Does outpatient cardiac rehabilitation help patients with acute myocardial infarction quit smoking?

Outpatient cardiac rehabilitation (OCR) reinforces patients' efforts to quit smoking, but the association between participation in OCR and long-term smoking status after acute myocardial infarction (AMI) is unknown. We studied hospitalized smokers with confirmed AMI from two multicenter prospective registries (PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008) to describe the association of OCR participation with smoking cessation. Eligible patients smoked at least 1 cigarette per day on average in the 30 days prior to enrollment and completed 12-month follow-up (N = 1307). Structured interviews were completed on subjects at baseline and during follow-up. OCR participation and abstinence from smoking within the prior 30-days (30-day point prevalence abstinence, PPA) were self-reported. We constructed a propensity model of OCR participation based on 22 baseline sociodemographic and clinical characteristics, and constructed hierarchical modified Poisson regression models of 30-day PPA at 12 months after matching on the propensity for OCR participation (with clinical site treated as a random effect). Seventy-four percent of subjects were referred to OCR at hospital discharge, but only 36% participated during follow-up. At 12-month follow-up, 30-day PPA was 57% in OCR participants, compared to 41% in matched OCR non-participants. Participation in OCR was a significant predictor of 30-day PPA at 12 months (adjusted RR 1.38, 95% CI 1.20-1.57). In conclusion, smokers who participated in OCR were significantly more likely to abstain from smoking 12 months after AMI hospitalization.

Depression Treatment and 1-Year Mortality After Acute Myocardial Infarction: 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.

Sex Differences in 1-Year All-Cause Rehospitalization in Patients After Acute Myocardial Infarction: A Prospective Observational Study.

BACKGROUND: Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI. METHODS: We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction. RESULTS: One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women. CONCLUSIONS: Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference.

Validation of the Seattle angina questionnaire in women with ischemic heart disease.

BACKGROUND: Although the Seattle Angina Questionnaire (SAQ) has been widely used to assess disease-specific health status in patients with ischemic heart disease, it was originally developed in a predominantly male population and its validity in women has been questioned. METHODS: Using data from 8892 men and 4013 women across 2 multicenter trials and 5 registries, we assessed the construct validity, test-retest reliability, responsiveness to clinical change, and predictive validity of the SAQ Summary Score (SS) and its 5 subdomains (Physical Limitation (PL), Anginal Stability (AS), Angina Frequency (AF), Treatment Satisfaction (TS), and Quality of Life (QoL)) separately in men and women. RESULTS: Comparable correlations of the SAQ SS with Canadian Cardiovascular Society class was demonstrated in both men and women (-0.48 for men, -0.46 for women). Similar correlations between the SAQ PL scale with treadmill exercise duration and Short Form-12 (SF-12) Physical Component Summary were observed in women and men (0.34-0.63 and 0.40-0.63, respectively). SAQ AS scores were significantly lower for both men and women with acute syndromes compared with 1 month later. The SAQ AF scale was strongly correlated with daily angina diaries (0.62 for men and 0.66 for women). The SAQ QoL scores were moderately correlated with the EQ5D visual analog scale and SF-12 general health question in men (0.43-0.50) and women (0.33-0.39). All SAQ scales demonstrated excellent reliability (intraclass correlation ≥0.78) in both men and women with stable CAD and were very sensitive to change after percutaneous coronary intervention (≥15-point difference in scores, standardized response mean ≥ 0.67). The SAQ SS was similarly predictive of 1-year mortality and cardiac re-hospitalizations for both men and women. CONCLUSION: The SAQ demonstrates similar psychometric properties in men and women with CAD. These findings provide evidence for validity of the SAQ in assessing women with IHD.

Noncardiac chest pain after acute myocardial infarction: Frequency and association with health status outcomes.

