Mayra Tisminetzky

Multiple cardiovascular comorbidities and acute myocardial infarction: temporal trends (1990-2007) and impact on death rates at 30 days and 1 year.

Background The objectives of this community-based study were to examine the overall and changing (1990–2007) frequency and impact on 30-day and 1-year death rates from multiple cardiovascular comorbidities in adults from a large central New England metropolitan area hospitalized with acute myocardial infarction (AMI). Methods The study population consisted of 9581 patients hospitalized with AMI at all 11 medical centers in the metropolitan area of Worcester, MA, during 10 annual periods between 1990 and 2007. The comorbidities examined included atrial fibrillation, diabetes, heart failure, hypertension, and stroke. Results Thirty-five percent of participants had a single diagnosed cardiovascular comorbidity, 25% had two, 12% had three, and 5% had four or more comorbidities. Between 1990 and 2007, the proportion of patients without any of these comorbidities decreased significantly, while the proportion of patients with multiple comorbidities increased significantly during the years under study. An increasing number of comorbidities was associated with higher 30-day and 1-year postadmission death rates in patients hospitalized with AMI. Conclusion Patients hospitalized with AMI carry a significant burden of comorbid cardiovascular disease that adversely impacts their 30-day and longer-term survival. Increased attention to the management of AMI patients with multiple cardiovascular comorbidities is warranted.

Symptom Presentation in Patients Hospitalized with Acute Heart Failure

The objectives of this study were to examine the type and frequency of symptoms in patients hospitalized with acute heart failure (HF) as well as the relationship between symptom patterns and patient characteristics, treatment practices, and hospital outcomes in patients hospitalized with decompensated HF.

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 (≤40%), 13% (n=521) had borderline preserved EF (41–49%), and 52% (n=2090) had preserved EF (≥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 <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.

Encouraging trends in acute myocardial infarction survival in the oldest old

BACKGROUND There are limited data informing the optimal treatment strategy for acute myocardial infarction in the oldest old (aged ≥85 years). The study aim was to examine whether decade-long increases in guideline-based cardiac medication use mediate declines in post-discharge mortality among oldest old patients hospitalized with acute myocardial infarction. METHODS The study sample included 1137 patients aged ≥85 years hospitalized in 6 biennial periods between 1997 and 2007 for acute myocardial infarction at all 11 greater Worcester, Massachusetts, medical centers. We examined trends in 90-day survival after hospital discharge and guideline-based medication use (aspirin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, lipid-lowering agents) for acute myocardial infarction during hospitalization and at discharge. Sequential multivariable Cox regression models examined the relationship among guideline-based medication use, study year, and 90-day post-discharge survival rates. RESULTS Patients hospitalized between 2003 and 2007 experienced higher 90-day survival rates than those hospitalized between 1997 and 2001 (69.1% vs 59.8%, P < .05). Between 1997 and 2007, the average number of guideline-based medications prescribed at discharge increased significantly (1.8 to 2.9, P < .001). The unadjusted hazard ratio for 90-day post-discharge mortality in 2003-2007 compared with 1997-2001 was 0.73 (95% confidence interval, 0.60-0.89); after adjustment for patient characteristics and guideline-based cardiac medication use, this relationship was no longer significant (hazard ratio, 1.26; 95% confidence interval, 1.00-1.58). CONCLUSIONS Between 1997 and 2007, 90-day survival improved among a population-based sample of patients aged ≥85 years hospitalized for acute myocardial infarction. This encouraging trend was explained by increased use of guideline-based medications.

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.

Multiple Chronic Conditions and Psychosocial Limitations in Patients Hospitalized with an Acute Coronary Syndrome

