Changing Trends in the Landscape of Patients Hospitalized With Acute Myocardial Infarction (2001 to 2011) (from the Worcester Heart Attack Study)

During the past several decades, new diagnostic tools, interventional approaches, and population-wide changes in the major coronary risk factors have taken place. However, few studies have examined relatively recent trends in the demographic characteristics, clinical profile, and the short-term outcomes of patients hospitalized for acute myocardial infarction (AMI) from the more generalizable perspective of a population-based investigation. We examined decade long trends (2001 to 2011) in patient\u27s demographic and clinical characteristics, treatment practices, and hospital outcomes among residents of the Worcester metropolitan area hospitalized with an initial AMI (n=3,730) at all 11 greater Worcester medical centers during 2001, 2003, 2005, 2007, 2009, and 2011. The average age of the study population was 68.5 years and 56.9% were men. Patients hospitalized with a first AMI during the most recent study years were significantly younger (mean age=69.9 years in 2001/2003; 65.2 years in 2009/2011), had lower serum troponin levels, and experienced a shorter hospital stay compared with patients hospitalized during the earliest study years. Hospitalized patients were more likely to received evidence-based medical management practices over the decade long period under study. Multivariable-adjusted regression models showed a considerable decline over time in the hospital death rate and a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular fibrillation during their acute hospitalization. These results highlight the changing nature of patients hospitalized with an incident AMI, and reinforce the need for surveillance of AMI at the community level

Temporal trends in cardiogenic shock complicating acute myocardial infarction

BACKGROUND: Limited information is available on trends in the incidence of and mortality due to cardiogenic shock complicating acute myocardial infarction. We studied the incidence of cardiogenic shock complicating acute myocardial infarction and in-hospital death rates among patients with this condition in a single community from 1975 through 1997. METHODS: We conducted an observational study of 9076 residents of metropolitan Worcester, Massachusetts, who were hospitalized with confirmed acute myocardial infarction in all local hospitals during 11 one-year periods between 1975 and 1997. Our study included periods before and after the advent of reperfusion therapy. RESULTS: The incidence of cardiogenic shock remained relatively stable over time, averaging 7.1 percent among patients with acute myocardial infarction. The results of a multivariable regression analysis indicated that the patients hospitalized during recent study years were not at a substantially lower risk for shock than patients hospitalized in the mid-to-late 1970s. Patients in whom cardiogenic shock developed had a significantly greater risk of dying during hospitalization (71.7 percent) than those who did not have cardiogenic shock (12.0 percent, P\u3c0.001). A significant trend toward an increase in in-hospital survival among patients with cardiogenic shock in the mid-to-late 1990s was found in crude and adjusted analyses. CONCLUSIONS: Our findings indicate no significant change in the incidence of cardiogenic shock complicating acute myocardial infarction over a 23-year period. However, the short-term survival rate has increased in recent years at the same time as the use of coronary reperfusion strategies has increased

Ten-Year (2001-2011) Trends in the Incidence Rates and Short-Term Outcomes of Early Versus Late Onset Cardiogenic Shock After Hospitalization for Acute Myocardial Infarction

BACKGROUND: Cardiogenic shock (CS) is a serious complication of acute myocardial infarction, and the time of onset of CS has a potential role in influencing its prognosis. Limited contemporary data exist on this complication, however, especially from a population-based perspective. Our study objectives were to describe decade-long trends in the incidence, in-hospital mortality, and factors associated with the development of CS in 3 temporal contexts: (1) before hospital arrival for acute myocardial infarction (prehospital CS); (2) within 24 hours of hospitalization (early CS); and (3) \u3e /=24 hours after hospitalization (late CS). METHODS AND RESULTS: The study population consisted of 5782 patients with an acute myocardial infarction who were admitted to all 11 hospitals in central Massachusetts on a biennial basis between 2001 and 2011. The overall proportion of patients who developed CS was 5.2%. The proportion of patients with prehospital CS (1.6%) and late CS (1.5%) remained stable over time, whereas the proportion of patients with early CS declined from 2.2% in 2001-2003 to 1.2% in 2009-2011. In-hospital mortality for prehospital CS increased from 38.9% in 2001-2003 to 53.6% in 2009-2011, whereas in-hospital mortality for early and late CS decreased over time (35.9% and 64.7% in 2001-2003 to 15.8% and 39.1% in 2009-2011, respectively). CONCLUSIONS: Development of prehospital and in-hospital CS was associated with poor short-term survival and the in-hospital death rates among those with prehospital CS increased over time. Interventions focused on preventing or treating prehospital and late CS are needed to improve in-hospital survival after acute myocardial infarction