BACKGROUND: The frequency of noncardiac chest pain (CP) hospitalization after acute myocardial infarction (AMI) is unknown, and its significance from patients' perspectives is not studied. OBJECTIVES: To assess the frequency of noncardiac CP admissions after AMI and its association with patients' self-reported health status. METHODS: We identified cardiac and noncardiac CP hospitalizations in the year after AMI from the 24-center TRIUMPH registry. Hierarchical repeated-measures regression was used to identify the association of these hospitalizations with patients' self-reported health status using the Seattle Angina Questionnaire Quality of Life domain (SAQ QoL) and Short Form 12 (SF-12) physical (PCS) and mental (MCS) component summary scores. RESULTS: Of 3,099 patients, 318 (10.3%) were hospitalized with CP, of whom 92 (28.9%) were hospitalized for noncardiac CP. Compared with patients not hospitalized with CP, noncardiac CP hospitalization was associated with poorer health status (SAQ QoL-adjusted differences: -8.9 points [95% CI -12.1 to -5.6]; SF-12 PCS: -2.5 points [95% CI -4.2 to -0.8] and SF-12 MCS: -3.5 points [95% CI -5.1 to -1.9]). The SAQ QoL for patients hospitalized with noncardiac CP was similar to patients hospitalized with cardiac CP (adjusted difference: 0.6 points [95% CI -3.2 to 4.5]; SF-12 PCS (0.9 points [95% CI -1.1 to 2.9]), but was worse with regard to SF-12 MCS (adjusted difference: -2.0 points [95% CI -3.9 to -0.2]). CONCLUSIONS: Noncardiac CP accounted for a third of CP hospitalizations within 1 year of AMI and was associated with similar disease-specific QoL as well as general physical and mental health status impairment compared with cardiac CP hospitalization.

Beyond restenosis: Patients' preference for drug eluting or bare metal stents.

OBJECTIVES: To assess patients' perspective about factors associated with stent choice. BACKGROUND: Drug eluting stents (DES) markedly reduce the risk of repeat percutaneous coronary intervention (PCI), but necessitate a longer duration of dual anti-platelet therapy (DAPT) as compared with bare metal stents (BMS). Thus, understanding patients' perspective about factors associated with stent choice is paramount. METHODS: Patients undergoing angiography rated, on a 10-point scale, the importance (1 = not important, 10 = most important) of avoiding repeat revascularization and avoiding the following potential DAPT drawbacks: bleeding/bruising, more pills/day, medication costs and delaying elective surgery. The factor, or group of factors, that was rated highest by each patient was identified. RESULTS: Among 311 patients, repeat revascularization was the single most important consideration to 14.4% of patients, while 20.6% considered avoiding one of the DAPT drawbacks as most important. Most patients (65%) considered avoiding at least one DAPT drawback as important as avoiding repeat revascularization. In no subgroup of patients did more than a quarter of patients prefer avoiding repeat revascularization above all other concerns. Among patients undergoing PCI, more than three quarters received a DES, regardless of their stated preferences (DES use among those most valuing DES benefits, avoiding DAPT drawbacks, or both equally were 78.7%, 86.2%, and 85.6%, respectively, P = 0.56). CONCLUSION: Most patients reported that avoiding DAPT drawbacks was as important as avoiding repeat revascularization. Eliciting patient preferences regarding stent type can enhance shared decision-making and allow physicians to better tailor stent choice to patients' goals and values. TRIAL REGISTRATION: Developing and Testing a Personalized Evidence-based Shared Decision-making Tool for Stent Selection (DECIDE-PCI). ClinicalTrials.gov Identifier: NCT02046902. URL: https://clinicaltrials.gov/ct2/show/NCT02046902 © 2017 Wiley Periodicals, Inc.

Initiation of ß-blocker therapy and depression after acute myocardial infarction.

