Ventricular Tachycardia and Hospital Readmission in Patients Discharged From the Hospital After an Acute Myocardial Infarction.

Background: Although ventricular tachycardia (VT) occurring during hospitalization for an acute myocardial infarction (AMI) increases mortality risk, its relationship with 30-day postdischarge rehospitalization has not been examined. Methods: Using data from the Worcester Heart Attack Study, we examined the association between early (during the first 48 hours of admission) and late (after 48 hours from admission) VT with 30-day postdischarge all-cause and cardiovascular disease (CVD)-related rehospitalization while analytically controlling for several demographic and clinical factors. Results: The study population consisted of 3534 patients who were hospitalized with an AMI between 2005 and 2015 (average age, 67.2 years; 40.7% women); VT occurred in 452 patients (13.7%), with the majority of instances (81.2%) occurring within 48 hours of admission. The 30-day all-cause rehospitalization rate was 17.3%, with 70.9% of the hospitalizations related to CVD. The odds of rehospitalization were 1.63 times (95% confidence interval [CI] = 0.99-2.69) and 1.12 times (95% CI = 0.83-1.51) higher for patients with AMI who developed late VT and early VT, respectively, compared to patients who did not develop VT. The risk of rehospitalization among patients with late VT was higher (odds ratio = 2.22 (95% CI = 0.79-6.26) in those with ST-segment-elevation AMI, compared to those with non-ST-segment-elevation AMI (odds ratio = 1.45 (95% CI = 0.81-2.57); early VT was not associated with rehospitalization in patients with either AMI subtype. No significant association was present between the occurrence of VT and CVD-related rehospitalization. Conclusions: Patients who develop late VT may experience a higher risk of 30-day rehospitalization following hospital discharge for AMI, especially among those with ST-segment-elevation AMI. Larger studies are needed to confirm our findings.

Contexte: Bien qu'une tachycardie ventriculaire (TV) survenant pendant une hospitalisation pour un infarctus aigu du myocarde (IAM) augmente le risque de décès, son lien avec une réhospitalisation dans les 30 jours suivant le congé n'a pas fait l'objet d'étude. Méthodologie: À partir des données de l'étude Worcester Heart Attack Study, nous avons étudié le lien entre les TV précoces (dans les 48 heures de l'hospitalisation) et tardives (après 48 heures d'hospitalisation) et les réhospitalisations liées à une maladie cardiovasculaire et toutes causes confondues 30 jours après le congé, tout en tenant compte de manière analytique de plusieurs facteurs démographiques et cliniques. Résultats: La population de l'étude était composée de 3 534 patients qui ont été hospitalisés pour un IAM entre 2005 et 2015 (âge moyen, 67,2 ans; 40,7 % de femmes). Une TV est survenue chez 452 patients (13,7 %), la majorité des cas (81,2 %) dans les 48 heures de l'hospitalisation. Le taux de réhospitalisations toutes causes confondues à 30 jours était de 17,3 %, 70,9 % des cas étant liés à une maladie cardiovasculaire. Chez les patients ayant eu un IAM et ayant subi une TV tardive ou précoce, les risques de réhospitalisation étaient respectivement 1,63 fois (intervalle de confiance [IC] à 95 % = 0,99-2,69) et 1,12 fois (IC à 95 % = 0,83-1,51) plus élevés que chez ceux qui n'avaient pas développé de TV. Le risque de réhospitalisation chez les patients ayant subi une TV tardive était plus élevé (risque relatif approché = 2,22 [IC à 95 % = 0,79-6,26]) chez ceux ayant eu un IAM avec élévation du segment ST que chez ceux ayant eu un IAM sans élévation du segment ST (risque relatif approché = 1,45 [IC à 95 % = 0,81-2,57]). La TV précoce n'a pas été associée à la réhospitalisation chez les patients dans l'un ou l'autre des sous-types d'IAM. Aucun lien important n'a été observé entre la survenue d'une TV et la réhospitalisation pour une maladie cardiovasculaire. Conclusions: Chez les patients qui développent une TV tardive, le risque de réhospitalisation 30 jours après le congé de l'hôpital pour un IAM peut être augmenté, particulièrement lorsque l'IAM s'accompagne d'une élévation du segment ST. De vastes études sont nécessaires pour confirmer nos observations.