Decade-long trends (1999-2009) in the characteristics, management, and hospital outcomes of patients hospitalized with acute myocardial infarction with prior diabetes and chronic kidney disease

BACKGROUND: Despite the increasing magnitude and impact, there are limited data available on the clinical management and in-hospital outcomes of patients who have diabetes mellitus (DM) and chronic kidney disease (CKD) at the time of hospitalization for acute myocardial infarction (AMI). The objectives of our population-based observational study in residents of central Massachusetts were to describe decade-long trends (1999-2009) in the characteristics, in-hospital management, and hospital outcomes of AMI patients with and without these comorbidities. METHODS: We reviewed the medical records of 6,018 persons who were hospitalized for AMI on a biennial basis between 1999 and 2009 at all eleven medical centers in central Massachusetts. Our sample consisted of the following four groups: DM with CKD (n=587), CKD without DM (n=524), DM without CKD (n=1,442), and non-DM/non-CKD (n=3,465). RESULTS: Diabetic patients with CKD were more likely to have a higher prevalence of previously diagnosed comorbidities, to have developed heart failure acutely, and to have a longer hospital stay compared with non-DM/non-CKD patients. Between 1999 and 2009, there were marked increases in the prescribing of beta-blockers, statins, and aspirin for patients with CKD and DM as compared to those without these comorbidities. In-hospital death rates remained unchanged in patients with DM and CKD, while they declined markedly in patients with CKD without DM (20.2% dying in 1999; 11.3% dying in 2009). CONCLUSION: Despite increases in the prescribing of effective cardiac medications, AMI patients with DM and CKD continue to experience high in-hospital death rates

Magnitude of and Prognostic Factors Associated With 1-Year Mortality After Hospital Discharge for Acute Decompensated Heart Failure Based on Ejection Fraction Findings

BACKGROUND: Limited data exist about the magnitude of and the factors associated with prognosis within 1 year for patients discharged from the hospital after acute decompensated heart failure. Data are particularly limited from the more generalizable perspective of a population-based investigation and should be further stratified according to currently recommended ejection fraction (EF) findings. METHODS AND RESULTS: The hospital medical records of residents of the Worcester, Massachusetts, metropolitan area who were discharged after acute decompensated heart failure from all 11 medical centers in central Massachusetts during 1995, 2000, 2002, 2004, and 2006 were reviewed. The average age of the 4025 study patients was 75 years, 93% were white, and 44% were men. Of these, 35% (n=1414) had reduced EF ( \u3c /=40%), 13% (n=521) had borderline preserved EF (41-49%), and 52% (n=2090) had preserved EF ( \u3e /=50%); at 1 year after discharge, death rates were 34%, 30%, and 29%, respectively (P=0.03). Older age, a history of chronic obstructive pulmonary disease, systolic blood pressure findings \u3c 150 mm Hg on admission, and hyponatremia were important predictors of 1-year mortality for all study patients, whereas several comorbidities and physiological factors were differentially associated with 1-year death rates in patients with reduced, borderline preserved, and preserved EF. CONCLUSIONS: This population-based study highlights the need for further contemporary research into the characteristics, treatment practices, natural history, and long-term outcomes of patients with acute decompensated heart failure and varying EF findings and reinforces ongoing discussions about whether different treatment guidelines may be needed for these patients to design more personalized treatment plans