INTRODUCTION: Although ß-blockers reduce mortality after acute myocardial infarction (AMI), early reports linking ß-blocker use with subsequent depression have potentially limited their use in vulnerable patients. We sought to provide empirical evidence to support or refute this concern by examining the association between ß-blocker initiation and change in depressive symptoms in AMI patients. METHODS: Using data from 2 US multicenter, prospective registries of AMI patients, we examined 1-, 6-, and 12-month changes in depressive symptoms after the index hospitalization among patients who were ß-blocker-naïve on admission. Depressive symptoms were assessed using the validated 8-item Patient Health Questionnaire (PHQ-8), which rates depressive symptoms from 0 to 24, with higher scores indicating more depressive symptoms. A propensity-matched repeated-measures linear regression model was used to compare change in depressive symptoms among patients who were and were not initiated on a ß-blocker after AMI. RESULTS: Of 3,470 AMI patients who were ß-blocker-naïve on admission, 3,190 (91.9%) were initiated on a ß-blocker and 280 (8.1%) were not. Baseline PHQ-8 scores were higher in patients not initiated on a ß-blocker (mean 5.78 ± 5.45 vs 4.88 ± 5.11, P = .005). PHQ-8 scores were progressively lower at 1, 6, and 12 months in both the ß-blocker (mean decrease at 12 months 1.16, P < .0001) and no-ß-blocker groups (mean decrease 1.71, P < .0001). After propensity matching 201 untreated patients with 567 treated patients, initiation of ß-blocker therapy was not associated with a difference in mean change in PHQ-8 scores at 1, 6, or 12 months after AMI (absolute mean difference with ß-blocker initiation at 12 months of 0.08, 95% CI -0.81 to 0.96, P = .86). CONCLUSIONS: Initiation of ß-blocker therapy after AMI was not associated with an increase in depressive symptoms. Restricting ß-blocker use because of concerns about depression appears unwarranted and may lead to undertreatment of AMI patients.

Socioeconomic status, cognitive-emotional factors, and health status following myocardial infarction: testing the Reserve Capacity Model.

Health disparities by socioeconomic status (SES) exist for many outcomes, including patients' subjective health status after myocardial infarction (MI). The Reserve Capacity Model (RCM), a theoretical means to understand such disparities, was tested to examine the possible mediating effects of cognitive-emotional factors on the association between SES and health status. Data from 2,348 post-MI patients in PREMIER were used. Indicators of SES were collected during hospitalization via personal interviews, while participants completed measures of stress and reserves at 1 month, depressive symptoms at 6 months, and health status at 1 year through telephone interviews. Structural equation model results provide partial support for the RCM, as cognitive-emotional factors partially mediated the association between SES and mental health status. For physical health status, results supported direct rather than indirect effects of SES. Findings suggest psychosocial interventions with patients of low SES will have their greatest effects on appraisals of psychological health status.

Initiation of statin therapy after acute myocardial infarction is not associated with worsening depressive symptoms: insights from the Prospective Registry Evaluating Outcomes After Myocardial Infarctions: Events and Recovery (PREMIER) and Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) registries.

BACKGROUND: Whereas statins are considered the cornerstone of prevention after acute myocardial infarction (AMI), concerns about worsening depression in association with their use have been raised. METHODS: Using data from 2 prospective AMI registries (PREMIER and TRIUMPH), we examined the change in depressive symptoms from baseline and at 1, 6 and 12 months among statin-naïve patients who were and were not discharged on a statin. Depressive symptoms were assessed with the 8-item Patient Health Questionnaire (PHQ-8). Within-group change in PHQ-8 scores from baseline to each follow-up period was assessed using paired t tests. A repeated-measures propensity-matched analysis examined whether changes in PHQ-8 scores from baseline were different between statin-treated and statin-untreated patients. RESULTS: Of 3,675 patients not previously treated with statins, 3,050 (83%) were discharged on a statin and 625 (17%) were not. Scores of PHQ-8 in the statin group decreased from baseline by a mean (± SD) of 0.9 (± 5.1), 1.2 (± 5), and 1.1 (± 5.1) at 1, 6, and 12 months, respectively. Corresponding changes in the nonstatin group were 0.9 (± 5.2), 1.3 (± 5.1), and 1.5 (± 5.8), respectively (P < .0001 for all comparisons). After propensity matching, 451 patients not discharged on statins with 1,240 patients discharged on statins, the mean change in PHQ-8 scores between baseline and the 3 follow-up time points was not significantly different between groups (mean between-group difference at 1 month: -0.13, 95% CI [-0.69 to 0.43], P = .65; at 6 months: -0.07, 95% CI [-0.66 to 0.52], P = .82; and at 12 months: -0.05, 95% CI [-0.67 to 0.58], P = .88). CONCLUSIONS: Initiation of statins after AMI was not associated with worsening depression.

Adherence to risk factor management instructions after acute myocardial infarction: the role of emotional support and depressive symptoms.

