Kensey Gosch

Serum potassium levels and mortality in acute myocardial infarction.

CONTEXT Clinical practice guidelines recommend maintaining serum potassium levels between 4.0 and 5.0 mEq/L in patients with acute myocardial infarction (AMI). These guidelines are based on small studies that associated low potassium levels with ventricular arrhythmias in the pre-β-blocker and prereperfusion era. Current studies examining the relationship between potassium levels and mortality in AMI patients are lacking. OBJECTIVE To determine the relationship between serum potassium levels and in-hospital mortality in AMI patients in the era of β-blocker and reperfusion therapy. DESIGN, SETTING, AND PATIENTS Retrospective cohort study using the Cerner Health Facts database, which included 38,689 patients with biomarker-confirmed AMI, admitted to 67 US hospitals between January 1, 2000, and December 31, 2008. All patients had in-hospital serum potassium measurements and were categorized by mean postadmission serum potassium level (<3.0, 3.0-<3.5, 3.5-<4.0, 4.0-<4.5, 4.5-<5.0, 5.0-<5.5, and ≥5.5 mEq/L). Hierarchical logistic regression was used to determine the association between potassium levels and outcomes after adjusting for patient- and hospital-level factors. MAIN OUTCOME MEASURES All-cause in-hospital mortality and the composite of ventricular fibrillation or cardiac arrest. RESULTS There was a U-shaped relationship between mean postadmission serum potassium level and in-hospital mortality that persisted after multivariable adjustment. Compared with the reference group of 3.5 to less than 4.0 mEq/L (mortality rate, 4.8%; 95% CI, 4.4%-5.2%), mortality was comparable for mean postadmission potassium of 4.0 to less than 4.5 mEq/L (5.0%; 95% CI, 4.7%-5.3%), multivariable-adjusted odds ratio (OR), 1.19 (95% CI, 1.04-1.36). Mortality was twice as great for potassium of 4.5 to less than 5.0 mEq/L (10.0%; 95% CI, 9.1%-10.9%; multivariable-adjusted OR, 1.99; 95% CI, 1.68-2.36), and even greater for higher potassium strata. Similarly, mortality rates were higher for potassium levels of less than 3.5 mEq/L. In contrast, rates of ventricular fibrillation or cardiac arrest were higher only among patients with potassium levels of less than 3.0 mEq/L and at levels of 5.0 mEq/L or greater. CONCLUSION Among inpatients with AMI, the lowest mortality was observed in those with postadmission serum potassium levels between 3.5 and <4.5 mEq/L compared with those who had higher or lower potassium levels.

Trends in the incidence of acute kidney injury in patients hospitalized with acute myocardial infarction.

BACKGROUND Acute kidney injury (AKI) is common in patients with acute myocardial infarction (AMI) and is associated with permanent renal impairment and death. Although guidelines increasingly emphasize AKI prevention, whether increased awareness has translated into reduced AKI rates is unclear. METHODS Among 33,249 consecutive hospitalizations in 31,532 unselected patients with AMI across 56 US centers from Cerner Corporations Health Facts database, we examined the temporal trends in AKI incidence from 2000 to 2008. Acute kidney injury was defined as an absolute increase in creatinine level of at least 0.3 mg/dL or a relative increase of at least 50% during hospitalization. RESULTS From 2000 to 2008, the mean age of patients increased (from 66.5 to 68.6 years), as did the known AKI risk factors, including chronic kidney disease, cardiogenic shock, diabetes mellitus, heart failure, coronary angiography, and percutaneous coronary intervention. Despite this, AKI incidence declined from 26.6% in 2000 to 19.7% in 2008 (P < .001). After multivariate adjustment, the trend of decreasing AKI rates persisted (4.4% decline per year; P < .001). In addition, in-hospital mortality also declined over time among patients developing AKI, from 19.9% in 2000 to 13.8% in 2008 (P = .003). CONCLUSIONS In a large national study, AKI incidence in patients hospitalized with AMI declined significantly from 2000 to 2008 despite the aging population and rising prevalence of AKI risk factors. These findings may reflect increased clinician awareness, better risk stratification, or greater use of AKI prevention efforts during this time period.

