Sex differences in trends and outcomes of acute myocardial infarction with mechanical complications in the United States.

BACKGROUND: Mechanical complications (MC) are rare but significant sequelae of acute myocardial infarction (AMI). Current data on sex differences in AMI with MC is limited. METHODS: We queried the National Inpatient Sample database to identify adult patients with the primary diagnosis of AMI and MC. The main outcome of interest was sex difference in-hospital mortality. Secondary outcomes were sex differences in the incidence of acute kidney injury (AKI), major bleeding, use of inotropes, permanent pacemaker implantation (PPMI), performance of percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), surgery (VSD repair and MV surgery), pericardiocentesis, use of mechanical circulatory support (MCS), ischemic stroke, and mechanical ventilation. RESULTS: Among AMI-MC cohort, in-hospital mortality was higher among females compared to males (41.24% vs 28.13%: aOR 1.39. 95% CI 1.079-1.798; p = 0.01). Among those who had VSD, females also had higher in-hospital mortality compared to males (56.7% vs 43.1%: aOR 1.74, 95% CI 1.12-2.69; p = 0.01). Females were less likely to receive CABG compared to males (12.03% vs 20%: aOR 0.49 95% CI 0.345-0.690; p < 0.001). CONCLUSION: Despite the decreasing trend in AMI admission, females had higher risk of MC and associated mortality. Significant sex disparities still exist in AMI treatment.

A simple smiFISH pipeline to quantify mRNA at the single-cell level in 3D.

Techniques allowing the precise quantification of mRNA at the cellular level are essential for understanding biological processes. Here, we present a semi-automated smiFISH (single-molecule inexpensive FISH) pipeline enabling quantification of mRNA in a small number of cells (∼40) in fixed whole mount tissue. We describe steps for sample preparation, hybridization, image acquisition, cell segmentation, and mRNA quantification. Although the protocol was developed in Drosophila, it can be optimized for use in other organisms. For complete details on the use and execution of this protocol, please refer to Guan et al.1.

Risk of Recall Associated With Modifications to High-risk Medical Devices Approved Through US Food and Drug Administration Supplements.

Importance: High-risk medical devices approved by the US Food and Drug Administration (FDA) can undergo modifications to their original premarket approval (PMA) via 1 of 5 types of supplements. Only panel track supplements (approximately 1%) require clinical data for approval. The association between device modifications and risk to patient safety has not previously been analyzed. Objective: To determine the association between PMA supplements and the risk of any device recall and high-risk (class 1) recall. Design, Setting, and Participants: In this cohort study, the FDA database was queried for original devices approved via PMA from January 1, 2008, through December 31, 2019. Supplement and recall data were obtained for these devices from January 1, 2008, through December 31, 2021, giving a minimum 2-year follow-up after initial approval. Data were analyzed from July 6 to August 6, 2022. Retrospective, time-to-event analysis investigated the association between the number and type of supplements and risk of recall. Exposures: Supplements submitted by manufacturers for FDA approval to modify devices. Main Outcomes and Measures: A mixed-effects Cox proportional hazards regression model with frailty terms was used, modeling device recall as an outcome variable during the observation period. A second model was performed for class 1 (high-risk) recall. Explanatory variables are the number of supplements, number of panel track supplements, and cardiovascular devices. Multivariable analysis was performed to identify independent risk factors for recall with hazard ratios (HRs) as the main end point. Results: A total of 373 original PMA devices with 10 776 associated supplements were included in the analysis. A median 2.5 (IQR, 1.2-5.0) supplements per device were approved annually. Cardiovascular devices contributed 138 supplements (37.0%), followed by microbiology with 45 (12.1%). No other specialty contributed more than 10%. Multivariable analysis demonstrated that each increase of 1 supplement per year was associated with increased risk of recall (HR, 1.28 [95% CI, 1.15-1.44]; P < .001). For class 1 recall, increased number of supplements (HR, 1.32 [95% CI, 1.06-1.64]; P = .01) and cardiovascular vsnoncardiovascular classification of devices (HR, 3.51 [95% CI, 1.15-10.72]; P = .03) were significantly associated with an increased risk of recall. Conclusions and Relevance: The findings of this cohort study suggest that PMA supplements are associated with an approximately 30% increased risk of any recall and class 1 recall. The FDA processes for approving modifications to high-risk medical devices should be reevaluated to optimize patient safety and public health.

