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

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

Association between Psychosocial Factors, Quality of Life and Atrial Fibrillation

Background: Atrial fibrillation (AF) is associated with cognitive and psychosocial comorbidities, and poorer quality of life (QOL). In this study, we aimed to study the association between cognition, psychosocial status and QOL at baseline and AF recurrence. Methods: We enrolled 222 symptomatic AF patients (64±10.0 years, 36% women) treated with a rhythm-control strategy. We performed cognitive, psychosocial, and QOL assessments using Montreal cognitive assessment (MOCA, cognitive impairment Results: A total of 123 (55%) participants experienced an AF recurrence over the 6-month follow-up period. Participants with an AF recurrence had higher rates of depression (31% vs.14%, p=0.022) and lower QOL (62±24 vs. 72±21, p=0.003) at baseline than did participants free from recurrence. In multivariable logistic regression models, lower baseline QOL, but not depression, anxiety, or cognition, was associated with a significantly higher odds of AF recurrence event (Odds Ratio: 0.98, CI 0.97-0.99). Conclusion: Lower AF-related QOL is associated with higher odds of AF recurrence over 6 months among symptomatic AF patients treated with rhythm control. Patient-reported variables have not previously been considered as risk factors for disease progression or prognosis. Our data suggests QOL may serve as a useful tool to aid clinicians in the management of AF patients

Religious practices and changes in health-related quality of life after hospital discharge for an acute coronary syndrome

BACKGROUND: Religious beliefs and practices influence coping mechanisms and quality of life in patients with various chronic illnesses. However, little is known about the influence of religious practices on changes in health-related quality of life (HRQOL) among hospital survivors of an acute coronary syndrome (ACS). The present study examined the association between several items assessing religiosity and clinically meaningful changes in HRQOL between 1 and 6 months after hospital discharge for an ACS. METHODS: We recruited patients hospitalized for an ACS at six medical centers in Central Massachusetts and Georgia (2011-2013). Participants reported making petition prayers for their health, awareness of intercessory prayers by others, and deriving strength/comfort from religion. Generic HRQOL was assessed with the SF-36(R)v2 physical and mental component summary scores. Disease-specific HRQOL was evaluated using the Seattle Angina Questionnaire Quality of Life subscale (SAQ-QOL). We separately examined the association between each measure of religiosity and the likelihood of experiencing clinically meaningful increase in disease-specific HRQOL (defined as increases by \u3e /=10.0 points) and Generic HRQOL (defined as increases by \u3e /=3.0 points) between 1- and 6-months post-hospital discharge. RESULTS: Participants (n = 1039) were, on average, 62 years old, 33% were women, and 86% were non-Hispanic White. Two-thirds reported praying for their health, 88% were aware of intercessions by others, and 85% derived strength/comfort from religion. Approximately 42, 40, and 26% of participants experienced clinically meaningful increases in their mental, physical, and disease-specific HRQOL respectively. After adjustment for sociodemographic, psychosocial, and clinical characteristics, petition (aOR:1.49; 95% CI: 1.09-2.04) and intercessory (aOR:1.72; 95% CI: 1.12-2.63) prayers for health were associated with clinically meaningful increases in disease-specific and physical HRQOL respectively. CONCLUSIONS: Most ACS survivors in a contemporary, multiracial cohort acknowledged praying for their health, were aware of intercessory prayers made for their health and derived strength and comfort from religion. Patients who prayed for their health and those aware of intercessions made for their health experienced improvement in their generic physical and disease-specific HRQOL over time. Healthcare providers should recognize that patients may use prayer as a coping strategy for improving their well-being and recovery after a life-threatening illness

Association of Left Atrial Function Index with Atrial Fibrillation and Cardiovascular Disease: The Framingham Offspring Study

BACKGROUND: Left atrial (LA) size, a marker of atrial structural remodeling, is associated with increased risk for atrial fibrillation (AF) and cardiovascular disease (CVD). LA function may also relate to AF and CVD, irrespective of LA structure. We tested the hypothesis that LA function index (LAFI), an echocardiographic index of LA structure and function, may better characterize adverse LA remodeling and predict incident AF and CVD than existing measures. METHODS AND RESULTS: In 1786 Framingham Offspring Study eighth examination participants (mean age, 66+/-9 years; 53% women), we related LA diameter and LAFI (derived from the LA emptying fraction, left ventricular outflow tract velocity time integral, and indexed maximal LA volume) to incidence of AF and CVD on follow-up. Over a median follow-up of 8.3 years (range, 7.5-9.1 years), 145 participants developed AF and 139 developed CVD. Mean LAFI was 34.5+/-12.7. In adjusted Cox regression models, lower LAFI was associated with higher risk of incident AF (hazard ratio=3.83, 95% confidence interval=2.23-6.59, lowest [Q1] compared with highest [Q4] LAFI quartile) and over 2-fold higher risk of incident CVD (hazard ratio=2.20, 95% confidence interval=1.32-3.68, Q1 versus Q4). Addition of LAFI, indexed maximum LA volume, or LA diameter to prediction models for AF or CVD did not significantly improve model discrimination for either outcome. CONCLUSIONS: In our prospective investigation of a moderate-sized community-based sample, LAFI, a composite measure of LA size and function, was associated with incident AF and CVD. Addition of LAFI to the risk prediction models for AF or CVD, however, did not significantly improve their performance

