Effect of intervention timing on one-year mortality in elderly non-ST-segment elevation myocardial infarction patients.

BACKGROUND: The best timing for early invasive therapy in non-ST-segment elevation myocardial infarction (NSTEMI) patients remains controversial. We sought to determine the optimal timing of early catheterization in order to improve long-term outcomes in elderly (>65 years old) patients with NSTEMI. METHODS: Using data from the CRUSADE registry linked to Medicare claims, we evaluated the association of early catheterization within the first 24 h or earlier time cut-points of NSTEMI presentation with long-term mortality among older Medicare beneficiaries. RESULTS: Of 15 575 NSTEMI patients from 398 CRUSADE hospitals (2003-2006), 3880 (24.9%) received early (≤12 h) catheterization. Compared with those undergoing later catheterization, patients treated early were younger and had less comorbid illness. Relative to those treated later, patients receiving early catheterization had similar 1-year all-cause mortality (11.8% vs 11.9%, P = 0.90). Using on- vs off-hour presentation as an instrumental variable, balancing potential measured and unmeasured confounders, early and later catheterization patients had nonsignificant differences in 1-year mortality (+5.6% [-11.5%, +22.7%]). Similar results were observed in clinically relevant subgroups, such as age (< or ≥75 years), gender, diabetes status, Global Registry of Acute Coronary Events score (< or ≥140), presence of heart failure, and sensitivity analyses of alternative definitions of early catheterization (≤6 and ≤24 h). CONCLUSIONS: Among older NSTEMI patients, we found that <24 h or earlier (neither <6 nor 12 h) of catheterization timing were not significantly associated with differences in long-term mortality.

Association Between Intensive Care Unit Usage and Long-Term Medication Adherence, Mortality, and Readmission Among Initially Stable Patients With Non-ST-Segment-Elevation Myocardial Infarction.

Background Hospitals in the United States vary in their use of intensive care units (ICUs) for hemodynamically stable patients with non-ST-segment-elevation myocardial infarction (NSTEMI). The association between ICU use and long-term outcomes after NSTEMI is unknown. Methods and Results Using data from the National Cardiovascular Data Registry linked to Medicare claims, we identified 65 256 NSTEMI patients aged ≥ 65 years without cardiogenic shock or cardiac arrest on presentation between 2011 and 2014. We compared 1-year medication non-adherence, cardiovascular readmission, and mortality across hospitals by ICU use using multivariable regression models. Among 520 hospitals, 154 (29.6%) were high ICU users (>70% of stable NSTEMI patients admitted to ICU), 270 (51.9%) were intermediate (30%-70%), and 196 (37.7%) were low (<30%). Compared with low ICU usage hospitals, no differences were observed in the risks of 1-year medication non-adherence (adjusted odds ratio 1.08, 95% CI, 0.97-1.21), mortality (adjusted hazard ratio 1.06, 95% CI, 0.98-1.15), and cardiovascular readmission (adjusted hazard ratio 0.99, 95% CI, 0.95-1.04) at high usage hospitals. Patients hospitalized at intermediate ICU usage hospitals had lower rates of evidence-based therapy and diagnostic catheterization within 24 hours of hospital arrival, and higher risks of 1-year mortality (adjusted hazard ratio 1.07, 95% CI, 1.02-1.12) and medication non-adherence (adjusted odds ratio 1.09, 95% CI, 1.02-1.15) compared with low ICU usage hospitals. Conclusions Routine ICU use is unlikely to be beneficial for hemodynamically stable NSTEMI patients; medication adherence, long-term mortality, and cardiovascular readmission did not differ for high ICU usage hospitals compared with hospitals with low ICU usage rates.

Readmissions After Acute Myocardial Infarction: How Often Do Patients Return to the Discharging Hospital?

