalt. Patients' characteristics and outcomes were compared based on the treatment strategy (invasive intervention vs. conservative treatment). Logistic regression was performed to assess the determinants of invasive intervention (vs. conservative treatment) and its association with 30-day mortality. Results: Nearly 67% of the patients (259/386) received invasive intervention, and the rest were treated conservatively. Those who were treated with an invasive intervention were younger and had a lower proportion of chronic heart failure than those treated conservatively. Age > 75 years compared to younger patients, pre-existing heart failure, and higher heart rate upon presentation were associated with lower odds of receiving invasive intervention. Hypertension (OR = 2.86, 95% CI [1.45-5.62]) and STEMI vs. NSTEMI (1.96, [1.10-3.68]) were associated with higher odds of invasive intervention. The adjusted odds of 30-day mortality were lower with invasive intervention compared to conservative treatment (0.25, [0.10-0.67]). Conclusions: One-third of the patients with in-hospital AMIs received conservative treatment. Younger age, absence of heart failure, lower heart rate, hypertension, and STEMI were determinants of invasive intervention usage. Invasive intervention had lower odds of 30-day mortality, but longitudinal studies are still needed to assess the efficacy of conservative vs. invasive strategies in in-hospital AMIs.
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Affiliation(s)
- Mohamad Assaf
- Institute for Medical Epidemiology, Biometrics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112 Halle (Saale), Germany; (M.A.); (D.C.); (K.H.)
| | - Daniela Costa
- Institute for Medical Epidemiology, Biometrics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112 Halle (Saale), Germany; (M.A.); (D.C.); (K.H.)
| | - Ljupcho Efremov
- German Cancer Research Center (DKFZ), 69120 Heidelberg, Germany;
| | - Karen Holland
- Institute for Medical Epidemiology, Biometrics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112 Halle (Saale), Germany; (M.A.); (D.C.); (K.H.)
| | - Rafael Mikolajczyk
- Institute for Medical Epidemiology, Biometrics and Informatics, Martin Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112 Halle (Saale), Germany; (M.A.); (D.C.); (K.H.)
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Breen TJ, Raphael CE, Ingraham B, Lane C, Huxley S, Roger VL, Jaffe A, Lewis B, Sandoval YB, Prasad A, Rihal CS, Gulati R, Singh M. Incidence and outcomes of high bleeding risk patients with type 1 and type 2 myocardial infarction in a community-based cohort: Application of the Academic Research Consortium High Bleeding Risk Criteria. Int J Cardiol 2024; 396:131565. [PMID: 37913957 PMCID: PMC10841724 DOI: 10.1016/j.ijcard.2023.131565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/29/2023] [Accepted: 10/27/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND AIMS The incidence and outcomes of high bleeding risk (HBR) patients in a community cohort according to the Academic Research Consortium (ARC) criteria is not known. We hypothesized that HBR is common and associated with worse outcomes for all-comers with myocardial infarction. METHODS We prospectively collected all patients with cardiac troponin T > 99th percentile upper limit of normal (≥0.01 ng/mL) in Olmsted County between 2003 and 2012. Events were retrospectively classified as type 1 myocardial infarction (T1MI), type 2 myocardial infarction (T2MI), or myocardial injury. Patients were further classified as HBR based on the "ARC-HBR definition." Outcomes included all-cause mortality, cardiovascular mortality, recurrent MI, stroke, and major bleeding. RESULTS 2419 patients were included in the final study; 1365 were classified as T1MI and 1054 as T2MI. Patients were followed for a median of 5.5 years. ARC-HBR was more common in T2MI than T1MI (73% vs 46%, p < 0.001). Among patients with T1MI, HBR was associated with higher all-cause mortality (HR 3.7, 95% CI 3.2-4.5, p < 0.001), cardiovascular mortality (4.7, 3.6-6.3, p < 0.001), recurrent MI (2.1, 1.6-2.7, p < 0.001), stroke (4.9, 2.9-8.4, p < 0.001), and major bleeding (6.5, 3.7-11.4, p < 0.001). For T2MI, HBR was similarly associated with higher all-cause mortality (HR 2.1, 95% CI 1.8-2.5, p < 0.001), cardiovascular mortality (2.7, 1.8-4.0, p < 0.001), recurrent MI (1.7, 1.1-2.6, p = 0.02) and major bleeding (HR 15.6, 3.8-63.8, p < 0.001). CONCLUSION HBR is common among unselected patients with T1MI and T2MI and is associated with increased overall and cardiovascular mortality, recurrent cardiovascular events, and major bleeding on long-term follow up.
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Affiliation(s)
- Thomas J Breen
- Department of Cardiovascular Medicine, Yale University, 20 York Street, New Haven, CT 06510, United States of America.
| | - Claire E Raphael
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Brenden Ingraham
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Conor Lane
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Sam Huxley
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Veronique L Roger
- Division of Intramural Research, National Heart Lung and Blood Institute, Bethesda, MD 20814, United States of America
| | - Allan Jaffe
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Bradley Lewis
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Yader B Sandoval
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Abhiram Prasad
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Charanjit S Rihal
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Rajiv Gulati
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
| | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States of America
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Ratwatte S, Ng ACC, Hyun K, Philip R, Boroumand F, Weber C, Kritharides L, Brieger D. Pre-hospital and in-hospital ST-elevation myocardial infarction from 2008 to 2020 in Australia. INTERNATIONAL JOURNAL OF CARDIOLOGY. CARDIOVASCULAR RISK AND PREVENTION 2023; 19:200214. [PMID: 37771608 PMCID: PMC10522901 DOI: 10.1016/j.ijcrp.2023.200214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 09/12/2023] [Accepted: 09/17/2023] [Indexed: 09/30/2023]
Affiliation(s)
- Seshika Ratwatte
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Austin Chin Chwan Ng
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Karice Hyun
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Robin Philip
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - Farzaneh Boroumand
- School of Mathematical and Physical Sciences, Macquarie University, NSW, Australia
| | - Courtney Weber
- School of Population and Global Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Leonard Kritharides
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
| | - David Brieger
- Department of Cardiology, Concord Repatriation General Hospital, NSW, Australia
- University of Sydney, Faculty of Medicine and Health, NSW, Australia
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Assaf M, Costa D, Massag J, Weber C, Mikolajczyk R, Lückmann SL. Comparison between In-Hospital and Out-of-Hospital Acute Myocardial Infarctions: Results from the Regional Myocardial Infarction Registry of Saxony-Anhalt (RHESA) Study. J Clin Med 2023; 12:6305. [PMID: 37834949 PMCID: PMC10573894 DOI: 10.3390/jcm12196305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/15/2023] Open
Abstract
AIMS Risk factors and outcomes of in-hospital ST elevation myocardial infraction (STEMI) are well explored. Recent findings show that non-ST elevation myocardial infarction (NSTEMI) accounts for the majority of in-hospital infarctions (IHMIs). Our aim was to identify differences between IHMI and out-of-hospital myocardial infraction (OHMI) in terms of risk factors, treatment and outcomes, including both STEMI and NSTEMI. METHODS We analyzed the Regional Myocardial Infarction Registry of Saxony-Anhalt dataset. Patient characteristics, treatments and outcomes were compared between IHMI and OHMI. The association between clinical outcomes and myocardial infarction type was assessed using generalized additive models. RESULTS Overall, 11.4% of the included myocardial infractions were IHMI, and the majority were NSTEMI. Patients with IHMI were older and had more comorbidities than those with OHMI. Compared to OHMI, in-hospital myocardial infarction was associated with higher odds of 30-day mortality (OR = 1.85, 95% CI 1.32-2.59) and complications (OR = 2.36, 95 % CI 1.84-3.01). CONCLUSIONS We provided insights on the full spectrum of IHMI, in both of its classifications. The proportion of IHMI was one ninth of all AMI cases treated in the hospital. Previously reported differences in the baseline characteristics and treatments, as well as worse clinical outcomes, in in-hospital STEMI compared to out-of-hospital STEMI persist even when including NSTEMI cases.
