Trends in the Frequency, Patient Characteristics, Management, and in-Hospital Outcomes of Diabetic Patients Presenting with Acute Myocardial Infarction

Background: Diabetic patients have more complications and higher hospital mortality rates after an acute myocardial infarction (AMI) than patients without diabetes (DM). Increased morbidity and mortality among diabetic patients suffering an AMI is especially concerning given the increasing prevalence of obesity and diabetes in the U.S. and worldwide. The objectives of this study were to describe recent trends in the frequency, patient characteristics, treatment practices, and in-hospital outcomes associated with STEMI and NSTEMI in diabetic compared with non-diabetic patients hospitalized with AMI. Methods: We reviewed the medical records of 6,903 persons, known to be either diabetic (n =2,329) or non-diabetic (n=4,574 ) who were hospitalized for STEMI or NSTEMI between 1997 and 2009 at all 11 greater Worcester medical centers. Results: Diabetic patients presenting with both STEMI and NSTEMI were more likely to be older, female, and obese, and to have a higher prevalence of comorbidities compared with non-diabetics. Diabetic patients were more likely to develop important in-hospital complications including heart failure (39% vs.27%),and atrial fibrillation (18% vs.16%), and had a longer hospital stay (6.3 days vs.5.4 days) compared to non-diabetics. Diabetic patients were significantly more likely to be treated with an angiotensin converting enzyme inhibitor or angiotensin receptor blocker and a diuretic. The proportion of patients undergoing cardiac catheterization during their index hospitalization for AMI approximately doubled during the period under study, while the proportion treated with PCI increased by 3 to 4-fold. The proportion of diabetic and non-diabetic patients undergoing cardiac catheterization was similar, though diabetics were less likely to be treated with PCI and more likely to receive CABG than non-diabetics. In-hospital mortality was significantly higher among diabetics than non-diabetics for both STEMI (13% vs. 10%) and NSTEMI (11% vs. 9%) Conclusions: During the period 1997 to 2009, the use of effective therapies for all patients presenting with AMI has improved, with a concomitant decrease in in-hospital complications and mortality . Nonetheless, diabetic patients experienced , more complications, and worse in-hospital outcomes compared to non-diabetics

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 (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

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

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

Trends in the magnitude of chronic conditions in patients hospitalized with a first acute myocardial infarction

Background: Among adults with heart disease, there is a high prevalence of concomitant chronic medical conditions. We studied patients with a first acute myocardial infarction to describe: sample population characteristics; trends of the most prevalent pairs of chronic conditions; and differences in hospital management according to burden of these morbidities. Methods and Results: Patients (n = 1,564) hospitalized with an incident AMI at the 3 major medical centers in central Massachusetts during 2005, 2011, and 2015 comprised the study population. Hospital medical records were reviewed to identify 11 more prevalent chronic conditions. The median age of this population was 68 years and 56% were men. The median number of previously diagnosed chronic conditions was 2. Patients hospitalized during 2015 were more likely to be younger than those hospitalized in the earliest study cohorts. The most common pairs of chronic conditions for those hospitalized in 2005 were: anemia-chronic kidney disease (31%), chronic kidney disease-heart failure (30%), and stroke-atrial fibrillation (27%). Among patients hospitalized during 2011, chronic kidney disease-heart failure (29%), hypertension-hyperlipidemia (27%), and hypertension-diabetes (27%) were the most common pairs whereas hypertension-hyperlipidemia (43%), diabetes-heart failure (30%), and chronic kidney disease-diabetes (23%) were the most frequent pairs recorded in 2015. There was a significant decrease in the odds of undergoing cardiac catheterization and a percutaneous coronary intervention in those with higher chronic disease burden in the most recent as compared to earliest study years. Conclusions: Our findings highlight the magnitude of chronic conditions in patients with AMI and the challenges of caring for this vulnerable population

Magnitude and Characteristics of Patients Who Survived an Acute Myocardial Infarction

BACKGROUND: The purpose of this study was to describe the magnitude and characteristics of patients who did not experience any significant major adverse cardiovascular event early (within 6 weeks) and late (during the first year) after hospital discharge for an acute myocardial infarction (AMI). METHODS AND RESULTS: Data from 12 243 patients discharged after an AMI from 233 sites across the United States in the TRANSLATE-ACS (Treatment With ADP Receptor Inhibitors: Longitudinal Assessment of Treatment Patterns and Events After Acute Coronary Syndrome) study were analyzed. Multivariable adjusted regression analyses modeled factors associated with 6-week and 1-year survivors who did not experience a recurrent AMI, stroke, unplanned coronary revascularization, or rehospitalization for unstable angina/chest pain during these time periods. The average age of this study population was 60.0 years, 72.0% were men, and 87.9% were white. In this population, 92.4% were classified as early low-risk survivors and 76.3% were classified as late low-risk survivors of an AMI. Factors associated with being an early and late postdischarge survivor included being male and having single-vessel coronary artery disease at the patient\u27s index hospitalization. Patients who were not first seen with any chronic health condition, had an index hospital stay of \u3c /=3 days, and had high baseline quality-of-life scores were more likely to be late low-risk survivors. CONCLUSIONS: Identifying low-risk survivors of an AMI may permit healthcare providers to focus more intensive efforts and interventions on those at higher risk of experiencing adverse cardiovascular events during the postdischarge transition period. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01088503

Race and place differences in patients hospitalized with an acute coronary syndrome: Is there double jeopardy? Findings from TRACE-CORE

The objectives of this longitudinal study were to examine differences between whites and blacks, and across two geographical regions, in the socio-demographic, clinical, and psychosocial characteristics, hospital treatment practices, and post-discharge mortality for hospital survivors of an acute coronary syndrome (ACS). In this prospective cohort study, we performed in-person interviews and medical record abstractions for patients discharged from the hospital after an ACS at participating sites in Central Massachusetts and Central Georgia during 2011-2013. Among the 1143 whites in Central Massachusetts, 514 whites in Central Georgia, and 277 blacks in Central Georgia, we observed a gradient of socioeconomic position with whites in Central Massachusetts being the most privileged, followed by whites and then blacks from Central Georgia; similar gradients pertained to psychosocial vulnerability (e.g., 10.7%, 25.1%, and 49.1% had cognitive impairment, respectively) and to the hospital receipt of all 4 evidence-based cardiac medications (35.5%, 18.1%, and 14.4%, respectively) used in the acute management of patients hospitalized with an ACS. Multivariable adjusted odds ratios (95% confidence intervals) for the receipt of a percutaneous coronary intervention for whites and blacks in Georgia vs. whites in Massachusetts were 0.57 (0.46-0.71) and 0.40(0.30-0.52), respectively. Thirty-day and one-year mortality risks exhibited a similar gradient. The results of this contemporary clinical/epidemiologic study in a diverse patient cohort suggest that racial and geographic disparities continue to exist for patients hospitalized with an ACS