Use of primary bariatric surgery among patients with obesity and diabetes. Insights from the Diabetes Collaborative Registry.

Despite its cardiometabolic benefits, bariatric surgery has historically been underused in patients with obesity and diabetes, but contemporary data are lacking. Among 1,520,182 patients evaluated from 2013 to 2019 within a multicenter, longitudinal, US registry of outpatients with diabetes, we found that 462,033 (30%) met eligibility for bariatric surgery. After a median follow-up of 854 days, 6310/384,859 patients (1.6%) underwent primary bariatric surgery, with a slight increase over time (0.38% per year [2013] to 0.68% per year [2018]). Patients who underwent bariatric surgery were more likely to be female (63% vs. 56%), white (87% vs. 82%), have higher body mass indices (42.1 ± 6.9 vs. 40.6 ± 5.9 kg/m2), and depression (23% vs. 14%; p < 0.001 for all). Over a median (IQR) follow-up after surgery of 722 days (364-993), patients who underwent bariatric surgery had lost an average of 11.8 ± 18.5 kg (23% of excess body weight), 10.2% were on fewer glucose-lowering medications, and 8.4% were on fewer antihypertensives. Despite bariatric surgery being safer and more accessible over the past two decades, less than one in fifty eligible patients with diabetes receive this therapy.

Post-transcriptional regulation of transcription factor codes in immature neurons drives neuronal diversity.

How the vast array of neuronal diversity is generated remains an unsolved problem. Here, we investigate how 29 morphologically distinct leg motoneurons are generated from a single stem cell in Drosophila. We identify 19 transcription factor (TF) codes expressed in immature motoneurons just before their morphological differentiation. Using genetic manipulations and a computational tool, we demonstrate that the TF codes are progressively established in immature motoneurons according to their birth order. Comparing RNA and protein expression patterns of multiple TFs reveals that post-transcriptional regulation plays an essential role in shaping these TF codes. Two RNA-binding proteins, Imp and Syp, expressed in opposing gradients in immature motoneurons, control the translation of multiple TFs. The varying sensitivity of TF mRNAs to the opposing gradients of Imp and Syp in immature motoneurons decrypts these gradients into distinct TF codes, establishing the connectome between motoneuron axons and their target muscles.

[Development and maintenance of the neuromuscular system]. / Développement et maintenance du système neuromusculaire.

Diseases of the locomotor system are at the origin of disabilities with severe social and economic consequences. The study of the neuromuscular system development and maintenance has become a key challenge for the scientific community in order to design efficient therapies. My thesis project aims to elucidate the mechanisms at the origin of the communication between motoneuron axons and their muscle targets in order to understand how specific innervations are generated during development and maintained during adulthood. The first part of the project will address the understanding of the mechanisms controlling the specific muscle-axon recognition during development. I will perform live imaging and fixed tissues experiments to visualize and understand the development of myoblasts and motoneurons at the same time. Then, I will perform transcriptomic experiments to discover molecules playing a role in the specific axon-muscle recognition. The second part of the project is meant to elucidate the mechanism controlling the system maintenance in the adult. To answer this question I will study the function of morphological transcription factors in adulthood, which are known as transcription factors controlling the morphology of motoneurons during development. To conclude, this project will lead to novel biological concepts that will increase our fundamental knowledge on developmental biology. Understanding the mechanisms that specify the muscle innervation will allow to find efficient ways to tackle neuromuscular diseases.

Association of Cognitive Impairment With Treatment and Outcomes in Older Myocardial Infarction Patients: A Report From the NCDR Chest Pain-MI Registry.

