Yingzi Deng

Trends in Mortality of Acute Myocardial Infarction After Discharge From the Hospital

Background—We assessed trends in the prognosis of patients with acute myocardial infarction hospitalized in New Jersey hospitals. In recent decades, in-hospital mortality has declined markedly but the decline in longer-term mortality is less pronounced, implying that mortality after discharge has worsened. Methods and Results—Using the Myocardial Infarction Data Acquisition System (MIDAS), we examined the outcomes of 285 397 patients hospitalized for a first acute myocardial infarction between 1986 and 2007. Mortality at discharge decreased by 9.4% from 16.9% to 7.5% (annual change, −0.44; 95% confidence interval, −0.49 to −0.40), but the decrease at 1 year was less pronounced (6.4%) because of an increase in mortality from discharge to 1 year after discharge (from 12.1% to 13.9%; annual change, +0.15; 95% confidence interval, +0.10 to +0.20). Mortality from 30 days after discharge to 1 year, a measure not affected by length of stay, increased by 1.2% (annual change, +0.10; 95% confidence interval, +0.06 to +0.23). The effect was more evident in the older age groups and was due to noncardiovascular mortality, especially from respiratory and renal diseases, septicemia, and cancer. All effects remained statistically significant (P<0.0001) after adjustment for demographics, comorbidities, infarction type, complications, and interventions. Piecewise linear regressions confirmed these trends. Conclusions—Postdischarge mortality of patients with acute myocardial infarction is increasing, primarily because of higher noncardiovascular mortality in the older age groups.

Comprehensive Stroke Centers Overcome the Weekend Versus Weekday Gap in Stroke Treatment and Mortality

Background and Purpose— Hospital staffing may be reduced on weekends. Prior studies of weekend disparities in stroke care have focused on in-hospital mortality with variable results. We hypothesized that 90-day mortality was higher in patients with stroke hospitalized on weekends versus weekdays, and this difference has been minimized over time by improvements in organization and delivery of stroke care. Methods— We used the Myocardial Infarction Data Acquisition System administrative database, which includes data on patients discharged with a primary diagnosis of cerebral infarction from all nonfederal acute care hospitals in New Jersey between 1996 and 2007. Out-of-hospital deaths were assessed by matching MIDAS records with New Jersey death registration files. New Jersey hospitals are designated by the state as comprehensive stroke centers, primary stroke centers, or nonstroke centers. The primary outcome measure was 90-day all-cause mortality after hospital admission. Results— A total of 134 441 patients were admitted with a primary diagnosis of cerebral infarction during the study period. A total of 23.4% were admitted to a comprehensive stroke center, 51.5% to a primary stroke center, and 25.1% to a nonstroke center. Ninety-day mortality was greater in patients with stroke admitted on weekends compared with weekdays (17.2% versus 16.5%; P=0.002). The adjusted risk of death at 90 days was significantly greater for weekend admission (hazard ratio, 1.05; 95% CI, 1.02 to 1.09). No difference in 90-day mortality was observed for patients admitted to comprehensive stroke centers on weekends versus weekdays (hazard ratio, 1.01; 95% CI, 0.95 to 1.08). Conclusions— Patients with stroke admitted on weekends to New Jersey hospitals had a significantly higher risk of death by 90 days. No such difference in mortality was observed at comprehensive stroke centers.

Association between chlorthalidone treatment of systolic hypertension and long-term survival.

CONTEXT In the Systolic Hypertension in the Elderly Program (SHEP) trial, conducted between 1985 and 1990, antihypertensive therapy with chlorthalidone-based stepped-care therapy resulted in a lower rate of cardiovascular events than placebo but effects on mortality were not significant. OBJECTIVE To study the gain in life expectancy of participants randomized to active therapy at the 22-year follow-up. DESIGN, SETTING, AND PARTICIPANTS A National Death Index ascertainment of death in the long-term follow-up of a randomized, placebo-controlled, clinical trial (SHEP) of patients aged 60 years or older with isolated systolic hypertension. Recruitment was between March 1, 1985, and January 15, 1988. After the end of a 4.5-year randomized phase of the SHEP trial, all participants were advised to receive active therapy. The time interval between the beginning of recruitment and the ascertainment of death by National Death Index (December 31, 2006) was approximately 22 years (21 years 10 months). MAIN OUTCOME MEASURES Cardiovascular death and all-cause mortality. RESULTS At the 22-year follow-up, life expectancy gain, expressed as the area between active (n = 2365) and placebo (n = 2371) survival curves, was 105 days (95% CI, -39 to 242; P = .07) for all-cause mortality and 158 days (95% CI, 36-287; P = .009) for cardiovascular death. Each month of active treatment was therefore associated with approximately 1 day extension in life expectancy. The active treatment group had higher survival free from cardiovascular death vs the placebo group (hazard ratio [HR], 0.89; 95% CI, 0.80-0.99; P = .03) but similar survival for all-cause mortality (HR, 0.97; 95% CI, 0.90-1.04; P = .42). There were 1416 deaths (59.9%) in the active treatment group and 1435 deaths (60.5%) in the placebo group (log-rank P = .38, Wilcoxon P = .24). Cardiovascular death was lower in the active treatment group (669 deaths [28.3%]) vs the placebo group (735 deaths [31.0%]; log-rank P = .03, Wilcoxon P = .02). Time to 70th percentile survival was 0.56 years (95% CI, -0.14 to 1.23) longer in the active treatment group vs the placebo group (11.53 vs 10.98 years; P = .03) for all-cause mortality and 1.41 years (95% CI, 0.34-2.61; 17.81 vs 16.39 years; P = .01) for survival free from cardiovascular death. CONCLUSION In the SHEP trial, treatment of isolated systolic hypertension with chlorthalidone stepped-care therapy for 4.5 years was associated with longer life expectancy at 22 years of follow-up.