Short and medium-term outcomes in individuals hospitalized with acute myocardial infarction and multiple chronic conditions: The Worcester heart attack study.

Background: Multiple chronic conditions (MCCs) are common in patients hospitalized with acute myocardial infarction (AMI). We examined the association of 12 MCCs with the risk of a 30-day hospital readmission and/or dying within one year among those discharged from the hospital after an AMI. We also examined the five most prevalent pairs of chronic conditions in this population and their association with the principal study endpoints. Methods: The study population consisted of 3,294 adults hospitalized with a confirmed AMI at the three major medical centers in central Massachusetts on an approximate biennial basis between 2005 and 2015. Patients were categorized as ≤1, 2-3, and ≥4 chronic conditions. Results: The median age of the study population was 67.9 years, 41.6% were women, and 15% had ≤1, 32% had 2-3, and 53% had ≥4 chronic conditions. Patients with ≥4 conditions tended to be older, had a longer hospital stay, and received fewer cardiac interventional procedures. There was an increased risk for being rehospitalized during the subsequent 30 days according to the presence of MCCs, with the highest risk for those with ≥4 conditions. There was an increased, but attenuated, risk for dying during the next year according to the presence of MCCs. Individuals with diabetes/hypertension and those with heart failure/chronic kidney disease were at particularly high risk for developing the principal study outcomes. Conclusion: Development of guidelines that include complex patients, particularly those with MCCs and those at high risk for adverse short/medium term outcomes, remain needed to inform best treatment practices.

Age and Sex Differences and Temporal Trends in the Use of Invasive and Noninvasive Procedures in Patients Hospitalized With Acute Myocardial Infarction.

Background Few studies have examined age and sex differences in the receipt of cardiac diagnostic and interventional procedures in patients hospitalized with acute myocardial infarction and trends in these possible differences during recent years. Methods and Results Data from patients hospitalized with a first acute myocardial infarction at the major medical centers in the Worcester, Massachusetts, metropolitan area were utilized for this study. Logistic regression analysis was used to examine age (<55, 55-64, 65-74, and ≥75 years) and sex differences in the receipt of echocardiography, exercise stress testing, coronary angiography, percutaneous coronary interventions, and coronary artery bypass graft surgery, and trends in the use of those procedures during patients' acute hospitalization, between 2005 and 2018, while adjusting for important confounding factors. The study population consisted of 1681 men and 1154 women with an initial acute myocardial infarction who were hospitalized on an approximate biennial basis between 2005 and 2018. A smaller proportion of women underwent cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery, while there were no sex differences in the receipt of echocardiography and exercise stress testing. Patients aged ≥75 years were less likely to undergo cardiac catheterization, percutaneous coronary intervention, and coronary artery bypass graft surgery, but were more likely to receive echocardiography compared with younger patients. Between 2005 and 2018, the use of echocardiography and coronary artery bypass graft surgery nonsignificantly increased among all age groups and both sexes, while the use of cardiac catheterization and percutaneous coronary intervention increased nonsignificantly faster in women and older patients. Conclusions We observed a continued lower receipt of invasive cardiac procedures in women and patients aged ≥75 years with acute myocardial infarction, but age and sex gaps associated with these procedures have narrowed during recent years.

Use of In-Situ Simulation Based Clinical Systems Test of Thoracic Robotic Surgery Emergencies.