Background Little is known regarding use of cardiac therapies and clinical outcomes among older myocardial infarction (MI) patients with cognitive impairment. Methods and Results Patients ≥65 years old with MI in the NCDR (National Cardiovascular Data Registry) Chest Pain-MI Registry between January 2015 and December 2016 were categorized by presence and degree of chart-documented cognitive impairment. We evaluated whether cognitive impairment was associated with all-cause in-hospital mortality after adjusting for known prognosticators. Among 43 812 ST-segment-elevation myocardial infarction (STEMI) patients, 3.9% had mild and 2.0% had moderate/severe cognitive impairment; among 90 904 non-ST-segment-elevation myocardial infarction (NSTEMI patients, 5.7% had mild and 2.6% had moderate/severe cognitive impairment. A statistically significant but numerically small difference in the use of primary percutaneous coronary intervention was observed between patients with STEMI with and without cognitive impairment (none, 92.1% versus mild, 92.8% versus moderate/severe, 90.4%; P=0.03); use of fibrinolysis was lower among patients with cognitive impairment (none, 40.9% versus mild, 27.4% versus moderate/severe, 24.2%; P<0.001). Compared with NSTEMI patients without cognitive impairment, rates of angiography, percutaneous coronary intervention, and coronary artery bypass grafting were significantly lower among patients with NSTEMI with mild (41%, 45%, and 70% lower, respectively) and moderate/severe cognitive impairment (71%, 74%, and 93% lower, respectively). After adjustment, compared with no cognitive impairment, presence of moderate/severe (STEMI: odds ratio, 2.2, 95% CI, 1.8-2.7; NSTEMI: odds ratio, 1.7, 95% CI, 1.4-2.0) and mild cognitive impairment (STEMI: OR, 1.3, 95% CI, 1.1-1.5; NSTEMI: odds ratio, 1.3, 95% CI, 1.2-1.5) was associated with higher in-hospital mortality. Conclusions Patients with NSTEMI with cognitive impairment are substantially less likely to receive invasive cardiac care, while patients with STEMI with cognitive impairment receive similar primary percutaneous coronary intervention but less fibrinolysis. Presence and degree of cognitive impairment was independently associated with increased in-hospital mortality. Approaching clinical decision making for older patients with MI with cognitive impairment requires further study.

Association of acute myocardial infarction cardiac arrest patient volume and in-hospital mortality in the United States: Insights from the National Cardiovascular Data Registry Acute Coronary Treatment And Intervention Outcomes Network Registry.

BACKGROUND: Little is known about how differences in out of hospital cardiac arrest patient volume affect in-hospital myocardial infarction (MI) mortality. HYPOTHESIS: Hospitals accepting cardiac arrest transfers will have increased hospital MI mortality. METHODS: MI patients (ST elevation MI [STEMI] and non-ST elevation MI [NSTEMI]) in the Acute Coronary Treatment Intervention Outcomes Network Registry were included. Hospital variation of cardiac arrest and temporal trend of the proportion of cardiac arrest MI patients were explored. Hospitals were divided into tertiles based on the proportion of cardiac arrest MI patients, and association between in-hospital mortality and hospital tertiles of cardiac arrest was compared using logistic regression adjusting for case mix. RESULTS: A total of 252 882 patients from 224 hospitals were included, of whom 9682 (3.8%) had cardiac arrest (1.6% of NSTEMI and 7.5% of STEMI patients). The proportion of MI patients who had cardiac arrest admitted to each hospital was relatively low (median 3.7% [25th, 75th percentiles: 3.0%, 4.5%]).with a range of 4.2% to 12.4% in the high-volume tertiles. Unadjusted in-hospital mortality increased with tertile: low 3.8%, intermediate 4.6%, and high 4.7% (P < 0.001); this was no longer significantly different after adjustment (intermediate vs high tertile odds ratio (OR) = 1.02; 95% confidence interval [0.90-1.16], low vs high tertile OR = 0.93 [0.83, 1.05]). CONCLUSIONS: The proportion of MI patients who have cardiac arrest is low. In-hospital mortality among all MI patients did not differ significantly between hospitals that had increased proportions of cardiac arrest MI patients. For most hospitals, overall MI mortality is unlikely to be adversely affected by treating cardiac arrest patients with MI.

30-Day Readmissions After Endovascular Thrombectomy for Acute Ischemic Stroke.