Effect of living alone on patient outcomes after hospitalization for acute myocardial infarction.

Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 United States centers from 2003 through 2004, to assess the association of living alone with outcomes after AMI. Outcome measurements included 4-year mortality, 1-year readmission, and 1-year health status using the Seattle Angina Questionnaire (SAQ) and the Short Form-12 Physical Health Component scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs 14.5%, p <0.001) but comparable rates of 1-year readmission (41.6% vs 38.3%, p = 0.79). Living alone was associated with lower unadjusted quality of life (mean SAQ -2.40, 95% confidence interval [CI] -4.44 to -0.35, p = 0.02) but had no impact on Short Form-12 Physical Health Component (-0.45, 95% CI -1.65 to 0.76, p = 0.47) compared to patients who did not live alone. After multivariable adjustment, patients who lived alone had a comparable risk of mortality (hazard ratio 1.35, 95% CI 0.94 to 1.93) and readmission (hazard ratio 0.99, 95% CI 0.76 to 1.28) as patients who lived with others. Mean quality-of-life scores remained lower in patients who lived alone (SAQ -2.91, 95% CI -5.56 to -0.26, p = 0.03). In conclusion, living alone may be associated with poorer angina-related quality of life 1 year after MI but is not associated with mortality, readmission, or other health status measurements after adjusting for other patient and treatment characteristics.

Glucose Variability and Mortality in Patients Hospitalized With Acute Myocardial Infarction

Background— Mean blood glucose (BG) during acute myocardial infarction (AMI) is an important predictor of inpatient mortality but does not capture glucose variability (GV), which has been shown to be independently associated with mortality in critically ill patients. Whether GV is associated with in-hospital mortality during AMI, after accounting for mean BG, is unknown. Methods and Results— We analyzed 18 563 consecutive patients with AMI with ≥3 BGs in the first 48 hours admitted to 61 US hospitals from 2000 to 2008. Five different GV metrics were compared for their ability to predict in-hospital mortality (range, standard deviation, mean amplitude of glycemic excursions, mean absolute glucose change, and average daily risk range) using hierarchical logistic regression models that sequentially adjusted for mean BG, hypoglycemia (<70 mg/dL), and multiple patient characteristics. In unadjusted analyses, range and average daily risk range had the highest C-indices (0.620 for range, 0.635 for average daily risk range; both P<0.0001). Greater GV was associated with higher mortality for all metrics (eg, mortality was 3.8%, 5.5%, 7.1%, and 11.3% for increasing quartiles of range, P<0.0001); however, the association between GV and mortality for each metric was no longer significant after multivariable adjustment. In contrast, mean BG remained an important predictor of survival (P<0.001, all models). Conclusions— Although greater GV is associated with increased risk of in-hospital mortality in patients with AMI in unadjusted analyses, GV is no longer independently predictive after controlling for multiple patient factors, including mean BG. These findings suggest that GV does not provide additional prognostic value above and beyond already recognized risk factors for mortality during AMI.

“I'm Not Just a Heart, I'm a Whole Person Here”: A Qualitative Study to Improve Sexual Outcomes in Women With Myocardial Infarction

Background Little is known about recovery of female sexual function following an acute myocardial infarction (MI). Interventions to improve sexual outcomes in women are limited. Methods and Results Semistructured, qualitative telephone interviews were conducted with 17 partnered women (aged 43 to 75 years) purposively selected from the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status Registry to deepen knowledge of recovery of female sexual function following an acute myocardial infarction (MI) and to improve sexual outcomes in women. Sixteen women had a monogamous relationship with a male spouse; 1 had a long‐term female partner. Most women resumed sexual activity within 4 weeks of their MI. Sexual problems and concerns were prevalent, including patient and/or partner fear of “causing another heart attack.” Few women received counseling about sexual concerns or the safety of returning to sex. Most women who discussed sex with a physician initiated the discussion themselves. Inquiry about strategies to improve sexual outcomes elicited key themes: need for privacy, patient‐centeredness, and information about the timing and safe resumption of sexual activity. In addition, respondents felt that counseling should be initiated by the treating cardiologist, who “knows whether your heart is safe,” and then reinforced by the care team throughout the rehabilitation period. Conclusions Partnered women commonly resume sexual activity soon after an MI with fear but without directed counseling from their physicians. Proactive attention to womens concerns related to sexual function and the safety of sexual activity following an MI could improve post‐MI outcomes for women and their partners.