BACKGROUND: Emotional support and depression may influence adherence to risk factor management instructions after acute myocardial infarction (AMI), but their role requires further investigation. PURPOSE: To examine the longitudinal association between perceived emotional support and risk factor management adherence and assess depressive symptoms as a moderator of this association. METHODS: Among 2,202 AMI patients, we assessed adherence to risk factor management instructions over the first recovery year. Modified Poisson mixed-effects regression evaluated associations, with adjustment for demographic and clinical factors. RESULTS: Patients with low baseline support had greater risk of poor adherence over the first year than patients with high baseline support (relative risk [RR] = 1.20, 95% confidence interval [CI] = 1.02-1.43). In stratified analyses, low support remained a significant predictor of poor adherence for non-depressed (RR = 1.41, 95% CI = 1.23-1.61) but not depressed (RR = 1.01, 95% CI = 0.78-1.30) patients (p for interaction < 0.001). CONCLUSIONS: Low emotional support is associated with poor risk factor management adherence after AMI. This relationship is moderated by depression, with a significant relationship observed only among non-depressed patients.

The prognostic importance of worsening renal function during an acute myocardial infarction on long-term mortality.

BACKGROUND: Although an acute worsening in renal function (WRF) commonly occurs among patients hospitalized for acute myocardial infarction (AMI), its long-term prognostic significance is unknown. We examined predictors of WRF and its association with 4-year mortality. METHODS: Acute myocardial infarction patients from the multicenter PREMIER study (N=2,098) who survived to hospital discharge were followed for at least 4 years. Worsening in renal function was defined as an increase in creatinine during hospitalization of ≥0.3 mg/dL above the admission value. Correlates of WRF were determined with multivariable logistic regression models and used, along with other important clinical covariates, in Cox proportional hazards models to define the independent association between WRF and mortality. RESULTS: Worsening in renal function was observed in 393 (18.7%) of AMI survivors. Diabetes, left ventricular systolic dysfunction, and a history of chronic kidney disease (documented history of renal failure with baseline creatinine>2.5 mg/dL) were independently associated with WRF. During 4-year follow-up, 386 (18.6%) patients died. Mortality was significantly higher in the WRF group (36.6% vs 14.4% in those without WRF, P<.001). After adjusting for other factors associated with WRF and long-term mortality, including baseline creatinine, WRF was independently associated with a higher risk of death (hazard ratio=1.64, 95% CI 1.23-2.19). CONCLUSIONS: Worsening in renal function occurs in approximately 1 of 6 AMI survivors and is independently associated with an adverse long-term prognosis. Further studies on interventions to minimize WRF or to more aggressively treat patients developing WRF should be tested.

Centralized Communication of Blood Culture Results Leveraging Antimicrobial Stewardship and Rapid Diagnostics.

OBJECTIVE: This study aimed to determine if integrating antimicrobial stewardship program (ASP) personnel with rapid diagnostic testing resulted in improved outcomes for patients with positive blood cultures. METHOD: Beginning in 2016, Saint Luke's Health System (SLHS) implemented a new process where all positive blood cultures were communicated to ASP personnel or SLHS pharmacy staff. Pharmacists then became responsible for interpreting results, assessing patient specific information, and subsequently relaying culture and treatment information to providers. This was a multisite, pre-post, quasi-experimental study (Pre: August to December 2014; Post: August to December 2016). Patients 18 years of age and older with a positive blood culture during admission were included (2014, n = 218; 2016, n = 286). Coprimary outcomes of time to optimal and appropriate therapy were determined from time of culture positivity via gram stain. Secondary outcomes focused on clinical, process, and fiscal endpoints. A pre-post intervention physician survey was conducted to assess the impact on antimicrobial decision making and perceived effect on patient outcomes. RESULTS: There was no difference in time to appropriate therapy groups (P = .079). Time to optimal therapy was 9.2 hours shorter in 2016 (P = .004). Provider surveys indicated the process improved communication among clinicians and facilitated a shared decision-making process with a perceived improvement in patient care. CONCLUSIONS: An ASP-led blood culture communication process for patients with positive blood cultures was shown to improve time to optimal therapy, support physicians in their decision making on critical lab data, and improve the care for hospitalized patients.