INTRODUCTION: With the advancement of robotic surgery, some thoracic surgeons have been slow to adopt to this new operative approach, in part because they are un-scrubbed and away from the patient while operating. Aiming to allay surgeon concerns of intra-operative emergencies, an insitu simulation-based clinical system's test (SbCST) can be completed to test the current clinical system, and to practice low-frequency, high-stakes clinical scenarios with the entire operating room (OR) team. METHODS: Six different OR teams completed an insitu SbCST of an intra-operative pulmonary artery injury during a robot-assisted thoracic surgery at a single tertiary care center. The OR team consisted of an attending thoracic surgeon, surgery resident, anesthesia attending, anesthesia resident, circulating nurse, and a scrub technician. This test was conducted with an entire OR team along with study observers and simulation center staff. Outcomes included the identified latent safety threats (LSTs) and possible solutions for each LST, culminating in a complete failure mode and effects analysis (FMEA). A Risk Priority Number (RPN) was determined for each LST identified. Pre- and post-simulation surveys using Likert scales were also collected. RESULTS: The six FMEAs identified 28 potential LSTs in four categories. Of these 28 LSTs, nine were considered high priority based on their Risk Priority Number (RPN) with seven of the nine being repeated multiple times. Pre- and post-simulation survey responses were similar, with the majority of participants (94%) agreeing that high fidelity simulation of intra-operative emergencies is helpful and provides an opportunity to train for high-stakes, low-frequency events. After completing the SbCST, more participants felt confident that they knew their role during an intra-operative emergency than their pre-simulation survey responses. All participants agreed that simulation is an important part of continuing education and is helpful for learning skills that are infrequently used. Following the SbCST, more participants agreed that they knew how to safely undock the da Vinci robot during an emergency. CONCLUSIONS: SbCSTs provide an opportunity to test the current clinical system with a low-frequency, high-stakes event and allow medical personnels to practice their skills and teamwork. By completing multiple SbCSTs, we were able to identify multiple LSTs within different OR teams, allowing for a broader review of the current clinical systems in place. The use of these SbCSTs in conjunction with debriefing sessions and FMEA completion allows for the most significant potential improvement of the current system. This study shows that SbCST with FMEA completion can be used to test current systems and create better systems for patient safety.

Temporal Trends and Patient Characteristics Associated with 30-Day Hospital Readmission Rates after a First Acute Myocardial Infarction.

BACKGROUND: Limited data exist about relatively recent trends in the magnitude and characteristics of patients who are re-hospitalized after hospital admission for an acute myocardial infarction. This study examined trends in the frequency and sociodemographic and clinical characteristics of patients readmitted to the hospital within 30 days after an initial acute myocardial infarction. METHODS: We reviewed the medical records of 3116 individuals who were hospitalized for a validated first acute myocardial infarction in 6 study periods between 2003 and 2015 at the 3 major medical centers in central Massachusetts. RESULTS: The median age of our population was 67 years, and 42% were women. The risk of being readmitted to the hospital within 30 days after an initial acute myocardial infarction increased slightly during the most recent study years after controlling for potentially confounding factors. Overall, older adults and patients with previously diagnosed atrial fibrillation, heart failure, diabetes, chronic kidney disease, stroke, and peripheral vascular disease were at higher risk for being readmitted to the hospital than respective comparison groups. For those hospitalized in the most recent study years of 2011/2015, a higher risk of rehospitalization was associated with a previous diagnosis of chronic kidney disease, peripheral vascular disease, the presence of 3 or more chronic conditions, and having developed atrial fibrillation or heart failure during the patient's hospitalization for a first acute myocardial infarction. CONCLUSIONS: We identified several groups at higher risk for hospital readmission in whom enhanced surveillance efforts as well as tailored educational and treatment approaches remain needed.

Trends in the magnitude of chronic conditions in patients hospitalized with a first acute myocardial infarction.