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Affiliation(s)
| | | | | | | | | | - Sara Lena Lückmann
- Institute for Medical Epidemiology, Biometrics and Informatics, Interdisciplinary Center for Health Sciences, Medical School of the Martin-Luther University Halle-Wittenberg, Magdeburger Str. 8, 06112 Halle, Germany; (M.A.)
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Stehli J, Dinh D, Dagan M, Dick R, Oxley S, Brennan A, Lefkovits J, Duffy SJ, Zaman S. Sex differences in treatment and outcomes of patients with in-hospital ST-elevation myocardial infarction. Clin Cardiol 2022; 45:427-434. [PMID: 35253228 PMCID: PMC9019891 DOI: 10.1002/clc.23797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND AND HYPOTHESIS Two cohorts face high mortality after ST-elevation myocardial infarction (STEMI): females and patients with in-hospital STEMI. The aim of this study was to evaluate sex differences in ischemic times and outcomes of in-hospital STEMI patients. METHODS Consecutive STEMI patients treated with percutaneous coronary intervention (PCI) were prospectively recruited from 30 hospitals into the Victorian Cardiac Outcomes Registry (2013-2018). Sex discrepancies within in-hospital STEMIs were compared with out-of-hospital STEMIs. The primary endpoint was 12-month all-cause mortality. Secondary endpoints included symptom-to-device (STD) time and 30-day major adverse cardiovascular events (MACE). To investigate the relationship between sex and 12-month mortality for in-hospital versus out-of-hospital STEMIs, an interaction analysis was included in the multivariable models. RESULTS A total of 7493 STEMI patients underwent PCI of which 494 (6.6%) occurred in-hospital. In-hospital versus out-of-hospital STEMIs comprised 31.9% and 19.9% females, respectively. Female in-hospital STEMIs were older (69.5 vs. 65.9 years, p = .003) with longer adjusted geometric mean STD times (104.6 vs. 94.3 min, p < .001) than men. Female versus male in-hospital STEMIs had no difference in 12-month mortality (27.1% vs. 20.3%, p = .92) and MACE (22.8% vs. 19.3%, p = .87). Female sex was not independently associated with 12-month mortality for in-hospital STEMIs which was consistent across the STEMI cohort (OR: 1.26, 95% CI: 0.94-1.70, p = .13). CONCLUSIONS In-hospital STEMIs are more frequent in females relative to out-of-hospital STEMIs. Despite already being under medical care, females with in-hospital STEMIs experienced a 10-min mean excess in STD time compared with males, after adjustment for confounders. Adjusted 12-month mortality and MACE were similar to males.
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Affiliation(s)
- Julia Stehli
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Epworth HealthCareRichmondVictoriaAustralia
| | - Diem Dinh
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Misha Dagan
- Department of General MedicineThe Alfred HospitalMelbourneVictoriaAustralia
| | - Ron Dick
- Epworth HealthCareRichmondVictoriaAustralia
| | | | - Angela Brennan
- School of Public Health and Preventive Medicine, Centre of Cardiovascular Research and Education in TherapeuticsMonash UniversityMelbourneVictoriaAustralia
| | - Jeffrey Lefkovits
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyRoyal Melbourne HospitalMelbourneVictoriaAustralia
| | - Stephen J. Duffy
- Nursing and Health Sciences, Faculty of MedicineMonash UniversityMelbourneVictoriaAustralia
- Department of CardiologyThe Alfred HospitalMelbourneVictoriaAustralia
| | - Sarah Zaman
- School of Clinical Sciences at Monash HealthMonash UniversityMelbourneVictoriaAustralia
- Westmead Applied Research CentreUniversity of SydneySydneyNew South WalesAustralia
- Department of CardiologyWestmead HospitalSydneyNew South WalesAustralia
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Stehli J, Dagan M, Dinh DT, Lefkovits J, Dick R, Oxley S, Brennan AL, Duffy SJ, Zaman S. Differences in outcomes of patients with in-hospital versus out-of-hospital ST-elevation myocardial infarction: a registry analysis. BMJ Open 2022; 12:e052000. [PMID: 35256441 PMCID: PMC8905957 DOI: 10.1136/bmjopen-2021-052000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES Patients with ST-elevation myocardial infarction (STEMI) that occur while already in hospital ('in-hospital STEMI') face high mortality. However, data about this patient population are scarce. We sought to investigate differences in reperfusion and outcomes of in-hospital versus out-of-hospital STEMI. DESIGN, SETTING AND PARTICIPANTS Consecutive patients with STEMI all treated with percutaneous coronary intervention (PCI) across 30 centres were prospectively recruited into the Victorian Cardiac Outcomes Registry (2013-2018). PRIMARY AND SECONDARY OUTCOMES Patients with in-hospital STEMI were compared with patients with out-of-hospital STEMI with a primary endpoint of 30-day major adverse cardiovascular events (MACE). Secondary endpoints included ischaemic times, all-cause mortality and major bleeding. RESULTS Of 7493 patients with PCI-treated STEMI, 494 (6.6%) occurred in-hospital. Patients with in-hospital STEMI were older (67.1 vs 62.4 years, p<0.001), more often women (32% vs 19.9%, p<0.001), with more comorbidities. Patients with in-hospital STEMI had higher 30-day MACE (20.4% vs 9.8%, p<0.001), mortality (12.1% vs 6.9%, p<0.001) and major bleeding (4.9% vs 2.3%, p<0.001), than patients with out-of-hospital STEMI. According to guideline criteria, patients with in-hospital STEMI achieved symptom-to-device times of ≤70 min and ≤90 min in 29% and 47%, respectively. Patients with out-of-hospital STEMI achieved door-to-device times of ≤90 min in 71%. Occurrence of STEMI while in hospital independently predicted higher MACE (adjusted OR 1.77, 95% CI 1.33 to 2.36, p<0.001) and 12-month mortality (adjusted OR 1.49, 95% CI 1.08 to 2.07, p<0.001). CONCLUSIONS Patients with in-hospital STEMI experience delays to reperfusion with significantly higher MACE and mortality, compared with patients with out-of-hospital STEMI, after adjustment for confounders. Focused strategies are needed to improve recognition and outcomes in this high-risk and understudied population.