Background When patients require readmission after a recent myocardial infarction (MI), returning to the discharging (index) hospital may be associated with better outcomes as a result of greater continuity in care. However, little evidence exists to answer this frequent patient question. Methods and Results Among Medicare patients aged ≥65 years discharged home alive post-MI from 491 US hospitals in the ACTION (Acute Coronary Treatment Intervention Outcomes Network) Registry, we compared reason for readmission, duration of rehospitalization, and 30-day mortality between patients readmitted to the index versus nonindex hospital within 30 days of index MI discharge. Among 53 471 MI patients, 7715 (14%) were readmitted within 30 days, and most readmitted patients (73%) returned to the discharging hospital. Reason for readmission was not significantly associated with location of readmission. In multivariable modeling, the strongest factors associated with readmission to a nonindex hospital were distance from the discharging hospital, transfer-in during the index MI hospitalization, and frequency of nonindex hospital admissions in the year preceding to the index MI. Duration of rehospitalization did not differ significantly between patients readmitted to the index versus nonindex hospital (median, 4 versus 3 days; P=0.17). Mortality risk was also not significantly different between patients readmitted to the index versus nonindex hospital overall (7.4 versus 7.7%; adjusted odds ratio, 0.89; 95% CI, 0.73-1.10) and when stratified by reason for readmission (P for interaction=0.61). Conclusions Post-MI readmissions did not differ in reason for readmission, duration of rehospitalization, or associated mortality when compared between patients who returned to the discharging hospital and those who sought care elsewhere.

Intensive Care Utilization in Stable Patients With ST-Segment Elevation Myocardial Infarction Treated With Rapid Reperfusion.

OBJECTIVES: The aims of this study were to describe variability in intensive care unit (ICU) utilization for patients with uncomplicated ST-segment elevation myocardial infarction (STEMI), evaluate the proportion of these patients who developed in-hospital complications requiring ICU care, and assess whether ICU use patterns and complication rates vary across categories of first medical contact to device times. BACKGROUND: In the era of rapid primary percutaneous coronary intervention, ICUs may be overutilized as patients presenting with STEMI are less likely to develop complications requiring ICU care. METHODS: Using data from the Chest Pain-MI Registry linked to Medicare claims, the authors examined patterns of ICU utilization among hemodynamically stable patients with STEMI ≥65 years of age treated with uncomplicated primary percutaneous coronary intervention, stratified by timing of reperfusion: early (first medical contact-to-device time ≤60 min), intermediate (61 to 90 min), or late (>90 min). RESULTS: Of 19,507 patients with STEMI treated at 707 hospitals, 82.3% were treated in ICUs, with a median ICU stay of 1 day (interquartile range [IQR]: 1 to 2 days). The median FMC-to-device time was 79 min (IQR: 63 to 99 min); 22.0% of patients had early, 44.8% intermediate, and 33.2% late reperfusion. ICU utilization rates did not differ between patients with early, intermediate, and late reperfusion times (82%, 83%, and 82%; p for trend = 0.44). Overall, 3,159 patients (16.2%) developed complications requiring ICU care while hospitalized: 3.7% died, 3.7% had cardiac arrest, 8.7% shock, 0.9% stroke, 4.1% high-grade atrioventricular block requiring treatment, and 5.7% respiratory failure. Patients with longer FMC-to-device times were more likely to develop at least 1 of these complications (early 13.4%, intermediate 15.7%, and late 18.7%; p for trend <0.001; adjusted odds ratio [early as reference] for intermediate: 1.13 [95% confidence interval: 1.01 to 1.25]; adjusted odds ratio for late: 1.22 [95% confidence interval: 1.08 to 1.37]). CONCLUSIONS: Although >80% of stable patients with STEMI are treated in the ICU after primary percutaneous coronary intervention, the risk for developing a complication requiring ICU care is 16%. Implementing a risk-based triage strategy, inclusive of factors such as degree of reperfusion delay, could optimize ICU utilization for patients with STEMI.

Advanced Practice Provider Versus Physician-Only Outpatient Follow-Up After Acute Myocardial Infarction.