BACKGROUND: Among adults with heart disease, there is a high prevalence of concomitant chronic medical conditions. We studied patients with a first acute myocardial infarction to describe: sample population characteristics; trends of the most prevalent pairs of chronic conditions; and differences in hospital management according to burden of these morbidities. METHODS AND RESULTS: Patients (n = 1,564) hospitalized with an incident AMI at the 3 major medical centers in central Massachusetts during 2005, 2011, and 2015 comprised the study population. Hospital medical records were reviewed to identify 11 more prevalent chronic conditions. The median age of this population was 68 years and 56% were men. The median number of previously diagnosed chronic conditions was 2. Patients hospitalized during 2015 were more likely to be younger than those hospitalized in the earliest study cohorts. The most common pairs of chronic conditions for those hospitalized in 2005 were: anemia-chronic kidney disease (31%), chronic kidney disease-heart failure (30%), and stroke-atrial fibrillation (27%). Among patients hospitalized during 2011, chronic kidney disease-heart failure (29%), hypertension-hyperlipidemia (27%), and hypertension-diabetes (27%) were the most common pairs whereas hypertension-hyperlipidemia (43%), diabetes-heart failure (30%), and chronic kidney disease-diabetes (23%) were the most frequent pairs recorded in 2015. There was a significant decrease in the odds of undergoing cardiac catheterization and a percutaneous coronary intervention in those with higher chronic disease burden in the most recent as compared to earliest study years. CONCLUSIONS: Our findings highlight the magnitude of chronic conditions in patients with AMI and the challenges of caring for this vulnerable population.

Age Differences in the Chief Complaint Associated With a First Acute Myocardial Infarction and Patient's Care-Seeking Behavior.

BACKGROUND: This study set out to describe age differences in patient's chief complaint related to a first myocardial infarction and how the "typicality" of patient's acute symptoms relates to extent of prehospital delay. METHODS: The medical records of 2586 residents of central Massachusetts hospitalized at 11 greater Worcester medical centers with a first myocardial infarction on a biennial basis between 2001 and 2011 were reviewed. RESULTS: The average age of the study population was 66.4 years, 39.6% were women, 40.2% were diagnosed with a ST-elevation myocardial infarction (STEMI), and 72.0 % presented with typical symptoms of myocardial infarction, namely acute chest pain or pressure. Patients were categorized into 5 age strata: >55 years (23%), 55-64 years (20%), 65-74 years (19%), 75-84 years (22%), and ≥85 years (16%). The lowest proportion (11%) of atypical symptoms of myocardial infarction was observed in patients <55 years, increasing to 17%, 28%, 40%, and 51% across the respective age groups. The most prevalent chief complaint reported at the time of hospitalization was chest pain, but the proportion of patients reporting this symptom decreased from the youngest (83%) to the oldest patient groups (45%). There was a slightly increased risk of prehospital delay across the different age groups (higher in the oldest old) in those who presented with atypical, rather than typical, symptoms of myocardial infarction. CONCLUSIONS: The present results provide insights to the presenting chief complaint of patients hospitalized with a first myocardial infarction according to age and the relation of symptom presentation to patient's care-seeking behavior.

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's 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.

Characteristics, Management, and Short-Term Outcomes of Adults ≥65 Years Hospitalized With Acute Myocardial Infarction With Prior Anemia and Heart Failure.

Our study objectives were to examine the impact of anemia and heart failure (HF) on in-hospital complications, and postdischarge outcomes (7 and 30-day rehospitalizations and mortality) in adults ≥65 years hospitalized with acute myocardial infarction (AMI). We used multivariable-adjusted logistic regression models to examine the association between the presence of anemia and/or HF, and the examined outcomes. The study population consisted of 3,863 patients ≥65 years hospitalized with AMI at the 3 major medical centers in Worcester, MA, during 6 annual periods between 2001 and 2011. Individuals were categorized into 4 groups based on the presence of previously diagnosed anemia (hemoglobin ≤10 mg/dl) and/or HF: Those without these conditions (n = 2,300), those with anemia only (n = 382), those with HF only (n = 837), and those with both conditions (n = 344). The median age of the study population was 79 years and 49% were men. Individuals who had been previously diagnosed with anemia and HF had the highest proportion of older adults (≥85 years) and the lowest proportion of those who had received any cardiac interventional procedure during hospitalization. After multivariable adjustment, individuals who presented with both previously diagnosed conditions were at the greatest risk for experiencing adverse events. Patients who presented with HF only were at higher risk for developing several clinical complications during hospitalization, whereas those with anemia only were at slightly higher risk of being rehospitalized within 7-days of their index hospitalization. In conclusion, anemia and HF are prevalent chronic conditions that increased the risk of adverse events in older adults hospitalized with AMI.