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Affiliation(s)
- Julia Stehli
- Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
- Epworth HealthCare, Richmond, Victoria, Australia
| | - Misha Dagan
- Department of General Medicine, Alfred Health, Melbourne, Victoria, Australia
| | - Diem T Dinh
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Jeffrey Lefkovits
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Department of Cardiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ron Dick
- Epworth HealthCare, Richmond, Victoria, Australia
| | | | - Angela L Brennan
- Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Stephen J Duffy
- Cardiovascular Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sarah Zaman
- School of Clinical Sciences at Monash Health, Monash University, Clayton, VIctoria, Australia
- Westmead Applied Research Centre, University of Sydney, Sydney, New South Wales, Australia
- Cardiology Department, Westmead Hospital, Westmead, New South Wales, Australia
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Govea A, Lipinksi J, Patel MP. Prehospital Evaluation, ED Management, Transfers, and Management of Inpatient STEMI. Interv Cardiol Clin 2021; 10:293-306. [PMID: 34053616 DOI: 10.1016/j.iccl.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
ST elevation myocardial infarction diagnoses have reduced in number over the past 10 years; however, associated morbidity and mortality remain high. Societal guidelines focus on early diagnosis and timely access to reperfusion, preferably percutaneous coronary intervention (PCI), with fibrinolytics reserved for those who cannot receive timely PCI. Proposed algorithms recommend emergency department bypass in stable patients with a clear diagnosis to reduced door-to-balloon time. Emergency providers should limit their evaluation, focusing on life-threatening comorbidities, unstable vitals, or contraindications to a catheterization laboratory. In-hospital patients prove diagnostically challenging because they may be unable to express symptoms, and reperfusion strategies can complicate other diagnoses.
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Affiliation(s)
- Alayn Govea
- Division of Cardiovascular Medicine, UC San Diego, San Diego, CA, USA; UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA
| | - Jerry Lipinksi
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Department of Internal Medicine, UC San Diego, San Diego, CA, USA
| | - Mitul P Patel
- UC San Diego Sulpizio Cardiovascular Center, 9452 Medical Center Drive #7411, La Jolla, CA 92037, USA; Division of Cardiovascular Medicine, UC San Diego Cardiovascular Institute, San Diego, CA, USA.
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8
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Soldati S, Di Martino M, Castagno D, Davoli M, Fusco D. In-hospital myocardial infarction and adherence to evidence-based drug therapies: a real-world evaluation. BMJ Open 2021; 11:e042878. [PMID: 33550255 PMCID: PMC7925929 DOI: 10.1136/bmjopen-2020-042878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES This study aimed to measure adherence to chronic polytherapy following an acute myocardial infarction (AMI) and to find out associations between adherence and the setting of AMI onset (in vs out of hospital) as well as other determinants. DESIGN Retrospective follow-up study. SETTING Population living in the Lazio Region, Italy. PARTICIPANTS This study included 25 779 hospitalised patients with a first diagnosis of AMI in 2012-2016, after the exclusion of those with hospital admission for AMI or related causes in the previous 5 years. PRIMARY AND SECONDARY OUTCOME MEASURES Patients were classified as in-hospital AMI (IH-AMI) or out of hospital AMI (OH-AMI) according to present-on-admission codes. Adherence was measured based on prescription claims during a 6-month follow-up after hospital discharge, using medication possession ratio (MPR). Adherence to chronic polytherapy was defined as MPR ≥75% to at least 3 of the following medications: antithrombotics, betablockers, ACE inhibitors/angiotensin receptor blockers and statins. RESULTS Among the entire cohort, 1 044 (4%) patients suffered IH-AMI. Overall, 15 440 (60%) patients were deemed adherent to chronic polytherapy. Female gender, older age, mental disorders, renal disease, asthma and ongoing concomitant treatments were factors associated with poor adherence. By contrast, patients with more severe AMI and those already taking evidence-based (E-B) drugs were more likely to be adherent. A strong association between the setting of AMI onset and adherence was observed: IH-AMI patients were 46% less likely to be adherent to E-B medications during their 6-month follow-up as compared with OH-AMI patients (OR 0.54; 95% CI 0.47 to 0.62; p<0.001). CONCLUSION Pharmacotherapy is not consistent with clinical guidelines, especially for IH-AMI patients. Our findings provide evidence on a previously unidentified groups of patients at risk for poor adherence, who might benefit from greater medical attention and dedicated healthcare interventions.
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Affiliation(s)
- Salvatore Soldati
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Davide Castagno
- Division of Cardiology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Rome, Italy
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Levine GN, Dai X, Henry TD, Calfon Press M, Denktas AE, Garberich RF, Jacobs AK, Jaski BE, Kaul P, Kontos MC, Stouffer GA, Smith SC. In-Hospital ST-Segment Elevation Myocardial Infarction: Improving Diagnosis, Triage, and Treatment. JAMA Cardiol 2019; 3:527-531. [PMID: 29466558 DOI: 10.1001/jamacardio.2017.5356] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Importance In-hospital ST-segment elevation myocardial infarction (STEMI) is a unique clinical entity with epidemiology, incidence, and outcomes distinct from that of out-of-hospital STEMI and has only within the past 10 years begun to receive increased attention and research. Patients with in-hospital STEMI are older, have more comorbidities, and more frequently have coagulopathies and contraindications for anticoagulation and fibrinolytic therapy. A standardized clinical definition of in-hospital STEMI is lacking. The objectives of this special communication are to (1) summarize the knowledge base regarding in-hospital STEMI; (2) review the challenges of diagnosis and treatment of patients with in-hospital STEMI; (3) present a standardized clinical definition for in-hospital STEMI; and (4) provide a quality improvement protocol to improve diagnosis, triage, and treatment of patients with in-hospital STEMI. Observations Patients with in-hospital STEMI less frequently present with typical angina symptoms, and an electrocardiogram is often obtained owing to changes in clinical status, changes on telemetry, or a finding of elevated cardiac biomarker. The frequent nontypical presentations often lead to substantial delays in the diagnosis of STEMI. Only 34% to 71% of patients with in-hospital STEMI undergo diagnostic catheterization, and only 22% to 56% undergo percutaneous coronary intervention. Even in contemporary reports, some studies report in-hospital mortality in the range of 31% to 42%. Three areas of delay in the treatment of patients with in-hospital STEMI that merit particular attention are (1) delays in electrocardiogram acquisition, (2) delays in electrocardiogram interpretation, and (3) delays in activation of existing STEMI systems of care. Conclusions and Relevance Treatment of patients with in-hospital STEMI is more complex and challenging than treatment of patients who develop out-of-hospital STEMI, leading to delays in diagnosis and triage and less frequent use of reperfusion therapy. Quality improvement programs targeted at decreasing delays and streamlining treatment of such patients may improve treatment and outcome.
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Affiliation(s)
| | - Xuming Dai
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
| | | | - Marcella Calfon Press
- Cardiology Division, Department of Medicine, Ronald Reagan Medical Center, University of California, Los Angeles in Westwood
| | | | - Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, Minnesota
| | | | - Brian E Jaski
- San Diego Cardiac Center, Sharp Memorial Hospital, San Diego, California
| | | | | | - George A Stouffer
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
| | - Sidney C Smith
- Division of Cardiology, McAllister Heart Institute, University of North Carolina at Chapel Hill
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10
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Lykov YV, Dyatlov NV, Morozova TE, Dvoretsky LI. [In-hospital Myocardial Infarction: Scale of the Problem]. KARDIOLOGIIA 2019; 59:52-60. [PMID: 31322090 DOI: 10.18087/cardio.2019.7.2645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/19/2019] [Indexed: 06/10/2023]
Abstract
All cases of acute myocardial infarction (AMI) can be divided into outpatient-onset AMI and in-hospital-onset AMI depending on the place and circumstances of their development. In this review we consider the problem of in-hospital AMI. Special attention is paid to specific features of its clinical manifestations and the scale of the clinical problem. Possible causes of difficulties in the diagnosis and treatment of this condition are presented in comparison with those in patients with outpatient-onset AMI.