Background Physician shortages and reimbursement changes have led to greater use of advanced practice providers ( APP s). Prevalence of and outcomes associated with APP care following myocardial infarction are unknown. Methods and Results We examined outpatient cardiology or primary care visits within 90 days post-myocardial infarction among 29 477 Medicare-insured patients aged ≥65 years from 364 hospitals in Acute Coronary Treatment Intervention Outcomes Network Registry. We compared medication adherence, all-cause readmission risk, mortality, and major adverse cardiovascular events between patients seen by APP s versus physicians only. Overall, 11% of myocardial infarction patients were treated by an APP . Patients seen by APP s were more likely to have diabetes mellitus (37% versus 33%) and heart failure (20% versus 16%), be discharged to a nursing facility (21% versus 13%) and had more outpatient visits within 90 days post-discharge (median 6 versus 5, P<0.01 for all) than those seen by physicians only. Adherence to evidence-based medications (adjusted odds ratio, 0.98; 95% confidence interval, 0.89-1.08) and readmission risks (adjusted hazard ratio, 1.11; 95% confidence interval, 0.99-1.26) were similar between patients seen by APP s versus physicians only. Risks of 90-day mortality (adjusted hazard ratio, 1.18; 95% confidence interval, 0.98-1.42) and major adverse cardiovascular events (adjusted hazard ratio, 1.06; 95% confidence interval, 0.90-1.23) were also similar between patients seen by APP s versus physicians only. Conclusions APP s were likely used to provide more frequent monitoring of high-risk post- MI patients. Medication adherence, readmission risk, mortality, and major adverse cardiovascular events did not differ substantially between patients seen by physician- APP teams than those seen by physicians only.

Long-Term Mortality of Older Patients With Acute Myocardial Infarction Treated in US Clinical Practice.

BACKGROUND: There is limited information about the long-term survival of older patients after myocardial infarction (MI). METHODS AND RESULTS: CRUSADE (Can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the ACC/AHA guidelines) was a registry of MI patients treated at 568 US hospitals from 2001 to 2006. We linked MI patients aged ≥65 years in CRUSADE to their Medicare data to ascertain long-term mortality (defined as 8 years post index event). Long-term unadjusted Kaplan-Meier mortality curves were examined among patients stratified by revascularization status. A landmark analysis conditioned on surviving the first year post-MI was conducted. We used multivariable Cox regression to compare mortality risks between ST-segment-elevation myocardial infarction and non-ST-segment-elevation myocardial infarction patients. Among 22 295 MI patients ≥ age 65 years (median age 77 years), we observed high rates of evidence-based medication use at discharge: aspirin 95%, ß-blockers 94%, and statins 81%. Despite this, mortality rates were high: 24% at 1 year, 51% at 5 years, and 65% at 8 years. Eight-year mortality remained high among patients who underwent percutaneous coronary intervention (49%), coronary artery bypass graft (46%), and among patients who survived the first year post-MI (59%). Median survival was 4.8 years (25th, 75th percentiles 1.1, 8.5); among patients aged 65-74 years it was 8.2 years (3.3, 8.9) while for patients aged ≥75 years it was 3.1 years (0.6, 7.6). Eight-year mortality was lower among ST-segment-elevation myocardial infarction than non-ST-segment-elevation myocardial infarction patients (53% versus 67%); this difference was not significant after adjustment (hazard ratio 0.94, 95% confidence interval, 0.88-1.00). CONCLUSIONS: Long-term mortality remains high among patients with MI in routine clinical practice, even among revascularized patients and those who survived the first year.

Risk Score to Predict Need for Intensive Care in Initially Hemodynamically Stable Adults With Non-ST-Segment-Elevation Myocardial Infarction.