Angina frequency after myocardial infarction and quality of life in older versus younger adults: the Prospective Registry Evaluating Myocardial Infarction: Event and Recovery study.

BACKGROUND Residual angina is known to be strongly associated with health-related quality of life (HRQL) in patients with chronic coronary artery disease. As the age of myocardial infarction (MI) survivors increases, better insights into the relationship between angina frequency and HRQL in older as compared to younger patients are needed to efficiently target medical resources. METHODS We evaluated angina frequency and HRQL at 1 and 6 months after MI in 1,795 post-MI survivors using the Seattle Angina Questionnaire (SAQ). We compared changes in HRQL between older (age ≥70 years, n = 464) and younger (age <70 years, n = 1,331) patients as a function of change in SAQ angina frequency scores using hierarchical linear modeling within site. RESULTS After adjusting for baseline HRQL and 26 other covariates, older patients with similar or improved angina control at 6 months had significantly greater improvements in HRQL than younger patients (difference in SAQ quality-of-life scale 8.77 points [CI 4.00-13.54, P = .0003] and 2.56 points [CI 0.66-4.47, P = .0084], respectively). However, older patients with increased angina experienced similar declines in HRQL as compared to younger patients. CONCLUSION In stable patients with coronary artery disease after a recent MI, changes in angina control were correlated with HRQL in both older and younger patients. However, improved angina control was associated with greater HRQL improvements in older than in younger adults, underscoring the importance of aggressive angina control in older patients.

Predictors of Physician Under-Recognition of Angina in Outpatients With Stable Coronary Artery Disease

Background—Under-recognition of angina by physicians may result in undertreatment with revascularization or medications that could improve patients’ quality of life. We sought to describe characteristics associated with under-recognition of patients’ angina. Methods and Results—Patients with coronary disease from 25 US cardiology outpatient practices completed the Seattle Angina Questionnaire before their clinic visit, quantifying their frequency of angina during the previous month. Immediately after the clinic visit, physicians independently quantified their patients’ angina. Angina frequency was categorized as none, monthly, and daily/weekly. Among 1257 patients, 411 reported angina in the previous month, of whom 173 (42%) were under-recognized by their physician, defined as the physician reporting a lower frequency category of angina than the patient. In a hierarchical logistic model, heart failure (odds ratio, 3.06, 95% confidence interval, 1.89–4.95) and less-frequent angina (odds ratio for monthly angina [versus daily/weekly], 1.69; 95% confidence interval, 1.12–2.56) were associated with greater odds of under-recognition. No other patient or physician factors were associated with under-recognition. Significant variability across physicians (median odds ratio, 2.06) was observed. Conclusions—Under-recognition of angina is common in routine clinical practice. Although patients with less-frequent angina and those with heart failure more often had their angina under-recognized, most variation was unrelated to patient and physician characteristics. The large variation across physicians suggests that some physicians are more accurate in assessing angina frequency than others. Standardized prospective use of a validated clinical tool, such as the Seattle Angina Questionnaire, should be tested as a means to improve recognition of angina and, potentially, improve appropriate treatment of angina.

Failure to reassess ejection fraction after acute myocardial infarction in potential implantable cardioverter/defibrillator candidates: Insights from the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health Status (TRIUMPH) registry