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Affiliation(s)
- Yu V Lykov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - N V Dyatlov
- Sechenov First Moscow State Medical University (Sechenov University)
| | - T E Morozova
- Sechenov First Moscow State Medical University (Sechenov University)
| | - L I Dvoretsky
- Sechenov First Moscow State Medical University (Sechenov University)
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11
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Tahir K, Pauley E, Dai X, Smith SC, Sweeney C, Stouffer GA. Mechanisms of ST Elevation Myocardial Infarction in Patients Hospitalized for Noncardiac Conditions. Am J Cardiol 2019; 123:1393-1398. [PMID: 30773247 DOI: 10.1016/j.amjcard.2019.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
ST elevation myocardial infarction (STEMI) occurring in patients hospitalized for a noncardiac condition is associated with a high mortality rate and thus we sought to determine the mechanisms underlying STEMI in this patient population. This is a single center retrospective study of 70 patients who had STEMI while hospitalized on a noncardiac service and underwent coronary angiography. Thrombotic in-hospital STEMI was defined by angiographic or intravascular imaging evidence of intracoronary thrombus, plaque rupture, or stent thrombosis. Thirty-six (51%) inpatient STEMIs developed in the operating room or various postoperative stages and 6 (9%) after endoscopy or a percutaneous procedure. Thrombotic etiologies were found in 39 (56%) patients. Nonthrombotic etiologies included vasospasm, supply-demand mismatch, and takotsubo cardiomyopathy. Patients in the thrombotic group were more likely to have antiplatelet medications discontinued on admission, had higher peak troponin levels and were more likely to undergo percutaneous coronary intervention than patients in the nonthrombotic group. Exposure to vasopressors, time from ECG to angiography, post-STEMI ejection fraction, length of stay, and in-hospital mortality were similar in both groups. There was no difference in the use of percutaneous coronary intervention in patients but longer ECG to coronary angiography times and fivefold higher in-hospital mortality in thrombotic inpatient STEMI compared with 643 patients who presented with an out-of-hospital STEMI during the same time period. In conclusion, thrombotic and nonthrombotic mechanisms cause STEMI in hospitalized patients and are associated with a high mortality.
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Bradley SM, Borgerding JA, Wood GB, Maynard C, Fihn SD. Incidence, Risk Factors, and Outcomes Associated With In-Hospital Acute Myocardial Infarction. JAMA Netw Open 2019; 2:e187348. [PMID: 30657538 PMCID: PMC6484558 DOI: 10.1001/jamanetworkopen.2018.7348] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
IMPORTANCE Studies of acute myocardial infarction (AMI) occurring outside the hospital have informed approaches to addressing risk, treatment, and patient outcomes. Similar insights for in-hospital AMI are lacking. OBJECTIVE To determine the incidence, risk factors, and outcomes associated with in-hospital AMI. DESIGN, SETTING, AND PARTICIPANTS Cohort, nested case-control, and matched cohort study of patients hospitalized in US Veterans Health Administration facilities between July 2007 and September 2009. The incidence of in-hospital AMI was determined from a complete cohort of in-hospital AMI relative to the total number of inpatient admissions. From the in-hospital AMI cohort, detailed medical record review was performed on 687 cases and 687 individually matched controls. Risk factors and outcomes associated with in-hospital AMI were determined from matched comparison of in-hospital AMI cases to hospitalized controls. EXPOSURES Candidate risk factors for in-hospital AMI included characteristics at the time of admission and in-hospital variables prior to the index date. MAIN OUTCOMES AND MEASURES In the determination of the incidence and risk factors associated with in-hospital AMI, the outcome of interest was in-hospital AMI. All-cause mortality was the main outcome of interest following in-hospital AMI. RESULTS A total of 5556 patients with in-hospital AMI (mean [SD] age, 73 [10] years; 5456 [98.2%] male) were identified among 1.3 million admissions, with an incidence of 4.27 in-hospital AMI events per 1000 admissions. Independent risk factors associated with in-hospital AMI included intensive care unit setting, history of coronary artery disease, heart rate greater than 100 beats/min, hemoglobin level less than 8 g/dL, and white blood cell count 14 000/μL or greater. Compared with the matched control group, mortality was significantly higher for patients with in-hospital AMI (in-hospital mortality, 26.4% vs 4.2%; 30-day mortality, 33.0% vs 10.0%; 1-year mortality, 59.2% vs 34.4%). CONCLUSIONS AND RELEVANCE In-hospital AMI was common and associated with common cardiovascular risk factors and markers of acute illness. Patient outcomes following in-hospital AMI were poor, with 1-year mortality approaching 60%. Further study of in-hospital AMI may yield opportunities to reduce in-hospital AMI risk and improve patient outcomes.
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Affiliation(s)
- Steven M. Bradley
- Minneapolis Heart Institute, Minneapolis, Minnesota
- Minneapolis Heart Institute Foundation, Minneapolis, Minnesota
| | | | - G. Blake Wood
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Charles Maynard
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington
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13
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Dai X, Garberich RF, Jaski BE, Smith SC, Henry TD. In-Hospital ST Elevation Myocardial Infarction: Clinical Characteristics, Management Challenges, and Outcome. Interv Cardiol Clin 2017; 5:471-480. [PMID: 28581996 DOI: 10.1016/j.iccl.2016.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Timely reperfusion therapy reduces complications and improves survival in ST elevation myocardial infarction (STEMI). An effective chain of survival has been established for STEMIs occur in the community (outpatient STEMI). Recent studies have identified a subgroup of patients who develop STEMI while hospitalized for primary conditions, often not directly related to coronary artery disease (in-hospital STEMI or inpatient STEMI). This article summarizes current understanding of patient demographics, clinical characteristics, care delivery system and outcomes of in-hospital STEMI, comparing with outpatient STEMI. We also identified opportunities for quality improvement and proposed strategies and future directions to improve care for these patients.
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Affiliation(s)
- Xuming Dai
- Division of Cardiology, University of North Carolina at Chapel Hill, 160 Dental Circle, Chapel Hill, NC 27599, USA.
| | - Ross F Garberich
- Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, 920 East 28th Street, Suite 100, Minneapolis, MN 55407, USA
| | - Brian E Jaski
- San Diego Cardiac Center, Sharp Healthcare, 3131 Berger Avenue, San Diego, CA 92123, USA
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina at Chapel Hill, 160 Dental Circle, Chapel Hill, NC 27599, USA
| | - Timothy D Henry
- Cedars-Sinai Heart Institute, 127 South San Vicente Boulevard, Suite A3100, Los Angeles, CA 90048, USA
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14
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Jaski BE, Grigoriadis CE, Dai X, Meredith RD, Ortiz BC, Stouffer GA, Thomas L, Smith SC. Factors Associated With Ineligibility for PCI Differ Between Inpatient and Outpatient ST-Elevation Myocardial Infarction. J Interv Cardiol 2016; 29:363-9. [PMID: 27364755 DOI: 10.1111/joic.12306] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES Without early revascularization, both inpatient and outpatient STEMIs have poor outcomes. Reasons for denying PCI for STEMI, however, remain uncertain. This single-center retrospective cohort study compares factors and outcomes associated with ineligibility for PCI between inpatients and outpatients following ST-elevation myocardial infarction (STEMI). METHODS A total of 1,759 STEMI patients between June 2009 and January 2015 were assessed. Individual medical records were reviewed to obtain reasons for PCI ineligibility for STEMI patients who did not receive reperfusion therapy. RESULTS Compared to outpatients with STEMI (n = 1,688), inpatients (n = 71) were less likely to receive coronary angiography (60.6% vs 95.9%; P < 0.001) or PCI (50.7% vs 80.9%; P < 0.001), with longer ECG/door to first device activation times (97 [78, 131] vs 63 [49, 78] minutes; P < 0.001). When coronary angiography was performed, however, similar rates of PCI and procedural success were seen in both groups. Principal contraindication for PCI was risk of bleeding within the inpatient population and complex coronary artery disease within the outpatient population. Total in-hospital mortality was higher in inpatient STEMIs compared to outpatients (42.2% vs 10.0%; P < 0.001), but lower for patients eligible for PCI in both groups. CONCLUSIONS Reasons for PCI ineligibility differ between inpatient and outpatient STEMIs. Inpatients have increased risks of bleeding, lower coronary angiography and PCI use, and higher in-hospital mortality. Especially for inpatients, specific PCI STEMI protocols that anticipate and overcome types of ineligibility and delay for cardiac catheterization may improve outcomes.