Underutilization of Evidence-Based Smoking Cessation Support Strategies Despite High Smoking Addiction Burden in Peripheral Artery Disease Specialty Care: Insights from the International PORTRAIT Registry.

Background Smoking is the most important risk factor for peripheral artery disease ( PAD ). Smoking cessation is key in PAD management. We aimed to examine smoking rates and smoking cessation interventions offered to patients with PAD consulting a vascular specialty clinic; and assess changes in smoking behavior over the year following initial visit. Methods and Results A total of 1272 patients with PAD and new or worsening claudication were enrolled at 16 vascular specialty clinics (2011-2015, PORTRAIT (Patient-Centered Outcomes Related to Treatment Practices in Peripheral Arterial Disease: Investigating Trajectories) registry). Interviews collected smoking status and cessation interventions at baseline, 3, 6, and 12 months. Among smokers, transition state models analyzed smoking transitions at each time point and identified factors associated with quitting and relapse. On presentation, 474 (37.3%) patients were active, 660 (51.9%) former, and 138 (10.8%) never smokers. Among active smokers, only 16% were referred to cessation counseling and 11% were prescribed pharmacologic treatment. At 3 months, the probability of quitting smoking was 21%; among those continuing to smoke at 3 months, the probability of quitting during the next 9 months varied between 11% and 12% ( P<0.001). The probability of relapse among initial quitters was 36%. At 12 months, 72% of all smokers continued to smoke. Conclusions More than one third of patients with claudication consulting a PAD provider are active smokers and few received evidence-based cessation interventions. Patients appear to be most likely to quit early in their treatment course, but many quickly relapse and 72% of all patients smoking at baseline are still smoking at 12 months. Better strategies are needed to provide continuous cessation support. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 01419080.

Predictors of weight change in overweight patients with myocardial infarction.

BACKGROUND: Weight loss is recommended among overweight survivors of myocardial infarction (MI). This study describes patterns of weight change among overweight patients with MI and identifies factors associated with weight change. METHODS: A prospective cohort of 1253 overweight or heavier (body mass index [BMI] > or = 25 kg/m2) post-MI patients were enrolled in the 19-center PREMIER study and followed up for 1 year to determine changes in weight. Patients were categorized at 1 month as overweight (BMI = 25-29.9 kg/m2), obese (BMI = 30-39.9 kg/m2), or morbidly obese (BMI > or = 40 kg/m2). Unadjusted percent weight change was assessed at 1 year, and multivariable linear regression was used to identify independent correlates of change. RESULTS: Mean weight change was -0.2% and varied by the severity of baseline obesity (+0.4% for overweight patients, -0.5% for obese patients, and -3.7% for morbidly obese patients [P < .001]). Multivariable analyses revealed the following to be significantly associated with weight change: depression 1 month post-MI (+2.7%, P = .001), lack of health insurance (+2%, P = .01), smoking cessation 1 month post-MI (+2.7% vs current smokers, P < .001), morbid obesity (+4.7% vs overweight patients, P < .0001), and increasing age (-0.8% per decade, P = .001). An interaction between smoking cessation and weight class was detected in that overweight patients who quit had a mean increase of 5.3% (95% CI 3.1%-7.4%), whereas no significant change was observed among obese and morbidly obese patients who quit. CONCLUSIONS: Although post-MI patients had negligible weight loss over 1 year, several sociodemographic, clinical, and lifestyle characteristics were associated with weight change. New, targeted interventions will likely be needed to improve weight management after an MI.

Self-reported use of complementary and alternative medicine in patients with previous acute coronary syndrome.