Decade-long trends in the timeliness of receipt of a primary percutaneous coronary intervention

OBJECTIVES: The purpose of this study was to examine decade-long trends (2001-2011) in, and factors associated with, door-to-balloon time within 90 minutes of hospital presentation among patients hospitalized with ST-segment elevation myocardial infarction (STEMI) who received a primary percutaneous coronary intervention (PCI). METHODS: Residents of central Massachusetts hospitalized with STEMI who received a primary PCI at two major PCI-capable medical centers in central Massachusetts on a biennial basis between 2001 and 2011 comprised the study population (n=629). Multivariable regression analyses were used to examine factors associated with failing to receive a primary PCI within 90 minutes after emergency department (ED) arrival. RESULTS: The average age of this patient population was 61.9 years; 30.5% were women, and 91.7% were White. During the years under study, 50.9% of patients received a primary PCI within 90 minutes of ED arrival; this proportion increased from 2001/2003 (17.2%) to 2009/2011 (70.5%) (P \u3c 0.001). Having previously undergone coronary artery bypass graft surgery, arriving at the ED by car/walk-in and during off-hours were significantly associated with a higher risk of failing to receive a primary PCI within 90 minutes of ED arrival. CONCLUSION: The likelihood of receiving a timely primary PCI in residents of central Massachusetts hospitalized with STEMI at the major teaching/community medical centers increased dramatically during the years under study. Several groups were identified for purposes of heightened surveillance and intervention efforts to reduce the likelihood of failing to receive a timely primary PCI among patients acutely diagnosed with STEMI

Trends and Characteristics Associated with the Risk of Re-hospitalization in Patients Discharged from the Hospital after Acute Myocardial Infarction

BACKGROUND: Despite encouraging declines in short-term mortality in patients hospitalized with acute myocardial infarction (AMI), repeat hospitalizations among those discharged from the hospital after AMI remain a major clinical and public health concern. Few studies, however, have described the relatively contemporary magnitude, factors associated with, as well as decade long trends in repeat hospitalizations for cardiovascular disease (CVD) and other causes in patients discharged from the hospital after AMI. METHODS: We reviewed the medical records of 6,018 residents of the Worcester (MA) metropolitan area who were hospitalized for AMI in 6 biennial periods between 1999 and 2009. Re-hospitalizations for any reason were recorded over a 2-year follow-up period. RESULTS: The average age of our study population was 70.3 years and 56.4% were men. Overall, 48.1% of our sample had at least 1 re-hospitalization for any cause after hospital discharge for AMI over the 2-year follow-up period. Of these, 45.7% of the repeat hospitalizations were attributed to CVD, 42.1% were non-CVD related, and 10.6% were due to AMI. The frequency of re-hospitalizations due to any cause declined slightly between 1999 and 2009 from 47.1% to 45.4% , marginally increased in those with CVD (from 46.3% to 47.9%) or non-CVD causes (from 36.9% to 38.3%), while the proportion of patients re-hospitalized for AMI decreased from 16.9% in 1999 to 13.9% in 2009. Older patients, those who developed an NSTEMI, who had a history of selected CVD and Non-CVD comorbidities, and who had received a percutaneous coronary intervention were more likely to have been re-hospitalized during the 2-year follow-up period, as compared with those who were not re-hospitalized (Table 1). CONCLUSIONS: The present results provide insights into the magnitude and causes of re-hospitalizations among patients discharged from the hospital after AMI .Risk of re-hospitalization after AMI was particularly high among older patients presenting with selected comorbidities

Pilot study of the characteristics of acute stroke events in patients discharged from the Carolina University Hospital, Puerto Rico in 2007