Impact of cardiac- and noncardiac-related conditions on adverse outcomes in patients hospitalized with acute myocardial infarction.

BACKGROUND: To examine the impact of cardiac- and noncardiac-related conditions on the risk of hospital complications and 7- and 30-day rehospitalizations in older adult patients with an acute myocardial infarction (AMI). METHODS AND RESULTS: The study population consisted of 3863 adults aged 65 years and older hospitalized with AMI in Worcester, Massachusetts, during six annual periods between 2001 and 2011. Individuals were categorized into four groups based on the presence of 11 previously diagnosed cardiac and noncardiac conditions. The median age of the study population was 79 years and 49% were men. Twenty-eight percent of patients had two or less cardiac- and no noncardiac-related conditions, 21% had two or less cardiac and one or more noncardiac conditions, 20% had three or more cardiac and no noncardiac conditions, and 31% had three or more cardiac and one or more noncardiac conditions. Individuals who presented with one or more noncardiac-related conditions were less likely to have been prescribed evidence-based medications and/or to have undergone coronary revascularization procedures than patients without any noncardiac condition. After multivariable adjustment, individuals with three or more cardiac and one or more noncardiac conditions were at greatest risk for all adverse outcomes. CONCLUSIONS: Older patients hospitalized with AMI carry a significant burden of cardiac- and noncardiac-related conditions. Older adults who presented with multiple cardiac and noncardiac conditions experienced the worse short-term outcomes and treatment strategies should be developed to improve their in-hospital and post-discharge care and outcomes.

Decade Long Trends (2001-2011) in the Incidence Rates of Initial Acute Myocardial Infarction.

Despite the magnitude and impact of acute coronary disease, there are limited population-based data in the United States describing relatively recent trends in the incidence rates of acute myocardial infarction (AMI). The objectives of this study were to describe decade long (2001-2011) trends in the incidence rates of initial hospitalized episodes of AMI, with further stratification of these rates by age, sex, and type of AMI, in residents of central Massachusetts hospitalized at 11 area medical centers. The study population consisted of 3,737 adults hospitalized with a first AMI at 11 medical centers in central Massachusetts on a biennial basis between 2001 and 2011. The median age of this study population was 70 years, 57% were men, and 90% were white. Patients hospitalized during the most recent study years (2009/11) were younger, more likely to be men, have more co-morbidities, and less in-hospital complications as compared with those in the earliest study years (2001/03). The overall age-adjusted hospital incidence rates (per 100,000 persons) of initial AMI declined (from 319 to 163), for men (from 422 to 219), women (from 232 to 120), for patients with a ST segment elevation (129 to 56), and for those with an non-ST segment elevation (190 to 107) between 2001 and 2011, respectively. In conclusion, the incidence rates of initial AMI declined appreciably in residents of central Massachusetts who were hospitalized with AMI during the years under study.

Mortality Associated With Opioid Overdose: A Review of Clinical Characteristics and Health Services Received in the Year Prior to Death.