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Affiliation(s)
- Brian E Jaski
- Sharp Healthcare, San Diego, California.,San Diego Cardiac Center, San Diego, California
| | | | - Xuming Dai
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | | | - Sidney C Smith
- University of North Carolina, Chapel Hill, North Carolina
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15
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Bekelis K, Missios S, Coy S, MacKenzie TA. Comparison of outcomes of patients with inpatient or outpatient onset ischemic stroke. J Neurointerv Surg 2016; 8:1221-1225. [PMID: 26733583 DOI: 10.1136/neurintsurg-2015-012145] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2015] [Revised: 11/27/2015] [Accepted: 12/02/2015] [Indexed: 11/03/2022]
Abstract
BACKGROUND Reperfusion times for ischemic stroke occurring in the outpatient setting have improved significantly in recent years. However, quality improvement efforts have largely ignored ischemic stroke occurring in patients hospitalized for unrelated indications. METHODS We performed a cohort study involving patients with ischemic stroke (with inpatient or outpatient onset) from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. A propensity score-adjusted regression analysis was used to assess the association of location of onset and outcomes. Mixed effects methods were employed to control for clustering at the hospital level. RESULTS Of the 176 571 ischemic strokes, 160 157 (90.7%) occurred outside of a hospital and 16 414 (9.3%) occurred in patients hospitalized for unrelated indications. Using a logistic regression model with propensity score adjustment, we demonstrated that inpatient stroke onset was associated with increased inpatient mortality (OR 3.09; 95% CI 2.81 to 3.38), rate of discharge to rehabilitation (OR 2.57; 95% CI 2.37 to 2.79), and length of stay (LOS) (β=11.58; 95% CI 10.73 to 12.42). In addition, it was associated with lower odds (OR 0.69; 95% CI 0.62 to 0.77) of undergoing stroke-related interventions (mechanical thrombectomy and intravenous tissue plasminogen activator) compared with outpatient stroke onset. CONCLUSIONS Using a comprehensive all-payer cohort of patients with ischemic stroke in New York State, we identified an association of inpatient stroke onset with fewer stroke-related interventions and increased mortality, rate of discharge to rehabilitation, and LOS.
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Affiliation(s)
- Kimon Bekelis
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA
| | - Symeon Missios
- Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA
| | - Shannon Coy
- Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Todd A MacKenzie
- The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, USA.,Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA.,Department of Community and Family Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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16
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Dai X, Kaul P, Smith SC, Stouffer GA. Predictors, treatment, and outcomes of STEMI occurring in hospitalized patients. Nat Rev Cardiol 2015; 13:148-54. [PMID: 26525542 DOI: 10.1038/nrcardio.2015.165] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
ST-segment elevation myocardial infarction (STEMI) is most commonly caused by an acute thrombotic occlusion of a coronary artery. For patients in whom the onset of STEMI occurs outside of hospital (outpatient STEMI), early reperfusion therapy with either fibrinolysis or primary percutaneous coronary intervention reduces complications and improves survival, compared with delayed reperfusion. STEMI systems of care are defined as integrated groups of separate entities focused on reperfusion therapy for STEMI, generally including emergency medical services, emergency medicine, cardiology, nursing, and hospital administration. These systems of care have been successful at reducing total ischaemia time and outpatient STEMI mortality. By contrast, much less is known about STEMI that occurs in hospitalized patients (inpatient STEMI), which has unique clinical features and much worse outcomes than outpatient STEMI. Inpatient STEMI is associated with older age, a higher female:male ratio, and more comorbidities than outpatient STEMI. Delays in diagnosis and infrequent use of reperfusion therapy probably also contribute to unfavourable outcomes for inpatient STEMI.
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Affiliation(s)
- Xuming Dai
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599-7075, USA
| | - Prashant Kaul
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599-7075, USA
| | - Sidney C Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599-7075, USA
| | - George A Stouffer
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599-7075, USA
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17
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Levitan EB, Olubowale OT, Gamboa CM, Rhodes JD, Brown TM, Muntner P, Deng L, Safford MM. Characteristics and prognosis of acute myocardial infarction by discharge diagnosis: the Reasons for Geographic and Racial Differences in Stroke study. Ann Epidemiol 2015; 25:499-504.e1. [PMID: 25770061 DOI: 10.1016/j.annepidem.2015.02.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 01/06/2015] [Accepted: 02/04/2015] [Indexed: 10/24/2022]
Abstract
PURPOSE To compare the characteristics and prognosis of acute myocardial infarctions (AMIs) that were not the primary reason for hospitalization, and thus not primary discharge diagnosis, to AMIs that were the primary reason for hospitalization. METHODS Primary discharge diagnoses for Reasons for Geographic and Racial Differences in Stroke study participants (black and white men and women age ≥45 years) with adjudicated AMIs were categorized as "AMI" or "other". Cox models were used to compare mortality up to 5 years post-AMI between primary discharge diagnoses of AMI and other. RESULTS Of 871 AMIs, primary discharge diagnosis was not AMI in 550 (63%). When primary discharge diagnosis was not AMI, average troponin elevations were smaller and heart failure was more common. Adjusted for participant and hospitalization characteristics, all-cause, coronary heart disease, and cardiovascular disease mortality after AMI were similar between groups (hazard ratios [95% confidence intervals]: 1.08 [0.80-1.47]; 1.29 [0.76-2.18]; and 0.86 [0.58-1.27], respectively). CONCLUSIONS Studies limited to individuals with primary discharge diagnosis of AMI may underestimate the burden of AMI and exclude a group with elevated risk of all-cause, coronary heart disease, and cardiovascular disease mortality.
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Affiliation(s)
- Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham.
| | | | - Christopher M Gamboa
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - J David Rhodes
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham
| | - Todd M Brown
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - Luqin Deng
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham
| | - Monika M Safford
- Division of Preventive Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham
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18
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Yun H, Safford MM, Brown TM, Farkouh ME, Kent S, Sharma P, Kilgore M, Bittner V, Rosenson RS, Delzell E, Muntner P, Levitan EB. Statin use following hospitalization among Medicare beneficiaries with a secondary discharge diagnosis of acute myocardial infarction. J Am Heart Assoc 2015; 4:jah3848. [PMID: 25666367 PMCID: PMC4345859 DOI: 10.1161/jaha.114.001208] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Patients with coronary heart disease are recommended to use statins following hospital discharge. Acute myocardial infarction (AMI) is a common complication of hospitalization, but the use of statins following discharge among patients who were not initially hospitalized for AMI has not been assessed adequately. Methods and Results Using the Medicare 5% national random sample, we determined statin use among beneficiaries who were hospitalized and who had a secondary discharge diagnosis of AMI and among beneficiaries who had a primary discharge diagnosis of AMI, coronary artery bypass grafting, or percutaneous coronary intervention in 2007–2009. Statin use was defined by a pharmacy (Medicare Part D) claim within 90 days following discharge. Of 8175 Medicare beneficiaries who did not take statins prior to hospitalization, 31.2% with AMI as a secondary discharge diagnosis, 60.5% with AMI as the primary discharge diagnosis, 67.6% with coronary artery bypass grafting, and 63.9% with a percutaneous coronary intervention initiated statins. After multivariable adjustment, the risk ratio for statin initiation comparing beneficiaries with a secondary versus primary discharge diagnosis of AMI was 0.59 (95% CI 0.54 to 0.65). Among 5468 Medicare beneficiaries taking statins prior to hospitalization, statin use following discharge was lower for those with AMI as a secondary discharge diagnosis (71.8%) compared with their counterparts with AMI, coronary artery bypass grafting, and percutaneous coronary intervention (84.1%, 83.8%, and 87.3%, respectively) as the primary discharge diagnosis. Conclusion Medicare beneficiaries with a secondary hospital discharge diagnosis of AMI were less likely to fill statins compared with those with other coronary heart disease events.