BACKGROUND As adults live longer, multiple chronic conditions have become more prevalent over the past several decades. We describe the prevalence of, and patient characteristics associated with, cardiac- and non-cardiac-related multimorbidities in patients discharged from the hospital after an acute coronary syndrome. METHODS We studied 2174 patients discharged from the hospital after an acute coronary syndrome at 6 medical centers in Massachusetts and Georgia between April 2011 and May 2013. Hospital medical records yielded clinical information including presence of eight cardiac-related and eight non-cardiac-related morbidities on admission. We assessed multiple psychosocial characteristics during the index hospitalization using standardized in-person instruments. RESULTS The mean age of the study sample was 61 years, 67% were men, and 81% were non-Hispanic whites. The most common cardiac-related morbidities were hypertension, hyperlipidemia, and diabetes (76%, 69%, and 31%, respectively). Arthritis, chronic pulmonary disease, and depression (20%, 18%, and 13%, respectively) were the most common noncardiac morbidities. Patients with ≥4 morbidities (37% of the population) were slightly older and more frequently female than those with 0-1 morbidity; they were also heavier and more likely to be cognitively impaired (26% vs 12%), have symptoms of moderate/severe depression (31% vs 15%), high perceived stress (48% vs 32%), a limited social network (22% vs 15%), low health literacy (42% vs 31%), and low health numeracy (54% vs 42%). CONCLUSION Multimorbidity, highly prevalent in patients hospitalized with an acute coronary syndrome, is strongly associated with indices of psychosocial deprivation. This emphasizes the challenge of caring for these patients, which extends well beyond acute coronary syndrome management.

Decade-Long Trends in the Frequency of 90-Day Rehospitalizations After Hospital Discharge for Acute Myocardial Infarction

There are limited data available describing relatively contemporary trends in 90-day rehospitalizations in patients who survive hospitalization after an acute myocardial infarction (AMI) in a community setting. We examined decade-long (2001 to 2011) trends in, and factors associated with, 90-day rehospitalizations in patients discharged from 3 central Massachusetts (MA) hospitals after AMI. Residents of the Worcester, MA, metropolitan area discharged after AMI from 3 central MA hospitals on a biennial basis from 2001 to 2011 comprised the study population (n = 4,810). The average age of this population was 69 years, 42% were women, and 92% were white. From 2001 to 2011, 30.0% of patients were rehospitalized within 90 days after hospital discharge, and 38% of 90-day rehospitalizations occurred after the first month after hospital discharge. Crude 90-day rehospitalization rates decreased from 31.5% in 2001/2003 to 27.3% in 2009/2011. After adjusting for several sociodemographic characteristics, co-morbidities, and in-hospital factors, there was a reduced risk of being rehospitalized within 90 days after hospital discharge in 2009/2011 compared with 2001/2003 (risk ratio = 0.87, 95% CI = 0.77 to 0.98); this trend was slightly attenuated (risk ratio = 0.90, 95% CI = 0.79 to 1.02) after further adjustment for hospital treatment practices. Female sex, having several previously diagnosed co-morbidities, an increased hospital stay, and the in-hospital development of atrial fibrillation, cardiogenic shock, and heart failure were significantly associated with an increased risk of being rehospitalized. In conclusion, the likelihood of subsequent 90-day rehospitalizations remained frequent, and we did not observe a significant decrease in these rates during the years under study.

Changing Trends in, and Characteristics Associated with, Not Undergoing Cardiac Catheterization in Elderly Adults Hospitalized with ST-Segment Elevation Acute Myocardial Infarction

To describe decade‐ long trends (1999–2009) in the rates of not undergoing cardiac catheterization and percutaneous coronary intervention (PCI) in individuals aged 65 and older presenting with an ST‐segment elevation acute myocardial infarction (STEMI) and factors associated with not undergoing these procedures.

Research Priorities to Advance the Health and Health Care of Older Adults with Multiple Chronic Conditions

To prioritize research topics relevant to the care of the growing population of older adults with multiple chronic conditions (MCCs).

Decade-long trends in the characteristics, management and hospital outcomes of diabetic patients with ST-segment elevation myocardial infarction:

Purpose: Our objectives were to describe recent trends in the characteristics and in-hospital outcomes in diabetic as compared with non-diabetic patients hospitalized with ST-segment elevation myocardial infarction (STEMI). Methods: We reviewed the medical records of 2537 persons with (n = 684) and without (n = 1853) a history of diabetes who were hospitalized for STEMI between 1997 and 2009 at 11 medical centres in Central Massachusetts. Results: Diabetic patients were more likely to be older, female and to have a higher prevalence of previously diagnosed comorbidities. Diabetic patients were more likely to have developed important in-hospital complications and to have a longer hospital stay compared with non-diabetic patients. Between 1997 and 2009, there was a marked decline in hospital mortality in diabetic (20.0%–5.6%) and non-diabetic (18.6%–7.5%) patients. Conclusion: Despite reduced hospital mortality in patients hospitalized with STEMI, diabetic patients continue to experience significantly more adverse outcomes than non-diabetics.