OBJECTIVE: To assess missed opportunities for reducing fatal opioid overdoses, characteristics of decedents by opioid overdose with and without problematic opioid use who received health care services within one year of death were examined. METHODS: Of 157 decedents in the Worcester, Massachusetts, area between 2008 and 2012, 112 had contact with the health care system. Electronic medical records were reviewed for clinical characteristics, health service use, universal precautions, and substance use disorder management. Problematic opioid use was defined as individuals having documented opioid use disorders or aberrant drug-related behavior. Data were analyzed with chi-square tests with adjusted residual for categorical variables and t tests for continuous variables. RESULTS: Decedents were predominantly Caucasian males with a mean±SD age of 41.0±11.7. Problematic opioid use by definition meant users (N=53) had opioid use disorder as a principal diagnosis and were likely to have a comorbid substance use disorder. Decedents with nonproblematic opioid use had diagnoses of chronic pain and mental illness. They were more likely to have been seen last in surgical and subspecialty settings (29% versus 11%). The proportion with an opioid prescription was higher among those with problematic use (72% versus 37%) who also had a higher total daily morphine equivalent, compared with those with nonproblematic use (165.4±282.7 versus 55.6±117.7 mg per day). CONCLUSIONS: Persons with problematic opioid use are a recognizable group with a high risk of death by opioid overdose whose therapeutic management needs improvement to reduce fatal outcomes. Different strategies must be developed for identifying and treating nonproblematic opioid use to reduce risk of death.

Magnitude and impact of multiple chronic conditions with advancing age in older adults hospitalized with acute myocardial infarction.

BACKGROUND: To examine age-specific differences in the frequency and impact of cardiac and non-cardiac conditions among patients aged 65 years and older hospitalized with acute myocardial infarction (AMI). METHODS: Study population consisted of 3863 adults hospitalized with AMI at 11 medical centers in central Massachusetts on a biennial basis between 2001 and 2011. The presence of 11 chronic conditions (five cardiac and six non-cardiac) was based on the review of hospital medical records. RESULTS: Participants' median age was 79 years, 49% were men, and had an average of three chronic conditions (average of cardiac conditions: 2.6 and average of non-cardiac conditions: 1.0). Approximately one in every two patients presented with two or more cardiac related conditions whereas one in every three patients presented with two or more non-cardiac related conditions. The most prevalent chronic conditions in our study population were hypertension, diabetes, heart failure, chronic kidney disease, and peripheral vascular disease. Patients across all age groups with a greater number of previously diagnosed cardiac or non-cardiac conditions were at higher risk for developing important clinical complications or dying during hospitalization as compared to those with 0-1 condition. CONCLUSIONS: The prevalence of multimorbidity among older adults hospitalized with AMI is high and associated with worse outcomes that should be considered in the management of this vulnerable population.

Recent Trends in Oral Anticoagulant Use and Post-Discharge Complications Among Atrial Fibrillation Patients with Acute Myocardial Infarction.

BACKGROUND: Atrial fibrillation (AF) is a common complication of acute myocardial infarction (AMI).The CHA2DS2VAScand CHADS2risk scoresare used to identifypatients with AF at risk for strokeand to guide oral anticoagulants (OAC) use, including patients with AMI. However, the epidemiology of AF, further stratifiedaccording to patients' risk of stroke, has not been wellcharacterized among those hospitalized for AMI. METHODS: We examined trends in the frequency of AF, rates of discharge OAC use, and post-discharge outcomes among 6,627 residents of the Worcester, Massachusetts area who survived hospitalization for AMI at 11 medical centers between 1997 and 2011. RESULTS: A total of 1,050AMI patients had AF (16%) andthe majority (91%)had a CHA2DS2VAScscore >2.AF rates were highest among patients in the highest stroke risk group.In comparison to patients without AF, patients with AMI and AF in the highest stroke risk category had higher rates of post-discharge complications, including higher 30-day re-hospitalization [27 % vs. 17 %], 30-day post-discharge death [10 % vs. 5%], and 1-year post-discharge death [46 % vs. 18 %] (p < 0.001 for all). Notably, fewerthan half of guideline-eligible AF patientsreceived an OACprescription at discharge. Usage rates for other evidence-based therapiessuch as statins and beta-blockers,lagged in comparison to AMI patients free from AF. CONCLUSIONS: Our findings highlight the need to enhance efforts towards stroke prevention among AMI survivors with AF.