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Affiliation(s)
- Huifeng Yun
- Department of Epidemiology, University of Alabama-Birmingham, Birmingham, AL (H.Y., S.K., P.S., E.D., P.M., E.B.L.)
| | - Monika M Safford
- School of Medicine, University of Alabama-Birmingham, Birmingham, AL (M.M.S., T.M.B., V.B.)
| | - Todd M Brown
- School of Medicine, University of Alabama-Birmingham, Birmingham, AL (M.M.S., T.M.B., V.B.)
| | - Michael E Farkouh
- Icahn School of Medicine at Mount Sinai, New York, NY (M.E.F., R.S.R.) Peter Munk Cardiac Centre and Heart and Stroke Richard Lewar Centre, University of Toronto, Toronto, Ontario, Canada (M.E.F.)
| | - Shia Kent
- Department of Epidemiology, University of Alabama-Birmingham, Birmingham, AL (H.Y., S.K., P.S., E.D., P.M., E.B.L.)
| | - Pradeep Sharma
- Department of Epidemiology, University of Alabama-Birmingham, Birmingham, AL (H.Y., S.K., P.S., E.D., P.M., E.B.L.)
| | - Meredith Kilgore
- Department of Health Care Organization and Policy, University of Alabama-Birmingham, Birmingham, AL (M.K.)
| | - Vera Bittner
- School of Medicine, University of Alabama-Birmingham, Birmingham, AL (M.M.S., T.M.B., V.B.)
| | - Robert S Rosenson
- Icahn School of Medicine at Mount Sinai, New York, NY (M.E.F., R.S.R.)
| | - Elizabeth Delzell
- Department of Epidemiology, University of Alabama-Birmingham, Birmingham, AL (H.Y., S.K., P.S., E.D., P.M., E.B.L.)
| | - Paul Muntner
- Department of Epidemiology, University of Alabama-Birmingham, Birmingham, AL (H.Y., S.K., P.S., E.D., P.M., E.B.L.)
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama-Birmingham, Birmingham, AL (H.Y., S.K., P.S., E.D., P.M., E.B.L.)
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19
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Shabani F, Farrier AJ, Smith R, Venkatesan M, Thomas C, Uzoigwe CE, Isaac S, Chami G. Hip fractures sustained in hospital: comorbidities and outcome. Postgrad Med J 2014; 91:61-4. [PMID: 25550523 DOI: 10.1136/postgradmedj-2014-132674] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Guidelines on the management of hip fracture in the elderly focus on fractures suffered in the community. Between 4% and 7% of hip fractures occur in hospital. Mortality is higher in those who sustain hip fracture in hospital than those who sustain a fracture in the community. However, it is not known if sustaining a nosocomial fracture is an independent risk factor for a poor outcome. OBJECTIVE To compare outcomes of hip fracture sustained in the community and sustained while in hospital for another reason. After adjusting for confounders, we sought to determine if sustaining a fracture in hospital was an independent risk factor for a poor outcome. METHODS Using the National Hip Fracture Database, we identified all patients admitted to Leicester Royal Infirmary with hip fracture between July 2009 and February 2013. We extracted demographic data, details of comorbidity, and 30-day and long-term mortality. Age, gender, American Society of Anaesthesiologists (ASA) grade, time to surgery, and survival were compared between patients with hospital-acquired and those with community-acquired hip fracture. RESULTS During the study period, 2987 patients were treated for hip fracture; 2984 were included in the study. Of these, 261 (8.7%) sustained the fracture while in hospital. Those who sustained the fracture in hospital were more commonly men (106/261 (41%)) than those with a community-acquired fracture (738/2723 (27%)) and had a worse ASA grade (III or IV, 215/230 (93%) vs 1647/2573 (64%)). Thirty-day mortality was higher in those with a hospital-acquired fracture (48/261 (18%)) than in those with a community-acquired fracture (212/2723 (7.8%)) (p<0.001). However, after adjustment for confounding variables, the association between hip fracture, in-hospital and 30-day mortality was not significant: OR 1.2 (95% CI 0.8 to 2.0), p=0.40. Longer-term mortality was associated with hip fracture in hospital after adjustment for confounding variables in multivariate proportional hazards regression: HR 1.5 (95% CI 1.2 to 1.8), p<0.001. CONCLUSIONS Patients who sustain hip fractures in hospital are unsurprisingly sicker than those who sustain hip fractures in the community. Although being in hospital is not an independent risk factor, this easily identifiable group of patients are at particular risk of a poor outcome. We suggest that it might be appropriate to consider modifying the guidelines for treatment of hip fracture for this group in an attempt to improve outcome.
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Affiliation(s)
| | - Adam J Farrier
- CT2 Orthopaedic Surgery, University Hospitals of North Tees, Stockton-on-Tees, UK
| | | | | | - Christopher Thomas
- ST3 Trauma and Orthopaedics, University Hospitals of Coventry and Warwick, Birmingham, UK
| | | | | | - George Chami
- Department of Orthopaedic and Trauma Surgery, NHS Tayside, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
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Kaul P, Federspiel JJ, Dai X, Stearns SC, Smith SC, Yeung M, Beyhaghi H, Zhou L, Stouffer GA. Association of inpatient vs outpatient onset of ST-elevation myocardial infarction with treatment and clinical outcomes. JAMA 2014; 312:1999-2007. [PMID: 25399275 PMCID: PMC4266685 DOI: 10.1001/jama.2014.15236] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
IMPORTANCE Reperfusion times for ST-elevation myocardial infarction (STEMI) occurring in outpatients have improved significantly, but quality improvement efforts have largely ignored STEMI occurring in hospitalized patients (inpatient-onset STEMI). OBJECTIVE To define the incidence and variables associated with treatment and outcomes of patients who develop STEMI during hospitalization for conditions other than acute coronary syndromes (ACS). DESIGN, SETTING, AND PARTICIPANTS Retrospective observational analysis of STEMIs occurring between 2008 and 2011 as identified in the California State Inpatient Database. EXPOSURES STEMIs were classified as inpatient onset or outpatient onset based on present-on-admission codes. Patients who had a STEMI after being hospitalized for ACS were excluded from the analysis. MAIN OUTCOMES AND MEASURES Regression models were used to evaluate associations among location of onset of STEMI, resource utilization, and outcomes. Adjustments were made for patient age, sex, comorbidities, and hospital characteristics. The analysis allowed for the location of inpatient STEMI to have a multiplicative rather than an additive effect for resource utilization since these measures were highly skewed. RESULTS A total of 62,021 STEMIs were identified in 303 hospitals, of which 3068 (4.9%) occurred in patients hospitalized for non-ACS indications. Patients with inpatient-onset STEMI were older (mean, 71.5 [SD, 13.5] years vs 64.9 [SD, 14.1] years; P < .001) and more frequently female (47.4% vs 32%; P < .001) than those with outpatient-onset STEMI. Patients with inpatient-onset STEMI had higher in-hospital mortality (33.6% vs 9.2%; adjusted odds ratio (AOR), 3.05; 95% CI, 2.76-3.38; P < .001), were less likely to be discharged home (33.7% vs 69.4%; AOR, 0.38; 95% CI, 0.34-0.42; P < .001), and were less likely to undergo cardiac catheterization (33.8% vs 77.8%; AOR, 0.19; 95% CI, 0.16-0.21; P < .001) or percutaneous coronary intervention (21.6% vs 65%; AOR, 0.23; 95% CI, 0.21-0.26; P < .001). Length of stay and inpatient charges were higher for inpatient-onset STEMI (mean length of stay, 13.4 days [95% CI, 12.8-14.0 days] vs 4.7 days [95% CI, 4.6-4.8 days]; adjusted multiplicative effect, 2.51; 95% CI, 2.35-2.69; P < .001; mean inpatient charges, $245,000 [95% CI, $235,300-$254,800] vs $129,000 [95% CI, $127,900-$130,100]; adjusted multiplicative effect, 2.09; 95% CI, 1.93-2.28; P < .001). CONCLUSIONS AND RELEVANCE Patients who had a STEMI while hospitalized for a non-ACS condition, compared with those with onset of STEMI as an outpatient, were less likely to undergo invasive testing or intervention and had a higher in-hospital mortality rate.
