Saif S. Rathore

Sex Differences in Long-Term Mortality after Myocardial Infarction: A Systematic Review

Background— Studies of sex differences in long-term mortality after acute myocardial infarction have reported mixed results. A systematic review is needed to characterize what is known about sex differences in long-term outcomes and to define gaps in knowledge. Methods and Results— We searched the Medline database from 1966 to December 2012 to identify all studies that provided sex-based comparisons of mortality after acute myocardial infarction. Only studies with at least 5 years of follow-up were reviewed. Of the 1877 identified abstracts, 52 studies met the inclusion criteria, of which 39 were included in this review. Most studies included fewer than one-third women. There was significant heterogeneity across studies in patient populations, methodology, and risk adjustment, which produced substantial variability in risk estimates. In general, most studies reported higher unadjusted mortality for women compared with men at both 5 and 10 years after acute myocardial infarction; however, many of the differences in mortality became attenuated after adjustment for age. Multivariable models varied between studies; however, most reported a further reduction in sex differences after adjustment for covariates other than age. Few studies examined sex-by-age interactions; however, several studies reported interactions between sex and treatment whereby women have similar mortality risk as men after revascularization. Conclusions— Sex differences in long-term mortality after acute myocardial infarction are largely explained by differences in age, comorbidities, and treatment use between women and men. Future research should aim to clarify how these differences in risk factors and presentation contribute to the sex gap in mortality.

Delay in reperfusion with transradial percutaneous coronary intervention for ST-elevation myocardial infarction: Might some delays be acceptable?

BACKGROUNDnRandomized clinical trials (RCTs) suggest benefits for the transradial approach to percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). However, transradial PCI may delay reperfusion, leading to its avoidance. We sought to quantify the delay in reperfusion from transradial PCI (transradial delay) that would need to be introduced to offset the potential mortality benefit of transradial PCI, compared with transfemoral, observed in RCTs.nnnMETHODSnWe developed a decision-analytic model to compare transfemoral and transradial PCI in STEMI. Thirty-day mortality rates were estimated by pooling STEMI patients from 2 RCTs comparing transfemoral and transradial PCI. We projected the impact of transradial delay using estimates of the increase in mortality associated with door-to-balloon time delays. Sensitivity analyses were performed to understand the impact of uncertainty in assumptions.nnnRESULTSnIn the base case, a transradial delay of 83.0 minutes was needed to offset the mortality benefit of transradial PCI. When the mortality benefit of transradial PCI was one-quarter that observed in RCTs, the delay associated with equivalent mortality was 20.9 minutes. In probabilistic sensitivity analyses, transradial PCI was preferred over transfemoral PCI in 97.5% of simulations when transradial delay was 30 minutes and in 79.0% of simulations when delay was 60 minutes.nnnCONCLUSIONSnA substantial transradial delay is required to eliminate even a fraction of the mortality benefit observed with transradial PCI in RCTs. Results were robust to changing multiple assumptions and have implications for operators reluctant to transition to transradial PCI in STEMI because of concern for delaying reperfusion.

Financial Stress and Outcomes after Acute Myocardial Infarction

Background Little is known about the association between financial stress and health care outcomes. Our objective was to examine the association between self-reported financial stress during initial hospitalization and long-term outcomes after acute myocardial infarction (AMI). Materials and Methods We used Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER) data, an observational, multicenter US study of AMI patients discharged between January 2003 and June 2004. Primary outcomes were disease-specific and generic health status outcomes at 1 year (symptoms, function, and quality of life (QoL)), assessed by the Seattle Angina Questionnaire [SAQ] and Short Form [SF]-12. Secondary outcomes included 1-year rehospitalization and 4-year mortality. Hierarchical regression models accounted for patient socio-demographic, clinical, and quality of care characteristics, and access and barriers to care. Results Among 2344 AMI patients, 1241 (52.9%) reported no financial stress, 735 (31.4%) reported low financial stress, and 368 (15.7%) reported high financial stress. When comparing individuals reporting low financial stress to no financial stress, there were no significant differences in post-AMI outcomes. In contrast, individuals reporting high financial stress were more likely to have worse physical health (SF-12 PCS mean difference −3.24, 95% Confidence Interval [CI]: −4.82, −1.66), mental health (SF-12 MCS mean difference: −2.44, 95% CI: −3.83, −1.05), disease-specific QoL (SAQ QoL mean difference: −6.99, 95% CI: −9.59, −4.40), and be experiencing angina (SAQ Angina Relative Risku200a=u200a1.66, 95%CI: 1.19, 2.32) at 1 year post-AMI. While 1-year readmission rates were increased (Hazard Ratiou200a=u200a1.50; 95%CI: 1.20, 1.86), 4-year mortality was no different. Conclusions High financial stress is common and an important risk factor for worse long-term outcomes post-AMI, independent of access and barriers to care.

Transfer Rates From Nonprocedure Hospitals After Initial Admission and Outcomes Among Elderly Patients With Acute Myocardial Infarction

IMPORTANCEnIt is unknown whether hospital transfer rates for patients with acute myocardial infarction admitted to nonprocedure hospitals (facilities that do not provide catheterization) vary and whether these rates further influence revascularization rates, length of stay, and mortality.nnnOBJECTIVESnTo examine hospital differences in transfer rates for elderly patients with acute myocardial infarction across nonprocedure hospitals and to determine whether these rates are associated with revascularization rates, length of stay, and mortality.nnnDESIGN, SETTING, AND PARTICIPANTSnWe used Medicare claims data from January 1, 2006, to December 31, 2008, to assess transfer rates in nonprocedure hospitals, stratified according to transfer rates as low (≤ 20%), mid-low (>20%-30%), mid-high (>30%-40%), or high (>40%). Data were analyzed for 55,962 Medicare fee-for-service patients admitted to 901 nonprocedure US hospitals with more than 25 admissions per year for acute myocardial infarction.nnnMAIN OUTCOMES AND MEASURESnWe compared rates of catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery during hospitalization and within 60 days, as well as hospital total length of stay, across groups. We measured risk-standardized mortality rates at 30 days and 1 year. RESULTS The median transfer rate was 29.4% (interquartile range [25th-75th percentile], 21.8%-37.8%). Higher transfer rates were associated with higher rates of catheterization (P <u2009.001), percutaneous coronary intervention (P <u2009.001), and coronary artery bypass graft surgery (P <u2009.001). Median length of stay was not meaningfully different across the groups. There was no meaningful evidence of associations between transfer rates and risk-standardized mortality at 30 days (mean [SD], 22.3% [2.6%], 22.1%u2009[2.3%], 22.3% [2.4%], and 21.7% [2.1%], respectively; P =u2009.054) or 1 year (43.9% [2.3%], 43.6%u2009[2.2%], 43.5% [2.4%], and 42.8%u2009[2.2%], respectively; P <u2009.001) for low, mid-low, mid-high, and high transfer groups.nnnCONCLUSIONS AND RELEVANCEnNonprocedure hospitals vary substantially in their use of the transfer process for elderly patients admitted with acute myocardial infarction. High-transfer hospitals had greater use of invasive cardiac procedures after admission compared with low-transfer hospitals. However, higher transfer rates were not associated with a significantly lower risk-standardized mortality rate at 30 days. Moreover, at 1 year there was only a 1.1% difference (42.8% vs 43.9%) between hospitals with higher and lower transfer rates. These findings suggest that, as a single intervention, promoting the transfer of patients admitted with acute myocardial infarction may not improve hospital outcomes.