Twenty-Five-Year (1986-2011) Trends in the Incidence and Death Rates of Stroke Complicating Acute Myocardial Infarction.

BACKGROUND: The occurrence of a stroke after an acute myocardial infarction is associated with increased morbidity and mortality rates. However, limited data are available, particularly from a population-based perspective, about recent trends in the incidence and mortality rates associated with stroke complicating an acute myocardial infarction. The purpose of this study was to examine 25-year trends (1986-2011) in the incidence and in-hospital mortality rates of initial episodes of stroke complicating acute myocardial infarction. METHODS: The study population consisted of 11,436 adults hospitalized with acute myocardial infarction at all 11 medical centers in central Massachusetts on a biennial basis between 1986 and 2011. RESULTS: In this study cohort, 159 patients (1.4%) experienced an acute first-ever stroke during hospitalization for acute myocardial infarction. The proportion of patients with acute myocardial infarction who developed a stroke increased through the 1990s but decreased slightly thereafter. Compared with patients who did not experience a stroke, those who experienced a stroke were significantly older, were more likely to be female, had a previous acute myocardial infarction, had a significant burden of comorbidities, and were more likely to have died (32.1% vs 10.8%) during their index hospitalization. Patients who developed a first stroke in the most recent study years (2003-2011) were more likely to have died during hospitalization than those hospitalized during earlier study years. CONCLUSIONS: Although the incidence rates of acute stroke complicating acute myocardial infarction remained relatively stable during the years under study, the in-hospital mortality rates of those experiencing a stroke have not decreased.

Trends in Length of Hospital Stay and the Impact on Prognosis of Early Discharge After a First Uncomplicated Acute Myocardial Infarction.

Few studies have examined recent trends in the length of stay (LOS) among patients hospitalized with a first uncomplicated acute myocardial infarction (AMI) and the impact of early hospital discharge on various short-term outcomes in these low-risk patients. We used data from 1,501 residents hospitalized with a first uncomplicated AMI from all central Massachusetts medical centers on a biennial basis between 2001 and 2011. The association between hospital LOS and subsequent hospital readmission or death was examined using logistic regression modeling. The average age of the study population was 63.7 years, 63.0% were men, and 91.4% were non-Hispanic whites. The average hospital LOS declined from 4.1 days in 2001 to 2.9 days in 2011. During the years under study, the average 30-day hospital readmission rate was 11.9%, whereas the 30- and 90-day death rates were 1.5% and 2.9%, respectively. The multivariable adjusted odds ratio of a 30-day hospital readmission (odds ratio [OR] = 0.81, 95% confidence interval [CI] = 0.52 to 1.41), or 30-day (OR = 0.93, 95% CI = 0.29 to 2.98) and 90-day (OR = 0.89, 95% CI = 0.36 to 2.20) death rates were not significantly different between patients who were discharged from central Massachusetts medical centers during the first 2 days as compared with those discharged thereafter. In conclusion, the average LOS in patients with a first uncomplicated AMI declined during the years under study, and early discharge from the hospital at day 2 or sooner of these low-risk patients does not appear to be associated with an increased risk of adverse events post discharge compared with those discharged at a later time.

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) ≥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.

Retraction notice to "Long-Term Trends (1986-2003)in the Use of Coronary Reperfusion Strategies in Patients Hospitalized With Acute Myocardial Infarction in Central Massachusetts" [Int. J Cardiol. 131 (2008) (83-89)].

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief and Author. This article is a duplicate of a paper that has already been published in the Journal of Thrombosis and Thrombolysis, 23 (2007) 163-71. http://dx.doi.org/10.1007/s11239-006-9029-0. One of the conditions of submission of a paper for publication is that authors declare explicitly that the paper is not under consideration for publication elsewhere. As such this article represents a severe abuse of the scientific publishing system. The scientific community takes a very strong view on this matter and apologies are offered to readers of the journal that this was not detected during the submission process.