Complementary and alternative medicine (CAM) use is common in patients with cardiovascular disease. Although numerous efforts have sought to understand CAM types and the prevalence of CAM, whether patients preferentially use CAM instead of evidence-based therapies is unknown. Self-reported use of CAM and evidence-based therapies in a prospective registry of hospitalized patients with acute coronary syndrome from March 1, 2001 to October 31, 2002 were examined. Poisson regression models were used to assess whether CAM use was independently associated with lower rates of aspirin, beta-blocker, and statin use in 596 patients with established coronary artery disease (CAD). Overall, CAM use was 19% in patients with CAD. Higher proportions of patients who used CAM were non-Caucasian (31% vs 12%), uninsured (12% vs 7%), economically burdened (58% vs 29%), and had depression (13% vs 6%, p<0.05 for all). Patients who used CAM were more likely to use beta blockers (64% vs 46%, p=0.008) and as likely to use aspirin (73% vs 74%, p=0.90) and statins (71% vs 68%, p=0.76) as non-CAM users. Adjusting for demographic and clinical factors did not change results (CAM users: RR 1.27, 95% confidence interval [CI] 1.01 to 1.60 for using beta blockers, RR 0.97, 95% CI 0.85 to 1.11 for using aspirin, and RR 1.05, 95% CI 0.87 to 1.28 for using statins). In conclusion, although CAM users with established CAD have worse socioeconomic status than nonusers, we found no evidence that they were less compliant with evidence-based therapies.

Acute myocardial infarction patients' information needs over the course of treatment and recovery.

BACKGROUND AND RESEARCH OBJECTIVE: Healthcare guidelines promote including patients in healthcare decision making to optimize treatment and recovery. However, prior research varies widely in the clinical context and conceptualization of patient involvement. The current study focuses on describing cardiac patients' preferences for involvement in decision making in the context of the myocardial infarction event continuum. SUBJECTS AND METHODS: Focus groups were conducted with 19 patients who had recently experienced a myocardial infarction and received care at a regional facility in the Midwest. Data were transcribed and analyzed qualitatively to identify themes related to patient's decision-making experiences. RESULTS AND CONCLUSIONS: Both the role of the patient in decision making and information needs change as the patient progresses from the acute event to recovery. However, this change seems to be curvilinear, rather than linear. To maximize outcomes, clinicians must assess preferences and increase awareness of evolving information needs throughout the myocardial infarction clinical situation.

Preinfarct Health Status and the Use of Early Invasive Versus Ischemia-Guided Management in Non-ST-Elevation Acute Coronary Syndrome.

Early invasive management improves outcomes in non-ST-elevation myocardial infarction (NSTEMI). The association between preinfarct health status and the selecting patients for early invasive management is unknown. The Prospective Registry Evaluating outcomes after Myocardial Infarctions: Events and Recovery and Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status are consecutive US multicenter registries, in which the associations between preinfarct angina frequency and quality of life (both assessed by the Seattle Angina Questionnaire on admission) and the Global Registry of Acute Coronary Events (GRACE) risk score and referral to early invasive management (coronary angiography within 48 hours) were evaluated using Poisson regression, after adjusting for site, demographics, and clinical and psychosocial variables. Of 3,768 patients with NSTEMI, 2,182 (57.9%) patients were referred for early invasive treatment. Patients with excellent, good, or very good baseline angina-specific quality of life, respectively, were more likely to receive early angiography, even after adjustment, as compared with patients reporting poor baseline quality of life because of angina (62.1.0%, 60.9%, 59.6%, vs 51.2%; adjusted relative risk [RR] = 1.09, 95% confidence interval [CI] 1.04 to 1.16; RR = 1.13, 95% CI 1.01 to 1.27; RR 1.14, 95% CI 0.99 to 1.31, respectively). Finally, patients with a GRACE score in the highest risk decile (199.5 to <321.4) had significantly lower rates of early invasive treatment (42.7%) than patients in the lowest decile of risk (67.6%; adjusted RR for continuous GRACE score per SD [1 SD = 40 points], 0.96, 95% CI 0.92 to 0.99, p = 0.019). In conclusion, in this real-world NSTEMI cohort, patients with the highest mortality risk and worst health status were less likely to be referred for early invasive management. Further work is needed to understand the role of preinfarct health status and in-hospital treatment strategy.

The Association Between Complementary and Alternative Medicine and Health Status Following Acute Myocardial Infarction.