BACKGROUND: Intensive care unit (ICU) use for initially stable patients presenting with non-ST-segment-elevation myocardial infarction (NSTEMI) varies widely across hospitals and minimally correlates with severity of illness. We aimed to develop a bedside risk score to assist in identifying high-risk patients with NSTEMI for ICU admission. METHODS AND RESULTS: Using the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry linked to Medicare data, we identified patients with NSTEMI aged ≥65 years without cardiogenic shock or cardiac arrest on presentation. Complications requiring ICU care were defined as subsequent development of cardiac arrest, shock, high-grade atrioventricular block, respiratory failure, stroke, or death during the index hospitalization. We developed and validated a model and integer risk score (Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU risk score) that uses variables present at hospital admission to predict requirement for ICU care. Of 29 973 patients with NSTEMI, 4282 (14%) developed a complication requiring ICU-level care, yet 12 879 (43%) received care in an ICU. Signs or symptoms of heart failure, initial heart rate, initial systolic blood pressure, initial troponin, initial serum creatinine, prior revascularization, chronic lung disease, ST-segment depression, and age had statistically significant associations with requirement for ICU care after adjusting for other risk factors. The ACTION ICU risk score had a C-statistic of 0.72. It identified 11% of patients as having very high risk (>30%) of developing complications requiring ICU care and 49% as having low likelihood (<10%) of requiring an ICU. CONCLUSIONS: The ACTION ICU risk score quantifies the risk of initially stable patients with NSTEMI developing a complication requiring ICU care, and could be used to more effectively allocate limited ICU resources.

Reassessment of Cardiac Function and Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Myocardial Infarction.

BACKGROUND: Guidelines recommend that patients with low ejection fraction (EF) after myocardial infarction (MI) have their EF reassessed 40 days after MI for implantable cardioverter-defibrillator (ICD) candidacy. This study examines rates of EF reassessment and their association with 1-year ICD implantation in post-MI patients with low EF. METHODS: We examined rates of postdischarge EF reassessment and ICD implantation among 10 289 Medicare-insured patients ≥65 years of age with an EF≤35% during the index MI admission from January 2007 through September 2010 in ACTION Registry-GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines). Multivariable Cox models tested the association between time-dependent EF reassessment and 1-year ICD implantation, stratified by revascularization status during the index MI admission. RESULTS: Among patients with EF ≤35% during the index MI admission, 66.8% (95% confidence interval [CI], 65.9-67.8) had EF reassessment within the next year. Revascularized patients were more likely to have EF reassessment (76.9% [95% CI, 75.8-78.0)] versus 53.7% [95% CI, 52.2-55.2]; P<0.001) and had shorter times to EF reassessment (median, 67 versus 84 days; P<0.001) than nonrevascularized patients. Among patients with EF reassessment, only 11% received an ICD within 1 year. Reassessment of EF was associated with a higher likelihood of ICD implantation for both revascularized (unadjusted, 12.1% versus 2.4%, P<0.001; adjusted hazard ratio, 10.6, 95% CI, 7.7-14.8) and nonrevascularized (unadjusted, 10.0% versus 1.7%, P<0.001; adjusted hazard ratio, 6.1, 95% CI, 4.1-9.2) patients. CONCLUSIONS: In US practice, EF reassessments are commonly performed among patients with MI with an initially reduced EF. Although 1-year EF reassessment is associated with increased likelihood of ICD implantation, 1-year ICD implantation rates remain very low even among patients with EF reassessment, regardless of revascularization status.

Intensive Care Unit Utilization and Mortality Among Medicare Patients Hospitalized With Non-ST-Segment Elevation Myocardial Infarction.