BACKGROUND: Stroke is the third leading cause of death in Puerto Rico. We examined the pre-hospital phase, management and case-fatality-rates (CFR) of patients discharged with acute stroke from the Carolina University of Puerto Rico Hospital during 2007. METHODS: Trained personnel collected information on demographics, delay-time, mode-of-transportation, management, and mortality from all medical records. STATAa was utilized to conduct univariate comparison of demographics, mode-of-transportation, therapeutics and diagnostic characteristics. Logistic regression analysis assessed cohort effect and controlled for confounders. RESULTS: The average age was 69.1 years, and 53% were males. The average delay between onset of symptoms suggestive of stroke and arrival at the emergency department was 4.5 hours. Only 62% of patients utilized Emergency Medical Services (EMS). Intravenous thrombolysis was not administered. Stroke mortality increased with age. Ischemic vs. hemorrhagic CFR was significantly higher (63.9% vs. 36.10%; p = 0.034). CONCLUSIONS: These findings highlight the potential benefit of evidence-based therapeutics and EMS use among stroke patients

Magnitude and impact of multiple chronic conditions with advancing age in older adults hospitalized with acute myocardial infarction

BACKGROUND: To examine age-specific differences in the frequency and impact of cardiac and non-cardiac conditions among patients aged 65years and older hospitalized with acute myocardial infarction (AMI). METHODS: Study population consisted of 3863 adults hospitalized with AMI at 11 medical centers in central Massachusetts on a biennial basis between 2001 and 2011. The presence of 11 chronic conditions (five cardiac and six non-cardiac) was based on the review of hospital medical records. RESULTS: Participants\u27 median age was 79years, 49% were men, and had an average of three chronic conditions (average of cardiac conditions: 2.6 and average of non-cardiac conditions: 1.0). Approximately one in every two patients presented with two or more cardiac related conditions whereas one in every three patients presented with two or more non-cardiac related conditions. The most prevalent chronic conditions in our study population were hypertension, diabetes, heart failure, chronic kidney disease, and peripheral vascular disease. Patients across all age groups with a greater number of previously diagnosed cardiac or non-cardiac conditions were at higher risk for developing important clinical complications or dying during hospitalization as compared to those with 0-1 condition. CONCLUSIONS: The prevalence of multimorbidity among older adults hospitalized with AMI is high and associated with worse outcomes that should be considered in the management of this vulnerable population

Decade-Long Trends in 30-Day Rehospitalization Rates After Acute Myocardial Infarction

BACKGROUND: There are limited data available describing relatively contemporary trends in 30-day rehospitalizations among patients who survive hospitalization after an acute myocardial infarction (AMI) in the community setting. We examined decade-long (2001-2011) trends in, and factors associated with, 30-day rehospitalizations in patients discharged from 3 central Massachusetts hospitals after AMI. METHODS AND RESULTS: Residents of the Worcester, MA, metropolitan area discharged after AMI from 3 central Massachusetts hospitals on a biennial basis between 2001 and 2011 comprised the study population (N=4810). Logistic regression analyses were used to examine the association between selected factors and 30-day rehospitalizations. The average age of this population was 69 years, 42% were women, and 92% were white. During the years under study, 18.5% of patients were rehospitalized within 30 days after hospital discharge. Crude 30-day rehospitalization rates decreased from 20.5% in 2001-2003 to 15.8% in 2009-2011. After adjusting for several patient characteristics, there was a reduced odds of being rehospitalized in 2009-2011 (odds ratio 0.74, 95% CI 0.61-0.91) compared with 2001-2003; this trend was slightly attenuated after further adjustment for hospital treatment practices. Female sex, having previously diagnosed heart failure and chronic kidney disease, and the development of in-hospital cardiogenic shock and heart failure were associated with an increased odds of being rehospitalized. CONCLUSIONS: While the likelihood of subsequent short-term rehospitalizations remained frequent, we observed an encouraging decline during the most recent years under study. Several high-risk groups were identified for purposes of heightened surveillance and intervention efforts to reduce the likelihood of being readmitted