BACKGROUND Current practice guidelines advocate delaying assessment of primary prevention implantable cardioverter/defibrillator (ICD) candidacy at least 40 days after an acute myocardial infarction (AMI) because early ICD implantation after AMI has not demonstrated survival benefit. The rate at which interval reassessment of left ventricular ejection fraction (LVEF) occurs in potential primary prevention ICD candidates is unknown. METHODS We examined patients with AMI in the TRIUMPH registry with inhospital LVEF <40% discharged alive after their index presentation, excluding patients with a prior ICD and those who declined ICD during the index admission or were discharged to hospice. We conducted multivariable Poisson modeling to identify independent factors associated with LVEF reassessment by 6 months after AMI. RESULTS Of the 533 patients meeting the inclusion criteria, only 187 (35.1%) reported LVEF reassessment in the first 6 months after AMI and only 13 patients (2.4%) underwent ICD implantation by 1 year. In multivariable analysis, early cardiology follow-up after AMI was associated with a higher likelihood of LVEF reassessment (odds ratio 1.16, 95% confidence interval 1.06-1.28), whereas uninsured status and cardiologist-driving inpatient medical decision making were associated with a lower likelihood of LVEF reassessment (odds ratios 0.84 [95% CI 0.74-0.96] and 0.78 [95% CI 0.68-0.91], respectively). CONCLUSIONS In contemporary practice, almost 2 of 3 potential primary prevention ICD candidates did not report follow-up LVEF evaluation, with a very low rate of ICD implantation at 1 year. These results suggest an important gap in quality, highlighting the need for better transitions of care.

Depression Treatment and 1-Year Mortality After Acute Myocardial InfarctionClinical Perspective: Insights From the TRIUMPH Registry (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status)

Background: Depression among patients with acute myocardial infarction (AMI) is prevalent and associated with an adverse quality of life and prognosis. Despite recommendations from some national organizations to screen for depression, it is unclear whether treatment of depression in patients with AMI is associated with better outcomes. We aimed to determine whether the prognosis of patients with treated versus untreated depression differs. Methods: The TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients’ Health Status) is an observational multicenter cohort study that enrolled 4062 patients aged ≥18 years with AMI between April 11, 2005, and December 31, 2008, from 24 US hospitals. Research coordinators administered the Patient Health Questionnaire-9 (PHQ-9) during the index AMI admission. Depression was defined by a PHQ-9 score of ≥10. Depression was categorized as treated if there was documentation of a discharge diagnosis, medication prescribed for depression, or referral for counseling, and as untreated if none of these 3 criteria was documented in the medical records despite a PHQ score ≥10. One-year mortality was compared between patients with AMI having: (1) no depression (PHQ-9<10; reference); (2) treated depression; and (3) untreated depression adjusting for demographics, AMI severity, and clinical factors. Results: Overall, 759 (18.7%) patients met PHQ-9 criteria for depression and 231 (30.4%) were treated. In comparison with 3303 patients without depression, the 231 patients with treated depression had 1-year mortality rates that were not different (6.1% versus 6.7%; adjusted hazard ratio, 1.12; 95% confidence interval, 0.63–1.99). In contrast, the 528 patients with untreated depression had higher 1-year mortality in comparison with patients without depression (10.8% versus 6.1%; adjusted hazard ratio, 1.91; 95% confidence interval, 1.39–2.62). Conclusions: Although depression in patients with AMI is associated with increased long-term mortality, this association may be confined to patients with untreated depression.

Incidence and Predictors of Cognitive Decline in Patients with Left Ventricular Assist Devices

Background—After left ventricular assist device (LVAD) placement for advanced heart failure, increased cerebral perfusion should result in improved cognitive function. However, stroke (a well-known LVAD complication) and subclinical cerebral ischemia may result in transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool. Methods and Results—Among 4419 patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent LVAD implantation between May 2012 and December 2013, cognitive function was assessed in 1173 patients with the Trail Making B Test before LVAD and at 3, 6, and 12 months. The test detects several forms of cognitive impairment, including subclinical stroke. Cognitive decline was defined as a clinically important increase during follow-up using a moderate Cohen d effect size of 0.5×baseline SD (32 s). The cumulative incidence of cognitive decline in the year after LVAD implantation, treating death and transplantation as competing risks, was 29.2%. In adjusted analysis, older age (≥70 versus <50 years; hazard ratio, 2.24; 95% confidence interval 1.46–3.44; Ptrend<0.001) and destination therapy (hazard ratio, 1.42; 95% confidence interval, 1.05–1.92) were significantly associated with greater risk of cognitive decline. Conclusions—Cognitive decline occurs commonly in patients in the year after LVAD and is associated with older age and destination therapy. These results could have important implications for patient selection and improved communication of risks before LVAD implantation. Additional studies are needed to explore the association between cognitive decline and subsequent stroke, health status, and mortality in patients after LVAD.