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Affiliation(s)
- Prashant Kaul
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Jerome J. Federspiel
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Xuming Dai
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Sally C. Stearns
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
- Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, NC
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Michael Yeung
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Hadi Beyhaghi
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
| | - Lei Zhou
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC
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Garberich RF, Traverse JH, Claussen MT, Rodriguez G, Poulose AK, Chavez IJ, Rutten-Ramos S, Hildebrandt DA, Henry TD. ST-elevation myocardial infarction diagnosed after hospital admission. Circulation 2014; 129:1225-32. [PMID: 24389237 DOI: 10.1161/circulationaha.113.005568] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Treatment times for ST-elevation myocardial infarction (STEMI) patients presenting to percutaneous coronary intervention hospitals have improved dramatically over the past 10 years, particularly for patients using emergency medical services. Limited data exist regarding treatment times and outcomes for patients who develop STEMI after hospital admission. METHODS AND RESULTS With the use of a comprehensive prospective regional STEMI program database, we evaluated the characteristics and outcomes for patients who develop STEMI after hospital admission. Of the 3795 consecutive STEMI patients treated by the use of the Minneapolis Heart Institute regional STEMI program from March 2003 to January 2013, 990 (26.1%) presented initially to the percutaneous coronary intervention facility, including 640 arriving via emergency medical services, 267 self/family driven, and 83 already admitted to the hospital. Patients with in-hospital presentation were older with higher body mass indexes, were more likely to have hypertension, and to present with pre-percutaneous coronary intervention cardiac arrest and cardiogenic shock. Door-to-balloon times (diagnostic ECG-to-balloon for in-hospital patients) were longer than for patients using emergency medical services (76 versus 51 minutes; P<0.001), but similar to self/family-driven patients (76 versus 66 minutes; P=0.13). In-hospital patients had longer lengths of stay (5 versus 3 versus 3 days; P<0.001) and higher 1-year mortality (16.9% versus 10.3% versus 7.1%; P=0.032). These patients frequently had high-risk and complex reasons for admission, including 30.1% with acute coronary syndrome, 22.9% postsurgery, 13.3% respiratory failure, and 8.4% ventricular fibrillation. CONCLUSIONS Patients who develop STEMI while in-hospital represent a unique, high-risk subset of patients. They have increased treatment time and lengths of stay and higher mortality rates than the patients presenting via emergency medical services or who are self/family driven.
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Affiliation(s)
- Ross F Garberich
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital, Minneapolis, MN
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22
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Low frequency mechanical actuation accelerates reperfusion in-vitro. Biomed Eng Online 2013; 12:121. [PMID: 24257116 PMCID: PMC4222658 DOI: 10.1186/1475-925x-12-121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2013] [Accepted: 11/12/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rapid restoration of vessel patency after acute myocardial infarction is key to reducing myocardial muscle death and increases survival rates. Standard therapies include thrombolysis and direct PTCA. Alternative or adjunctive emergency therapies that could be initiated by minimally trained personnel in the field are of potential clinical benefit. This paper evaluates a method of accelerating reperfusion through application of low frequency mechanical stimulus to the blood carrying vessels. MATERIALS AND METHOD We consider a stenosed, heparinized flow system with aortic-like pressure variations subject to direct vessel vibration at the occlusion site or vessel deformation proximal and distal to the occlusion site, versus a reference system lacking any form of mechanical stimulus on the vessels. RESULTS The experimental results show limited effectiveness of the direct mechanical vibration method and a drastic increase in the patency rate when vessel deformation is induced. For vessel deformation at occlusion site 95% of clots perfused within 11 minutes of application of mechanical stimulus, for vessel deformation 60 centimeters from the occlusion site 95% percent of clots perfused within 16 minutes of stimulus application, while only 2.3% of clots perfused within 20 minutes in the reference system. CONCLUSION The presented in-vitro results suggest that low frequency mechanical actuation applied during the pre-hospitalization phase in patients with acute myocardial infarction have potential of being a simple and efficient adjunct therapy.
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Dai X, Bumgarner J, Spangler A, Meredith D, Smith SC, Stouffer GA. Acute ST-elevation myocardial infarction in patients hospitalized for noncardiac conditions. J Am Heart Assoc 2013; 2:e000004. [PMID: 23557748 PMCID: PMC3647284 DOI: 10.1161/jaha.113.000004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Major advances have been made in the treatment of ST‐elevation myocardial infarction (STEMI) in outpatients. In contrast, little is known about outcomes in STEMI that occur in patients hospitalized for a noncardiac condition. Methods and Results This was a retrospective, single‐center study of inpatient STEMIs from January 1, 2007, to July 31, 2011. Forty‐eight cases were confirmed to be inpatient STEMIs of a total of 139 410 adult discharges. These patients were older and more often female and had higher rates of chronic kidney disease and prior cerebrovascular events compared with 227 patients with outpatient STEMIs treated during the same period. Onset of inpatient STEMI was heralded most frequently by a change in clinical status (60%) and less commonly by patient complaints (33%) or changes on telemetry. Coronary angiography and percutaneous coronary intervention were performed in 71% and 56% of patients, respectively. The median time to obtain ECG (41 [10, 600] versus 5 [2, 10] minutes; P<0.001), ECG to angiography time (91 [26, 209] versus 35 [25, 46] minutes; P<0.001) and ECG to first device activation (FDA) (129 [65, 25] versus 60 [47, 76] minutes; P<0.001) were longer for inpatient versus outpatient STEMI. Survival to discharge was lower for inpatient STEMI (60% versus 96%; P<0.001), and this difference persisted after adjusting for potential confounders. Conclusions Patients who develop a STEMI while hospitalized for a noncardiac condition are older and more often female, have more comorbidities, have longer ECG‐to‐FDA times, and are less likely to survive than patients with an outpatient STEMI.