OBJECTIVES: The authors sought to investigate the incidence, predictors, and causes of 30-day nonelective readmissions after endovascular thrombectomy (EVT). BACKGROUND: Randomized trials have demonstrated that EVT improves outcomes in patients with acute ischemic stroke. METHODS: The Nationwide Readmissions Database, years 2013 and 2014, was used to identify hospitalizations for a primary diagnosis of acute ischemic stroke during which patients underwent EVT, with or without intravenous thrombolysis. The incidence and reasons of 30-day readmissions were investigated. A hierarchical Cox regression model was used to identify independent predictors of 30-day nonelective readmissions. A propensity score-matched analysis was performed to compare the risk of 30-day nonelective readmissions in those who underwent EVT versus thrombolysis alone. RESULTS: Among 2,055,365 weighted hospitalizations with acute ischemic stroke and survival to discharge, 10,795 (0.5%) underwent EVT. The 30-day readmission rate was 12.4% within a median of 9 days (interquartile range: 4 to 18 days). Diabetes mellitus, coagulopathy, Medicare or Medicaid insurance, and gastrostomy during the index hospitalization were independent predictors of 30-day readmission, but coadministration of thrombolytics with EVT was not an independent predictor. The most common reasons for readmission were infections (17.2%), cardiac causes (17.0%), and recurrent stroke or transient ischemic attack (14.8%). Compared with thrombolysis alone, the hazard of 30-day readmissions was similar (hazard ratio: 0.98; 95% confidence interval: 0.91 to 1.05; p = 0.55). CONCLUSIONS: In patients hospitalized with acute ischemic stroke who underwent EVT, 30-day nonelective readmissions were common, occurring in approximately 1 in 8 patients, but were similar to those of patients treated with thrombolysis alone. Risk of readmission was associated with certain patient demographics, comorbidities, and complications, but not thrombolysis coadministration. Infections, cardiac causes, and recurrent stroke or transient ischemic attack are the most common reasons for readmission after EVT, emphasizing the need for comprehensive multidisciplinary treatment in the transition to outpatient care.

Visualize Drosophila Leg Motor Neuron Axons Through the Adult Cuticle.

The majority of work on the neuronal specification has been carried out in genetically and physiologically tractable models such as C. elegans, Drosophila larvae, and fish, which all engage in undulatory movements (like crawling or swimming) as their primary mode of locomotion. However, a more sophisticated understanding of the individual motor neuron (MN) specification-at least in terms of informing disease therapies-demands an equally tractable system that better models the complex appendage-based locomotion schemes of vertebrates. The adult Drosophila locomotor system in charge of walking meets all of these criteria with ease, since in this model it is possible to study the specification of a small number of easily distinguished leg MNs (approximately 50 MNs per leg) both using a vast array of powerful genetic tools, and in the physiological context of an appendage-based locomotion scheme. Here we describe a protocol to visualize the leg muscle innervation in an adult fly.

The Association of Frailty With In-Hospital Bleeding Among Older Adults With Acute Myocardial Infarction: Insights From the ACTION Registry.

OBJECTIVES: The aim of this study was to determine whether frailty is associated with increased bleeding risk in the setting of acute myocardial infarction (AMI). BACKGROUND: Frailty is a common syndrome in older adults. METHODS: Frailty was examined among AMI patients ≥65 years of age treated at 775 U.S. hospitals participating in the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) Registry from January 2015 to December 2016. Frailty was classified on the basis of impairments in 3 domains: walking (unassisted, assisted, wheelchair/nonambulatory), cognition (normal, mildly impaired, moderately/severely impaired), and activities of daily living. Impairment in each domain was scored as 0, 1, or 2, and a summary variable consisting of 3 categories was then created: 0 (fit/well), 1 to 2 (vulnerable/mild frailty), and 3 to 6 (moderate-to-severe frailty). Multivariable logistic regression was used to examine the independent association between frailty and bleeding. RESULTS: Among 129,330 AMI patients, 16.4% had any frailty. Frail patients were older, more often female, and were less likely to undergo cardiac catheterization. Major bleeding increased across categories of frailty (fit/well 6.5%; vulnerable/mild frailty 9.4%; moderate-to-severe frailty 9.9%; p < 0.001). Among patients who underwent catheterization, both frailty categories were independently associated with bleeding risk compared with the non-frail group (vulnerable/mild frailty adjusted odds ratio [OR]: 1.33, 95% confidence interval [CI]: 1.23 to 1.44; moderate-to-severe frailty adjusted OR: 1.40, 95% CI: 1.24 to 1.58). Among patients managed conservatively, there was no association of frailty with bleeding (vulnerable/mild frailty adjusted OR: 1.01, 95% CI: 0.86 to 1.19; moderate-to-severe frailty adjusted OR: 0.96, 95% CI: 0.81 to 1.14). CONCLUSIONS: Frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) than nonfrail patients, making attention to clinical strategies to avoid bleeding imperative in this population.