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

Recent trends in the characteristics and prognosis of patients hospitalized with acute heart failure

BACKGROUND: Despite the magnitude and impact of heart failure (HF) in the United States, relatively little data are available that describe the prognosis associated with acute HF, especially from the perspective of a population-based investigation. The purpose of this nonconcurrent prospective study was to describe the overall, and changing trends therein, prognosis of 4228 patients discharged from all eleven greater Worcester (MA) medical centers after a documented episode of acute HF and factors associated with an increased risk of dying after hospital discharge. METHODS: The study population consisted of residents of the Worcester metropolitan area discharged after being hospitalized for acute HF at all greater Worcester medical centers during 1995 (n = 1783) and 2000 (n = 2445). RESULTS: The 3-month (20% versus 18%), 1-year (41% versus 38%), and 5-year (84% versus 82%) death rates were lower in patients discharged from all metropolitan Worcester hospitals in 2000 versus 1995, respectively. Improving long-term survival rates for patients discharged in 2000 as compared with 1995 were magnified after controlling for several confounding demographic and clinical factors of prognostic importance. A number of potentially modifiable demographic, medical history, and clinical factors were associated with an increased risk of dying during the first year after hospital discharge for acute HF. CONCLUSION: The results of this community-wide observational study suggest improving trends in the long-term prognosis after acute HF. Despite these encouraging trends, the long-term prognosis for patients with acute HF remains poor, and several at-risk groups can be identified for early intervention and increased monitoring efforts

Admission Hyperglycemia in Setting of Acute Heart Failure is Associated with Increased In-hospital Mortality Among Patients without Diabetes

Background: Heart Failure (HF) in the setting of comorbid diabetes mellitus (DM) has been extensively examined and is associated with increased mortality. More recently, hyperglycemia independent of DM status during critical illness admissions has become recognized as an indicator of poor outcomes. Despite evolving understanding of DM in the setting of acute HF, hyperglycemia at time of admission for acute HF has not been examined with regard to in-hospital treatment and patient outcomes. Objective: The goal of this study is to examine differences in in-hospital treatment and outcomes of patients hospitalized for acute HF according to glycemic status. Methods: The sample consisted of 9,748 residents of the Worcester (MA) metropolitan area hospitalized at all 11 greater Worcester medical centers for acute decompensated HF during the years 1995 - 2004 with data available on diabetic status and admission glucose measurements. Patients were stratified into three groups based on history of DM and admission hyperglycemia defined by glucose ≥200 mg/dL: 1) nondiabetic, normoglycemic (NDNG); 2) non-diabetic, hyperglycemic (NDHG); and 3) diabetic (DM). Results: Non-diabetic, normoglycemic patients were similar to NDHG patients with respect to age and medical history and were significantly older and less likely to have a history of various comorbid conditions such as hypertension, stroke and renal disease when compared to diabetics (p-values Conclusions: The results of our population-based investigation suggest that non-diabetic patients hospitalized for acute HF who are hyperglycemic at the time of admission represent a vulnerable group of patients at risk for increased mortality during hospitalization. Hyperglycemia ≥200 mg/dL during acute HF hospitalization should be taken into account when providing in-hospital management for HF with additional consideration given to ascertainment of diabetic status and glycemic control

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

Prognostic value of geriatric conditions for death and bleeding in older patients with atrial fibrillation

Background: Geriatric conditions, such as frailty and cognitive impairment, are prevalent in older patients with atrial fibrillation (AF). We examined the prognostic value of geriatric conditions for predicting 1-year mortality and bleeding events in these patients. Methods: SAGE (Systematic Assessment of Geriatric Elements)-AF study is a multicenter cohort study which enrolled individuals (mean age 75 years, 48% women, 86% taking oral anticoagulation) 65 years and older with AF and CHA2DS2 -VASc score of 2 or higher from clinics in Massachusetts and Georgia, USA between 2016 and 2018. A six-component geriatric assessment included validated measures of frailty, cognitive function, social support, depressive symptoms, vision, and hearing was performed at baseline. Study endpoints included all-cause mortality and clinically relevant bleeding. Results: At 1 year, 1,097 (96.5%) individuals attended the follow up visit, 44 (3.9%) had died, and 56 (5.1%) had clinically relevant bleeding. After adjustment for demographic and clinical factors, social isolation (odds ratio [OR] 1.69, 95% confidence interval [CI]: 1.01-2.84), depression (OR 1.94, 95% CI: 1.28-2.95) and frailty (OR 2.55, 95% CI: 1.55-4.19) were significantly associated with the composite endpoint of death or clinically relevant bleeding. After multivariable adjustment, depression (OR 1.79, 95% CI 1.09-2.93) and frailty (OR 2.83, 95% CI 1.55-5.17) were significantly associated with clinically relevant bleeding. Conclusions: Social isolation, depression, and frailty were prognostic of dying or experiencing clinically relevant bleeding during the coming year in older men and women with AF. Assessing geriatric impairments merits consideration in the care of these patients