Importance: Intensive care unit (ICU) utilization may have important implications for the care and outcomes of patients with non-ST-segment elevation myocardial infarction (NSTEMI). Objectives: To examine interhospital variation in ICU utilization in the United States for older adults with hemodynamically stable NSTEMI and outcomes associated with ICU utilization among patients with low, moderate, or high mortality risk. Design, Setting, and Participants: This study was a retrospective analysis of 28 018 Medicare patients 65 years or older admitted with NSTEMI to 346 hospitals participating in the Acute Coronary Treatment and Intervention Outcomes Network (ACTION)-Get With the Guidelines from April 1, 2011, through December 31, 2012. Patients with cardiogenic shock or cardiac arrest on presentation were excluded. Data analysis was performed from May 7 through October 8, 2015. Exposures: Hospitals with high (>70% of patients with NSTEMI treated in an ICU during the index hospitalization), intermediate (30%-70%), or low (<30%) ICU utilization. Main Outcomes and Measures: Thirty-day mortality. Results: Of 28 018 patients with NSTEMI 65 years or older (median age, 77 years [interquartile range, 71-84 years]; female, 13 055 [46.6%]; nonwhite race, 3931 [14.0%]), 11 934 (42.6%) had an ICU stay. The proportion of patients with NSTEMI treated in the ICU varied across hospitals (median, 38%; interquartile range, 26%-54%), but no significant differences were found in hospital or patient characteristics among high, intermediate, or low ICU utilization hospitals. Compared with high ICU utilization hospitals, low or intermediate ICU utilization hospitals were only marginally more selective of higher-risk patients, as determined by ACTION in-hospital mortality risk score or initial troponin level. The median ACTION risk score for patients treated in the ICU at low and intermediate ICU utilization hospitals was 34 compared with 33 for patients not treated in the ICU; at high ICU utilization hospitals, the median ACTION mortality risk score was 33 for patients treated in the ICU and 34 for patients not treated in the ICU. Thirty-day mortality rates did not significantly differ based on hospital ICU utilization (high vs low: 8.7% vs 8.7%; adjusted odds ratio, 0.91; 95% CI, 0.76-1.08; intermediate vs low: 9.6% vs 8.7%; adjusted odds ratio, 1.06; 95% CI, 0.94-1.20). The association between hospital ICU utilization and mortality did not change when considered among patients with ACTION risk scores greater than 40, 30 to 40, and less than 30 (adjusted interaction P = .86). Conclusions and Relevance: Utilization of the ICU for older patients with NSTEMI varied significantly among hospitals. This variability was not explained by hospital characteristics or driven by patient risk. Mortality after myocardial infarction did not significantly differ among high, intermediate, or low ICU utilization hospitals.

Implantable Cardioverter-Defibrillator Use Among Medicare Patients With Low Ejection Fraction After Acute Myocardial Infarction.

IMPORTANCE: Implantable cardioverter-defibrillators (ICDs) are not recommended within 40 days of myocardial infarction (MI); thus, ICD implantation might not be considered during the post-MI care transition. OBJECTIVE: To examine ICD implantation rates and associated mortality among older MI patients with low ejection fraction (EF). DESIGN, SETTING, AND PARTICIPANTS: Retrospective observational study of Medicare beneficiaries with an EF of 35% or less after MI, treated at 441 US hospitals between 2007 and 2010, excluding patients with prior ICD implantation. Follow-up data were available through December 2010. EXPOSURES: ICD implantation within 1 year of MI vs no ICD implantation within 1 year of MI. MAIN OUTCOMES AND MEASURES: Patient characteristics associated with receiving an ICD within 1 year after discharge and 2-year mortality associated with ICD implantation. RESULTS: Among 10,318 MI patients with EF of 35%or lower, the cumulative 1-year ICD implantation rate was 8.1% (95%CI, 7.6%-8.7%). Patients with ICD implantation were more likely to have prior coronary artery bypass graft procedures, higher peak troponin levels, in-hospital cardiogenic shock, and cardiology follow-up within 2 weeks after discharge relative to patients who did not receive an ICD within 1 year. Implantation of ICD was associated with lower 2-year mortality (15.3 events per 100 patient-years [128 deaths in 838 patient-years] vs 26.4 events per 100 patient-years [3033 deaths in 11 479 patient-years]; adjusted HR, 0.64; 95%CI, 0.53-0.78). [table: see text] CONCLUSIONS AND RELEVANCE: In this large registry study of older patients who experienced MI from 2007-2010, fewer than 1 in 10 eligible patients with low EF received an ICD within 1 year after MI, although ICD implantation was associated with lower risk-adjusted mortality at 2 years. Additional research is needed to determine evidence-based approaches to increase ICD implantation among eligible patients.