BACKGROUND: Complementary and alternative medicines (CAM) are commonly used in patients with cardiovascular disease. Although there is lack of evidence regarding the benefit of CAM on cardiovascular morbidity and mortality, health-status benefits could justify CAM use. HYPOTHESIS: Adoption of mind-body CAM after acute myocardial infarction (AMI) is associated with improved health status, though other forms of CAM are not associated with health-status improvement. METHODS: Patients with AMI from 24 US sites were assessed for CAM use (categorized as mind-body, biological, and manipulative therapies) prior to and 1 year after AMI. Among patients who reported not using CAM prior to their AMI, association of initiating CAM on patients' health status at 1 year after AMI was assessed using Angina Frequency and Quality of Life domains from the Seattle Angina Questionnaire and the Short Form-12 Physical and Mental Component scales. Multivariable regression helped examine association between use of different CAM therapies and health status. RESULTS: Among 1884 patients not using CAM at the time of their AMI, 33% reported initiating ≥1 forms of CAM therapy 1 year following AMI: 62% adopted mind-body therapies, 42% adopted biological therapies, and 15% began using manipulative therapies. In both unadjusted and adjusted analyses, we found no association between different types of CAM use and health-status improvement after AMI. CONCLUSIONS: There was no association between CAM use and health-status recovery after AMI. Until randomized trials suggest otherwise, these findings underscore the importance of focusing on therapies with proven effectiveness after AMI.

Association Between Cardiac Rehabilitation Participation and Health Status Outcomes After Acute Myocardial Infarction.

IMPORTANCE: Cardiac rehabilitation (CR) improves survival after acute myocardial infarction (AMI), and referral to CR has been introduced as a performance measure of high-quality care. The association of participation in CR with patients' health status (eg, quality of life, symptoms, and functional status) is poorly defined. OBJECTIVE: To examine the association of participation in CR with health status outcomes after AMI. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted of patients enrolled in 2 AMI registries: PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008. The analytic cohort was restricted to 4929 patients with data available on baseline health status, 6- or 12- month follow-up health status, and participation in CR. Data analysis was performed from 2014 to 2015. EXPOSURES: Participation in at least 1 CR session within 6 months of hospital discharge. MAIN OUTCOMES AND MEASURES: Patient health status was quantified using the Seattle Angina Questionnaire (SAQ) and the 12-Item Short-Form Health Survey (SF-12). The primary outcomes of interest were the mean differences in SAQ domain scores during the 12 months after AMI between patients who did and did not participate in CR. Secondary outcomes were the mean differences in the SF-12 summary scores and all-cause mortality. RESULTS: After successfully matching the cohorts of the 4929 patients (3328 men and 1601 women; mean [SD] age, 60.0 [12.2] years) for the propensity to participate in CR and comparing the groups using linear, mixed-effects models, mean differences in the SAQ and SF-12 domain scores were similar at 6 and 12 months between the 2012 patients participating in CR (3 were unable to be matched) and the 2894 who did not participate (20 were unable to be matched). At 6 months, the mean difference was -0.76 (95% CI, -2.05 to 0.52) for the SAQ quality of life score, -1.53 (95% CI, -2.57 to -0.49) for the SAQ angina frequency score, 0.38 (95% CI, -0.51 to 1.27) for the SAQ treatment satisfaction score, -0.42 (95% CI, -1.65 to 0.79) for the SAQ physical limitation score, 0.50 (95% CI, -0.22 to 1.22) for the SF-12 physical component score, and 0.13 (95% CI, -0.53 to 0.79) for the SF-12 mental component score. At 12 months, the mean difference was -0.89 (95% CI, -2.20 to 0.43) for the SAQ quality of life score, -1.05 (95% CI, -2.12 to 0.02) for the SAQ angina frequency score, 0.38 (95% CI, -0.54 to 1.29) for the SAQ treatment satisfaction score, -0.14 (95% CI, -1.41 to 1.14) for the SAQ physical limitation score, 0.17 (95% CI, -0.57 to 0.92) for the SF-12 physical component score, and 0.12 (95% CI, -0.56 to 0.80) for the SF-12 mental component score. In contrast, the hazard rate of all-cause mortality (up to 7 years) associated with participating in CR was 0.59 (95% CI, 0.46-0.75). CONCLUSIONS AND RELEVANCE: In a cohort of 4929 patients with AMI, we found that those who did and did not participate in CR had similar reported health status during the year following AMI; however, participation in CR did confer a significant survival benefit. These findings underscore the need for increased use of validated patient-reported outcome measures to further examine if and how health status can be maximized for patients who participate in CR.