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Affiliation(s)
- Xuming Dai
- Division of Cardiology, University of North Carolina, Chapel Hill, NC 27599-7075, USA
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24
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Politi A, Martinoni A, Klugmann S, Zanini R, Onofri M, Guagliumi G, Fiorentini C, Lettieri C, Belli G, Piccaluga E, De Cesare N, D'Urbano M, Ettori F, Repetto A, Musumeci G, Castiglioni B, Colombo P, Passamonti E, Bramucci E, Cattaneo L, Ferrari G, Repetto S, Bartorelli A, Pirelli S, De Servi S. LombardIMA: a regional registry for coronary angioplasty in ST-elevation myocardial infarction. J Cardiovasc Med (Hagerstown) 2011; 12:43-50. [DOI: 10.2459/jcm.0b013e328340334d] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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25
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Bernardi G, Di Chiara A, Armellini I. The Acute Myocardial Infarction with ST Segment Elevation Udine Registry (Come-to-Udine): predictors of 3 years mortality. J Cardiovasc Med (Hagerstown) 2009; 10:474-84. [DOI: 10.2459/jcm.0b013e32832a56c9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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26
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Siegel RJ, Luo H. Ultrasound thrombolysis. ULTRASONICS 2008; 48:312-20. [PMID: 18462769 DOI: 10.1016/j.ultras.2008.03.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2007] [Revised: 03/06/2008] [Accepted: 03/09/2008] [Indexed: 05/08/2023]
Abstract
Ultrasound energy for thrombolysis dates back to 1976. Trubestein et al. demonstrated first in vitro that a rigid wire delivery low frequency ultrasound energy could disrupt clot. These investigators also showed that this system had potential for peripheral arterial clot dissolution in vivo in animal studies [G. Trubestein, C. Engel, F. Etzel, Clinical Science 51 (1976) 697s-698s]. Subsequently, four basic approaches to ultrasonic thrombolysis have been pursued--two without pharmacological agents: (1) catheter-delivered external transducer ultrasound, (2) transcutaneous-delivered HIFU external ultrasound without drug delivery and ultrasound in conjunction with thrombolytic drugs and/or microbubbles or other agents, (3) Catheter-delivered transducer-tipped ultrasound with local drug delivery, and (4) transcutaneous-delivered low frequency ultrasound with concomitant systemic (intravenous) drug delivery for site specific ultrasound augmentation. This article reviews recent data on therapeutic ultrasound for thrombolysis in vitro, in vivo, in animal studies, as well as in human clinical trials.
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Affiliation(s)
- Robert J Siegel
- Cedars-Sinai Medical Center, Cardiac Noninvasive Laboratory, David Geffen School of Medicine at UCLA, 8700 Beverly Boulevard, Room 5623, Los Angeles, CA 90048, USA.
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Møller JE, Søndergaard E, Poulsen SH, Egstrup K. The Doppler echocardiographic myocardial performance index predicts left-ventricular dilation and cardiac death after myocardial infarction. Cardiology 2001; 95:105-11. [PMID: 11423716 DOI: 10.1159/000047355] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
To investigate the value of the Doppler-derived myocardial performance index to predict early left-ventricular (LV) dilation and cardiac death after a first acute myocardial infarction (AMI), Doppler echocardiography was performed within 24 h of hospital admission, on day 5, 1 and 3 months after AMI in 125 consecutive patients. The index measured on day 1 correlated well with the change in end-diastolic volume index observed from day 1 to 3 months following AMI (r = 0.66, p < 0.0001). One-year survival in patients with Doppler index <0.63 was 89%, and 37% in patients with index > or = 0.63, (p < 0.0001). Multivariate analysis identified myocardial performance index > or = 0.63 (relative risk 5.6, p < 0.0001), E-wave deceleration time <140 ms (relative risk 2.7, p = 0.008) and Killip class > or = II (relative risk 4.0, p = 0.04) to be independent predictors of cardiac death. Therefore, we conclude that the Doppler echocardiographic myocardial performance index is a predictor of LV dilation and cardiac death after a first AMI.
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Affiliation(s)
- J E Møller
- Department of Medicine, Svendborg Hospital, Svendborg, Denmark.
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28
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Møller JE, Søndergaard E, Poulsen SH, Seward JB, Appleton CP, Egstrup K. Color M-mode and pulsed wave tissue Doppler echocardiography: powerful predictors of cardiac events after first myocardial infarction. J Am Soc Echocardiogr 2001; 14:757-63. [PMID: 11490323 DOI: 10.1067/mje.2001.113367] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
To assess the association between color M-mode flow propagation velocity and the early diastolic mitral annular velocity (E(m)) obtained with tissue Doppler echocardiography and to assess the prognostic implications of the indexes, echocardiography was performed on days 1 and 5, and 1 and 3 months after a first myocardial infarction in 67 consecutive patients. Flow propagation velocity correlated well with E(m) (r = 0.72, P <.0001). The ratio of peak E-wave velocity (E) to flow propagation velocity also correlated well with E/E(m) (r = 0.87, P <.0001). The positive predictive value of E/FPV > or =1.5 to identify patients with Killip class > or =II was 90%, and the negative predictive value 92%. The corresponding values for E/E(m) > or =10 were 70% and 90%. Cox proportional hazards analysis identified E/flow propagation velocity > or =1.5 (relative risk, 12.4 [95% confidence interval, 4.1-37.3]), E/E(m) > or =10 (relative risk, 11.5 [95% confidence interval, 3.8-34.7]), and Killip class > or =II (relative risk, 7.8 [95% confidence interval, 1.6-40.4]) to be predictors of the composite end point of cardiac death and readmission because of heart failure. Thus flow propagation velocity and E(m) are closely related after myocardial infarction and appear to have similar prognostic information.
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Affiliation(s)
- J E Møller
- Department of Medicine, Svendborg Hospital, Svendborg, Denmark.
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29
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Møller JE, Søndergaard E, Poulsen SH, Appleton CP, Egstrup K. Serial Doppler echocardiographic assessment of left and right ventricular performance after a first myocardial infarction. J Am Soc Echocardiogr 2001; 14:249-55. [PMID: 11287887 DOI: 10.1067/mje.2001.111478] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We sought to investigate the relation between left ventricular (LV) and right ventricular (RV) function assessed with the Doppler-derived myocardial performance index (MPI), to assess serial changes, and to investigate the prognostic value of biventricular assessment of cardiac function after a first myocardial infarction (MI). To do so, serial Doppler echocardiography was performed in 77 consecutive patients with a first MI. Right ventricular MPI correlated significantly with LV MPI (r = 0.51, P <.0001). In patients with echocardiographic signs of RV MI, the RV MPI was significantly higher (0.59 +/- 0.18 versus 0.44 +/- 0.19, P =.001), whereas no difference in LV MPI was seen (0.55 +/- 0.19 versus 0.56 +/- 0.13, P = not significant). Right ventricular MPI showed a rapid normalization during follow-up, whereas LV MPI did not decrease. During follow-up, 23 patients died of cardiac causes or were readmitted because of worsening heart failure. Multivariate Cox analysis indicated LV MPI (relative risk 4.9 [95% CI 1.8-13.5], P =.002) and RV MPI (relative risk 3.8 [1.3-17.0], P =.01) to be predictors of cardiac events. Thus the RV MPI is frequently abnormal after a first MI but normalizes rapidly on follow-up, and biventricular assessment of cardiac function may improve the prognostic accuracy compared with LV assessment alone.
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