Pediatric Disaster Triage: Multiple Simulation Curriculum Improves Prehospital Care Providers' Assessment Skills.

OBJECTIVE: Paramedics and emergency medical technicians (EMTs) triage pediatric disaster victims infrequently. The objective of this study was to measure the effect of a multiple-patient, multiple-simulation curriculum on accuracy of pediatric disaster triage (PDT). METHODS: Paramedics, paramedic students, and EMTs from three sites were enrolled. Triage accuracy was measured three times (Time 0, Time 1 [two weeks later], and Time 2 [6 months later]) during a disaster simulation, in which high and low fidelity manikins and actors portrayed 10 victims. Accuracy was determined by participant triage decision concordance with predetermined expected triage level (RED [Immediate], YELLOW [Delayed], GREEN [Ambulatory], BLACK [Deceased]) for each victim. Between Time 0 and Time 1, participants completed an interactive online module, and after each simulation there was an individual debriefing. Associations between participant level of training, years of experience, and enrollment site were determined, as were instances of the most dangerous mistriage, when RED and YELLOW victims were triaged BLACK. RESULTS: The study enrolled 331 participants, and the analysis included 261 (78.9%) participants who completed the study, 123 from the Connecticut site, 83 from Rhode Island, and 55 from Massachusetts. Triage accuracy improved significantly from Time 0 to Time 1, after the educational interventions (first simulation with debriefing, and an interactive online module), with a median 10% overall improvement (p < 0.001). Subgroup analyses showed between Time 0 and Time 1, paramedics and paramedic students improved more than EMTs (p = 0.002). Analysis of triage accuracy showed greatest improvement in overall accuracy for YELLOW triage patients (Time 0 50% accurate, Time1 100%), followed by RED patients (Time 0 80%, Time 1 100%). There was no significant difference in accuracy between Time 1 and Time 2 (p = 0.073). CONCLUSION: This study shows that the multiple-victim, multiple-simulation curriculum yields a durable 10% improvement in simulated triage accuracy. Future iterations of the curriculum can target greater improvements in EMT triage accuracy.

Decade-Long Trends (2001 to 2011) in the Use of Evidence-Based Medical Therapies at the Time of Hospital Discharge for Patients Surviving Acute Myocardial Infarction.

Optimization of medical therapy during discharge planning is vital for improving patient outcomes after hospitalization for acute myocardial infarction (AMI). However, limited information is available about recent trends in the prescribing of evidence-based medical therapies in these patients, especially from a population-based perspective. We describe decade-long trends in the discharge prescribing of aspirin, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, ß blockers, and statins in hospital survivors of AMI. The study population consisted of 5,253 patients who were discharged from all 11 hospitals in central Massachusetts after AMI in 6 biennial periods from 2001 to 2011. Combination medical therapy (CMT) was defined as the prescription of all 4 cardiac medications at hospital discharge. The average age of this patient population was 69.2 years and 57.7% were men. Significant increases were observed in the use of CMT, from 25.6% in 2001 to 48.7% in 2011, with increases noted for each of the individual cardiac medications examined. Subgroup analysis also showed improvement in discharge prescriptions for P2Y12 inhibitors in patients who underwent a percutaneous coronary intervention. Presence of a do-not-resuscitate order, before co-morbidities, hospitalization for non-ST-segment elevation myocardial infarction, admission to a nonteaching hospital, and failure to undergo cardiac catheterization or a percutaneous coronary intervention were associated with underuse of CMT. In conclusion, our study demonstrates encouraging trends in the prescribing of evidence-based medications at hospital discharge for AMI. However, certain patient subgroups continue to be at risk for underuse of CMT, suggesting the need for strategies to enhance compliance with current practice guidelines.