Trends in Incidence and Mortality Rates of Ventricular Septal Rupture During Acute Myocardial Infarction

Since the introduction of reperfusion in the treatment of acute myocardial infarction (AMI), rates of ventricular septal rupture (VSR) and associated mortality have decreased, but it is not known if incidence and mortality have continued to decrease. We describe trends in incidence and mortality rates of patients with postinfarction VSR during the previous 2 decades and identify risk factors that predict the development and mortality of this rare but catastrophic complication. We analyzed occurrence and mortality rates in patients with first AMI with (n = 408) and without VSR (n = 148,473) who were hospitalized from 1990 to 2007 using the New Jersey Myocardial Infarction Data Acquisition System (MIDAS) database. The annual rate of VSR in AMI was 0.25% to 0.31%. Compared to patients with AMI without VSR, patients with VSR were older, more likely to be women, had increased rate of chronic renal disease, congestive heart failure, and cardiogenic shock, and were less likely to be hypertensive or diabetic (all p values < 0.0001). During the 18-year study period, we found no change in hospital and 1-year mortalities, which were 41% and 60% in 1990 to 1992 and 44% and 56% in 2005 to 2007, respectively. The survival benefit associated with VSR surgical repair was seen only in hospital (hazard ratio 0.66, 95% confidence interval 0.45 to 0.95) but not at 30 days or 1 year. In conclusion, despite improvement in medical treatment and revascularization techniques, the rate of VSR complicating AMI has not changed during the previous 2 decades, and the mortality associated with VSR has remained high and relatively constant.

Incidence and trends of heart failure admissions after coronary artery bypass grafting surgery

Factors related to hospitalization for heart failure (HF) following coronary artery bypass grafting (CABG) surgery were studied.

Competing cardiovascular and noncardiovascular risks and longevity in the systolic hypertension in the elderly program.

We examined the effect of chlorthalidone-based stepped care on the competing risks of cardiovascular (CV) versus non-CV death in the Systolic Hypertension in the Elderly Program (SHEP). Participants were randomly assigned to chlorthalidone-based stepped-care therapy (n = 2,365) or placebo (n = 2,371) for 4.5 years, and all participants were advised to take active therapy thereafter. At the 22-year follow-up, the gain in life expectancy free from CV death in the active treatment group was 145 days (95% confidence interval [CI] 23 to 260, p = 0.012). The gain in overall life expectancy was smaller (105 days, 95% CI -39 to 242, p = 0.073) because of a 40-day (95% CI -87 to 161) decrease in survival from non-CV death. Compared with an age- and gender-matched cohort, participants had markedly higher overall life expectancy (Wilcoxon p = 0.00001) and greater chance of reaching the ages of 80 (81.3% vs 57.6%), 85 (58.1% vs 37.4%), 90 (30.5% vs 22.0%), 95 (11.9% vs 8.8%), and 100 years (3.7% vs 2.8%). In conclusion, Systolic Hypertension in the Elderly Program participants had higher overall life expectancy than actuarial controls and those randomized to active therapy had longer life expectancy free from CV death but had a small increase in the competing risk of non-CV death.

TCT-658 Do Drug Eluting Stents Improve Survival in All Comers?

Sunao Nakamura, Hisao Ogawa, Jang-Ho Bae, Yeo Cahyadi, Wasan Udayachalerm, Damras Tresukosol, Sudaratana Tansuphaswadikul New Tokyo Hospital, Chiba, Japan, Kumamoto University Hospital, Kumamoto, Japan, Konyang University Hospital, Daejeon, Korea, Republic of, Husada Hospital, Jakarta, Indonesia, King Chulalongkorn Memorial Hospital, Bangkok, Thailand, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand, Chest Disease Institute, Nonthaburi, Thailand

THE RELATIONSHIP BETWEEN BODY MASS INDEX AND MORTALITY AMONG 60,000 CORONARY ARTERY BYPASS GRAFT PATIENTS; DOES THE OBESITY PARADOX EXIST?

Results: Of a total of 60,635 pts, 27.3% were women and 85.2% White. 21.9% had normal BMI, 42.3% were overweight and 35.8% were obese. Average age was 66. Overweight and obese pts were younger, less likely to be women or smokers and to have myocardial infarction, left main disease, heart failure, chronic renal disease, cerebrovascular disease and chronic lung disease. They were more likely to have diabetes and hypertension. Post CABG mortality at 30 days, 90 days and between 90 days and 2 years was higher (p <0.0001 for all) in normal BMI pts than in either the overweight or obese group. Multivariate analyses indicated that mortality among normal BMI pts was significantly higher at 90 days and even more so at 2 years after CABG surgery (see figure).