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.

Streptococcus Agalactiae Infective Endocarditis in a Healthy Middle-aged Man: Uncommon but Life-threatening.

Streptococcus agalactiae (S.agalactiae) is known to cause invasive infections in pregnant women, newborns, and immunosuppressed patients. It is an uncommon but life-threatening case of infective endocarditis in middle-aged otherwise healthy adults. We present a case of a patient with life-threatening infective endocaritis caused by Streptococcus agalactiae, who passed away despite medical treatment.

A Right Ventricular Mass in a Patient with Squamous Cell Lung Cancer: A Case Report and Review of Literature.

Cardiac metastasis is much more common than primary cardiac tumors. Lung cancer is one of the most common primary malignancies to metastasize to the heart. It is not common for metastasis in the heart to present as a cavitary mass. To our knowledge, four cases have been reported in the literature showing metastatic lung cancer to the heart, presenting as a right ventricular mass.

Differing Strategies Despite Shared Lineages of Motor Neurons and Glia to Achieve Robust Development of an Adult Neuropil in Drosophila.

In vertebrates and invertebrates, neurons and glia are generated in a stereotyped manner from neural stem cells, but the purpose of invariant lineages is not understood. We show that two stem cells that produce leg motor neurons in Drosophila also generate neuropil glia, which wrap and send processes into the neuropil where motor neuron dendrites arborize. The development of the neuropil glia and leg motor neurons is highly coordinated. However, although motor neurons have a stereotyped birth order and transcription factor code, the number and individual morphologies of the glia born from these lineages are highly plastic, yet the final structure they contribute to is highly stereotyped. We suggest that the shared lineages of these two cell types facilitate the assembly of complex neural circuits and that the two birth order strategies-hardwired for motor neurons and flexible for glia-are important for robust nervous system development, homeostasis, and evolution.

Contemporary Patterns of Early Coronary Angiography Use in Patients With Non-ST-Segment Elevation Myocardial Infarction in the United States: Insights From the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry.

OBJECTIVES: The study sought to characterize patient- and hospital-level variation in early angiography use among non-ST-segment elevation myocardial infarction (NSTEMI) patients. BACKGROUND: Contemporary implementation of guideline recommendations for early angiography use in NSTEMI patients in the United States have not been described. METHODS: The study analyzed NSTEMI patients included in ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry (2012 to 2014) who underwent in-hospital angiography. Timing of angiography was categorized as early (≤24 h) vs. delayed (>24 h). The study evaluated factors associated with early angiography, hospital-level variation in early angiography use, and the relationship with quality-of-care measures. RESULTS: A total of 79,760 of 138,688 (57.5%) patients underwent early angiography. Factors most strongly associated with delayed angiography included weekend or holiday presentation, lower initial troponin ratio values, higher initial creatinine values, heart failure on presentation, and older age. Median hospital-level use of early angiography was 58.5% with wide variation across hospitals (21.7% to 100.0%). Patient characteristics did not differ substantially across hospitals grouped by tertiles of early angiography use (low, middle, and high). Hospitals in the highest tertile tended to more commonly use guideline-recommended medications and had higher defect-free care quality scores. CONCLUSIONS: In contemporary U.S. practice, high-risk clinical characteristics were associated with lower use of early angiography in NSTEMI patients; hospital-level use of early angiography varied widely despite few differences in case mix. Hospitals that most commonly utilized early angiography also had higher quality-of-care metrics, highlighting the need for improved NSTEMI guideline adherence.