Differences in short-term versus long-term outcomes of older black versus white patients with myocardial infarction: findings from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of American College of Cardiology/American Heart Association Guidelines (CRUSADE).

BACKGROUND: Blacks are less likely than whites to receive coronary revascularization and evidence-based therapies after acute myocardial infarction, yet the impact of these differences on long-term outcomes is unknown. METHODS AND RESULTS: We linked Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes With Early Implementation of American College of Cardiology/American Heart Association Guidelines (CRUSADE) registry data to national Medicare claims, creating a longitudinal record of care and outcomes among 40 500 patients with non-ST-segment-elevation myocardial infarction treated at 446 hospitals to examine mortality and readmission rates (mean follow-up, 2.4 years) among black and white patients. Relative to whites (n=37 384), blacks (n=3116) were more often younger and female; more often had diabetes mellitus and renal failure; and received less aggressive interventions, including cardiac catheterization (60.7% versus 54.0%; P<0.001), percutaneous coronary intervention (32.1% versus 23.8%; P<0.001), and coronary bypass surgery (9.2% versus 5.7%; P<0.001). Although blacks had lower 30-day mortality (9.1% versus 9.9%; adjusted hazard ratio, 0.80; 95% confidence interval, 0.71-0.92), they had higher observed mortality at 1 year (27.9% versus 24.5%; P<0.001), although this was not significant after adjustment on long-term follow-up (hazard ratio, 1.00; 95% confidence interval, 0.94-1.07). Black patients also had higher 30-day (23.6% versus 20.0%; P<0.001) and 1-year (62.0% versus 54.6%; P<0.001) all-cause readmission, but these differences were no longer significant after risk adjustment on 30-day (hazard ratio, 1.02; 95% confidence interval, 0.92-1.13) and long-term (hazard ratio, 1.05; 95% confidence interval, 1.00-1.11) follow-up. CONCLUSIONS: Although older blacks with an acute myocardial infarction had lower initial mortality rates than whites, this early survival advantage did not persist during long-term follow-up. The reasons for this are multifactorial but may include differences in comorbidities and postdischarge care.

Left ventricular ejection fraction assessment among patients with acute myocardial infarction and its association with hospital quality of care and evidence-based therapy use.

BACKGROUND: The left ventricular ejection fraction (LVEF) has prognostic and therapeutic utility after acute myocardial infarction (AMI). Although LVEF assessment is a key performance measure among AMI patients, contemporary rates of in-hospital assessment and its association with therapy use have not been well characterized. METHODS AND RESULTS: We examined rates of in-hospital LVEF assessment among 77 982 non-ST-elevation myocardial infarction patients and 50 863 ST-elevation myocardial infarction patients in Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With The Guidelines between January 2007 and September 2009, after excluding patients who died in-hospital or who were transferred to another acute care facility, discharged to end-of-life care, or had missing LVEF assessment status. LVEF assessment increased significantly over time, with higher rates among ST-elevation myocardial infarction than non-ST-elevation myocardial infarction patients (95.1% versus 91.6%; P<0.001). Excluding patients with prior heart failure did not alter these observations. Significant interhospital variability in LVEF assessment rates was observed. Compared with patients with in-hospital LVEF assessment, patients who did not have LVEF assessed were older and more likely to have clinical comorbidities. In multivariable modeling, lower overall hospital quality of AMI care was also associated with lower likelihood of LVEF assessment (odds ratio for failure to assess LVEF, 1.09; 95% confidence interval, 1.05-1.13 per 10% decrease in defect-free care). Patients with in-hospital LVEF assessment were more likely to be discharged on evidence-based secondary prevention medication therapies compared with patients without LVEF assessment. CONCLUSIONS: The assessment of LVEF among patients with AMI has improved significantly over time, yet significant interhospital variability exists. Patients who did not have in-hospital LVEF assessment were less likely to receive evidence-based medications at discharge. These patients represent targets for future quality improvement efforts.

Predicting long-term mortality in older patients after non-ST-segment elevation myocardial infarction: the CRUSADE long-term mortality model and risk score.