The association of left ventricular ejection fraction with clinical outcomes after myocardial infarction: Findings from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines (GWTG) Medicare-linked database.

BACKGROUND: Little is known about the relationship between ejection fraction (EF) and clinical outcomes among older patients with myocardial infarction in contemporary clinical practice. METHODS: Data on 82,558 patients 65 years or older with ST-elevation myocardial infarction or non-ST-elevation myocardial infarction who survived to hospital discharge in the ACTION Registry-GWTG (2007-2011) were linked to Medicare data. Multivariable Cox proportional hazard modeling was used to assess the association between EF reported during hospitalization and 1-year mortality, using EF as a categorical variable (≤35%, >35% and ≤45%, >45% and <55%, and ≥55%) and as a continuous variable. Secondary outcomes of interest were 1-year all-cause, cardiovascular, and heart failure readmissions. RESULTS: The risk of 1-year mortality was 29.0% in patients with EF ≤ 35%, compared with 13.0% in patients in the reference group, EF ≥ 55% (adjusted hazard ratio [HR] 1.58, 95% CI 1.51-1.66). Relative to patients with EF ≥ 55%, patients with EF ≤ 35% had an increased risk of 1-year all-cause readmission (adjusted HR 1.20, 95% CI 1.17-1.24), cardiovascular readmission (adjusted HR 1.36, 95% CI 1.31-1.41), and heart failure readmission (adjusted HR 2.43, 95% CI 2.28-2.60). For patients with EF ≤ 40%, the hazard of mortality increased by 26% for every 5% decrease in EF, a finding that remained after risk adjustment (adjusted HR 1.11, 95% CI 1.09-1.12). CONCLUSIONS: Low EF after MI remains an important risk factor for postdischarge mortality and hospital readmission, even after adjustment for patient and hospital characteristics.

Timing of First Postdischarge Follow-up and Medication Adherence After Acute Myocardial Infarction.

IMPORTANCE: The use of evidence-based medication therapy in patients after acute myocardial infarction (AMI) improves long-term prognosis, yet the current rates of adherence are poor. OBJECTIVE: To determine whether earlier outpatient follow-up after AMI is associated with higher rates of medication adherence. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis was conducted of 20 976 Medicare patients older than 65 years discharged alive after an AMI between January 2, 2007, and October 1, 2010, from 461 Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines hospitals in the United States. Patients were grouped based on the timing of first follow-up clinic visit within 1 week, 1 to 2 weeks, 2 to 6 weeks, or more than 6 weeks after hospital discharge. Data analysis was conducted from September 26, 2014, to April 22, 2015. MAIN OUTCOMES AND MEASURES: Medication adherence was defined as the proportion of days with more than 80% coverage using Medicare Part D prescription fill records and was examined at 90 days and 1 year after discharge for ß-blockers, platelet P2Y12 receptor inhibitors, statins, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. RESULTS: Among 20 976 Medicare-insured patients discharged alive after acute MI, 10 381 (49.5%) were men; mean (SD) age was 75.8 (7.5) years. The median time to the first outpatient follow-up visit after hospital discharge was 14 days (interquartile range, 7-28 days). Overall, the first follow-up clinic visit occurred 1 week or less after discharge in 5542 (26.4%) patients, 1 to 2 weeks in 5246 (25.0%), 2 to 6 weeks in 6830 (32.6%), and more than 6 weeks in 3358 (16.0%) individuals. Rates of medication adherence for secondary prevention therapies ranged from 63.4% to 68.7% at 90 days and 54.4% to 63.5% at 1 year. Compared with patients with follow-up visits within 1 week, those with follow-up in 1 to 2 weeks and 2 to 6 weeks had no significant difference in medication adherence; however, patients with follow-up more than 6 weeks after discharge had lower adherence at both 90 days (56.8%-61.3% vs 64.7%-69.3%; P < .001) and 1 year (49.5%-57.7% vs 55.4%-64.1%; P < .001). Patients with delayed follow-up more than 6 weeks were more likely to reside in communities with lower household incomes and educational levels (both P < .001); however, their clinical characteristics were similar to those of patients with earlier follow-up. After adjusting for these differences, delayed follow-up of more than 6 weeks remained associated with lower medication adherence at 90 days (odds ratio [OR], 0.74 [95% CI, 0.70-0.78]) and 1 year (OR, 0.79 [95% CI, 0.73-0.85]) compared with follow-up of 6 weeks or less. CONCLUSIONS AND RELEVANCE: Delayed outpatient follow-up beyond the first 6 weeks after AMI is associated with worse short-term and long-term patient medication adherence. These data support the concept that medication adherence is modifiable via improved care transitions.

Modest Associations Between Electronic Health Record Use and Acute Myocardial Infarction Quality of Care and Outcomes: Results From the National Cardiovascular Data Registry.

BACKGROUND: In 2009, national legislation promoted wide-spread adoption of electronic health records (EHRs) across US hospitals; however, the association of EHR use with quality of care and outcomes after acute myocardial infarction (AMI) remains unclear. METHODS AND RESULTS: Data on EHR use were collected from the American Hospital Association Annual Surveys (2007-2010) and data on AMI care and outcomes from the National Cardiovascular Data Registry Acute Coronary Treatment and Interventions Outcomes Network Registry-Get With The Guidelines. Comparisons were made between patients treated at hospitals with fully implemented EHR (n=43 527), partially implemented EHR (n=72 029), and no EHR (n=9270). Overall EHR use increased from 82.1% (183/223) hospitals in 2007 to 99.3% (275/277) hospitals in 2010. Patients treated at hospitals with fully implemented EHRs had fewer heparin overdosing errors (45.7% versus 72.8%; P<0.01) and a higher likelihood of guideline-recommended care (adjusted odds ratio, 1.40 [confidence interval, 1.07-1.84]) compared with patients treated at hospitals with no EHR. In non-ST-segment-elevation AMI, fully implemented EHR use was associated with lower risk of major bleeding (adjusted odds ratio, 0.78 [confidence interval, 0.67-0.91]) and mortality (adjusted odds ratio, 0.82 [confidence interval, 0.69-0.97]) compared with no EHR. In ST-segment-elevation MI, outcomes did not significantly differ by EHR status. CONCLUSIONS: EHR use has risen to high levels among hospitals in the National Cardiovascular Data Registry. EHR use was associated with less frequent heparin overdosing and modestly greater adherence to acute MI guideline-recommended therapies. In non-ST-segment-elevation MI, slightly lower adjusted risk of major bleeding and mortality were seen in hospitals implemented with full EHRs; however, in ST-segment-elevation MI, differences in outcomes were not seen.

Risk factor burden and control at the time of admission in patients with acute myocardial infarction: Results from the NCDR.

BACKGROUND: Understanding risk factor burden and control as well as perceived risk prior to acute myocardial infarction (MI) presentation may identify gaps in contemporary systems of care. METHODS: Patients presenting with MI in the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry--Get With the Guidelines between January 2007 and November 2013 (N = 443,117) were stratified into 5 mutually exclusive risk categories: Framingham Risk Score (FRS) <10% 74,990 (16.9%), FRS 10% to 20% 90,429 (20.4%), FRS >20% 25,701 (5.8%), diabetes without cardiovascular disease (CVD) 67,779 (15.3%), and prior CVD 184,218 (41.6%). Low-density lipoprotein cholesterol and non-high-density lipoprotein cholesterol (non-HDL-C) goals and statin eligibility were determined based on the Third Adult Treatment Panel. RESULTS: At presentation, 66.3% met the low-density lipoprotein cholesterol goal, 66.8% met the non-HDL-C goal, 63.7% were nonsmokers, and 65.1% of patients with prior CVD were on aspirin. Only 36.1% of patients met all assessed risk factor control metrics. Overall statin eligibility prior to MI was 60.8%, and 61.1% of statin-eligible patients reported statin use. CONCLUSION: Risk factor control prior to MI was suboptimal, with the majority of individuals failing to meet at least 1 risk factor control metric. More effective system-based interventions are needed to promote adherence to prevention targets.