OBJECTIVES: We sought to develop a long-term mortality risk prediction model and a simplified risk score for use in older patients with non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: Limited data are available regarding long-term mortality rates and concomitant risk predictors after acute myocardial infarction in contemporary community practice. METHODS: From the CRUSADE registry, a total of 43,239 (NSTEMI) patients aged ≥65 years treated at 448 hospitals in the United States from 2003 to 2006 were linked to Centers for Medicare and Medicaid Services data to track longitudinal all-cause mortality (median follow-up 453 days). Cox proportional hazard modeling was used to determine baseline independent demographic, clinical, and laboratory variables associated with long-term mortality. A simplified long-term mortality risk score was subsequently developed from these results. RESULTS: The median age of this population was 77 years, and mortality rates at 1, 2, and 3 years were 24.4%, 33.2%, and 40.3%, respectively. We identified 22 variables independently associated with long-term mortality in a full model (c-statistic 0.754 in the derivation sample and 0.744 in the validation sample). The CRUSADE long-term mortality risk score was limited to the 13 most clinically and statistically significant variables from the full model yet retained comparable discrimination in the derivation and validation samples (c-statistics 0.734 and 0.727, respectively) and had good calibration across the risk spectra. CONCLUSIONS: Older patients face substantial long-term mortality risks after NSTEMI that can be accurately predicted from baseline characteristics. These prognostic estimates may support informed treatment decision-making and comparison of long-term provider outcomes.

Use of guidelines-recommended management and outcomes among women and men with low-level troponin elevation: insights from CRUSADE.

BACKGROUND: Troponin elevation above the upper limit of normal (ULN) is diagnostic of myocardial infarction, but interpretation of "gray-zone" troponin elevations (1 to 1.5x ULN) remains uncertain. Using the CRUSADE database, we explored relationships between sex and treatment and outcomes among patients with troponin 1 to 1.5x ULN. METHODS AND RESULTS: We compared treatment and outcomes among women and men using logistic generalized estimating equation method. Overall, 5049 of 85 671 (5.9%) non-ST-segment elevation acute coronary syndromes patients (2156 women, 2893 men) had troponin 1 to 1.5x ULN within 24 hours of presentation. Compared with troponin >1.5x ULN, "gray-zone" patients less often received all guidelines-indicated acute (mean composite score, 63% versus 72%) and discharge therapies (mean composite score, 73% versus 78%), but received them more frequently than patients with troponin <1x ULN (mean composite scores, 58% acute and 67% discharge). Among "gray-zone" patients, acute and discharge therapy use was similar between women and men, except acute aspirin (adjusted odds ratio, 0.80 [95% CI, 0.65 to 0.98]) and discharge angiotensin-converting enzyme inhibitors (adjusted odds ratio, 0.77 [95% CI, 0.67 to 0.88]). "Gray-zone" patients had lower mortality (2.3%) than the >1.5x ULN (4.5%) group but higher than the <1x ULN group (1.1%). Outcomes were similar among "gray-zone" women and men (adjusted odds ratios: death, 0.88 [95% CI, 0.58 to 1.35]; death/myocardial infarction, 0.77 [95% CI, 0.55 to 1.06]; transfusion, 1.04 [95% CI, 0.85 to 1.27]). CONCLUSIONS: Patients with non-ST-segment elevation acute coronary syndromes and low-level troponin elevations had lower overall risk and received less aggressive guidelines-based treatment than those with greater troponin elevations, but treatment patterns were largely similar by sex across troponin elevation groups.

Insurance coverage and care of patients with non-ST-segment elevation acute coronary syndromes.

BACKGROUND: The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear. OBJECTIVE: To compare NSTE ACS care patterns by insurance type. DESIGN: Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage. SETTING: 521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005. PATIENTS: 37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older. MEASUREMENTS: Guideline-recommended treatments, and in-hospital outcomes. RESULTS: Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18). LIMITATIONS: Self-pay patients and patients without insurance were not assessed. CONCLUSIONS: NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation.