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

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

Differential effect of anticoagulation according to cognitive function and frailty in older patients with atrial fibrillation.

BACKGROUND: In older patients with atrial fibrillation (AF), cognitive impairment and frailty are prevalent. It is unknown whether the risk and benefit of anticoagulation differ by cognitive function and frailty. METHODS: A total of 1244 individuals with AF with age ≥65 years and a CHADSVASC score ≥2 were recruited from clinics in Massachusetts and Georgia between 2016 and 18 and followed until 2020. At baseline, frailty status and cognitive function were assessed. Hazard ratios of anticoagulation on physician adjudicated outcomes were adjusted by the propensity for receiving anticoagulation and stratified by cognitive function and frailty status. RESULTS: The average age was 75.5 (± 7.1) years, 49% were women, and 86% were prescribed oral anticoagulants. At baseline, 528 (42.4%) participants were cognitively impaired and 172 (13.8%) were frail. The adjusted hazard ratios of anticoagulation for the composite of major bleeding or death were 2.23 (95% confidence interval: 1.08-4.61) among cognitively impaired individuals and 0.94 (95% confidence interval: 0.49-1.79) among cognitively intact individuals (P for interaction = 0.08). Adjusted hazard ratios for anticoagulation were 1.84 (95% confidence interval: 0.66-5.13) among frail individuals and 1.39 (95% confidence interval: 0.84-2.40) among not frail individuals (P for interaction = 0.67). CONCLUSION: Compared with no anticoagulation, anticoagulation is associated with more major bleeding episodes and death in older patients with AF who are cognitively impaired.

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

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

Presence of Geriatric Conditions Is Prognostic of Major Bleeding in Older Patients with Atrial Fibrillation: a Cohort Study.

BACKGROUND: In older patients with atrial fibrillation (AF), physical, cognitive, and psychosocial limitations are prevalent. The prognostic value of these conditions for major bleeding is unclear. OBJECTIVE: To determine whether geriatric conditions are prospectively associated with major bleeding in older patients with AF on anticoagulation. DESIGN: Multicenter cohort study with 2-year follow-up from 2016 to 2020 in Massachusetts and Georgia from cardiology, electrophysiology, and primary care clinics. PARTICIPANTS: Diagnosed with AF, age 65 years or older, CHA2DS2-VASc score of 2 or higher, and taking oral anticoagulant (n=1,064). A total of 6507 individuals were screened. MAIN MEASURES: A six-component geriatric assessment of frailty, cognitive function, social support, depressive symptoms, vision, and hearing. Main outcome was major bleeding adjudicated by a physician panel. KEY RESULTS: At baseline, participants were, on average, 75.5 years old and 49% were women. Mean CHA2DS2-VASc score was 4.5 and the mean HAS-BLED score was 3.3. During 2.0 (± 0.4) years of follow-up, 95 (8.9%) participants developed an episode of major bleeding. After adjusting for key covariates and accounting for competing risk from death, cognitive impairment (hazard ratio [HR] 1.62, 95% confidence interval [CI]: 1.02-2.56) and frailty (HR 2.77, 95% CI 1.38-5.58) were significantly associated with the development of major bleeding. CONCLUSIONS: In older patients with AF taking anticoagulants, cognitive impairment and frailty were independently associated with major bleeding.

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

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

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

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

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

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

Changing Trends in the Landscape of Patients Hospitalized With Acute Myocardial Infarction (2001 to 2011) (from the Worcester Heart Attack Study).

During the past several decades, new diagnostic tools, interventional approaches, and population-wide changes in the major coronary risk factors have taken place. However, few studies have examined relatively recent trends in the demographic characteristics, clinical profile, and the short-term outcomes of patients hospitalized for acute myocardial infarction (AMI) from the more generalizable perspective of a population-based investigation. We examined decade long trends (2001 to 2011) in patient's demographic and clinical characteristics, treatment practices, and hospital outcomes among residents of the Worcester metropolitan area hospitalized with an initial AMI (n = 3,730) at all 11 greater Worcester medical centers during 2001, 2003, 2005, 2007, 2009, and 2011. The average age of the study population was 68.5 years and 56.9% were men. Patients hospitalized with a first AMI during the most recent study years were significantly younger (mean age = 69.9 years in 2001/2003; 65.2 years in 2009/2011), had lower serum troponin levels, and experienced a shorter hospital stay compared with patients hospitalized during the earliest study years. Hospitalized patients were more likely to received evidence-based medical management practices over the decade long period under study. Multivariable-adjusted regression models showed a considerable decline over time in the hospital death rate and a significant reduction in the proportion of patients who developed atrial fibrillation, heart failure, and ventricular fibrillation during their acute hospitalization. These results highlight the changing nature of patients hospitalized with an incident AMI, and reinforce the need for surveillance of AMI at the community level.

Supplying Pharmacist Home Visit and Anticoagulation Professional Consultation During Transition of Care for Patients With Venous Thromboembolism.

OBJECTIVE: The aim of the study was to assess the feasibility, satisfaction, and effectiveness of a care transition intervention with pharmacist home visit and subsequent anticoagulation expert consultation for patients with new episode of venous thromboembolism within a not-for-profit health care network. METHODS: We randomized patients to the intervention or control. During the home visit, a clinical pharmacist assessed medication management proficiency, asked open-ended questions to discuss knowledge gaps, and distributed illustrated medication instructions. Subsequent consultation with anticoagulation expert further filled knowledge gaps. At 30 days, we assessed satisfaction with the intervention and also measured the quality of care transition, knowledge of anticoagulation and venous thromboembolism, and anticoagulant beliefs (level of agreement that anticoagulant is beneficial, is worrisome, and is confusing/difficult to take). RESULTS: The mean ± SD time required to conduct home visits was 52.4 ± 20.5 minutes and most patients agreed that the intervention was helpful. In general, patients reported a high-quality care transition including having been advised of safety issues related to medications. Despite that, the mean percentage of knowledge items answered correctly among patients was low (51.5 versus 50.7 for intervention and controls, respectively). We did not find any significant difference between intervention and control patients for care transition quality, knowledge, or anticoagulant beliefs. CONCLUSIONS: We executed a multicomponent intervention that was feasible and rated highly. Nevertheless, the intervention did not improve care transition quality, knowledge, or beliefs. Future research should examine whether alternate strategies potentially including some but not all components of our intervention would be more impactful.

Are We Optimizing the Use of Dual Antiplatelet Therapy in Patients Hospitalized with Acute Myocardial Infarction?

BACKGROUND: Dual antiplatelet therapy (DAPT) is a mainstay treatment for hospital survivors of an acute myocardial infarction (AMI). However, there are limited data on the prescribing patterns of DAPT among patients hospitalized with AMI during recent years. OBJECTIVE: To examine decade-long trends (2001-2011) in the use of DAPT versus antiplatelet monotherapy and patient characteristics associated with DAPT use. METHODS: The study population consisted of 2389 adults hospitalized with an initial AMI at all 11 central Massachusetts medical centers on a biennial basis between 2001 and 2011. DAPT was defined as the discharge use of aspirin plus either clopidogrel or prasugrel. Logistic regression analysis was used to identify patient characteristics associated with DAPT use. RESULTS: The average age of the study population was 65 years, and 69% of patients were discharged on DAPT. The use of DAPT at the time of hospital discharge increased from 49% in 2001 to 74% in 2011; this increasing trend was seen across all age groups, both sexes, types of AMI, and in those who underwent a PCI. After multivariable adjustment, patients 65-74 years old (adjusted odds ratio (aOR) = 0.53, 95% CI: 0.36-0.80) and those who underwent coronary artery bypass surgery (aOR = 0.11, 95% CI: 0.07-0.18) were less likely to have received DAPT, while men (aOR = 14.60, 95% CI: 10.66-19.98) and those who underwent cardiac catheterization and stenting (aOR = 14.60, 95% CI: 10.66-19.98) were significantly more likely to have received DAPT at discharge than respective comparison groups. CONCLUSIONS: Between 2001 and 2011, the use of DAPT increased markedly among patients hospitalized with AMI. However, a significant proportion of patients were not discharged on this therapy. Greater awareness is needed to incorporate DAPT into the management of patients hospitalized with AMI.

Successful use of fondaparinux in the setting of heparin-induced thrombocytopenia with thrombosis confirmed by serotonin-release assay and Factor V Leiden.

WHAT IS KNOWN AND OBJECTIVE: The off-label use of fondaparinux in patients with heparin-induced thrombocytopenia with thrombosis (HITT) has historically been controversial. We present a case of successful fondaparinux use to treat HITT confirmed by the serotonin-release assay in the setting of other significant clotting and bleeding risk factors. CASE SUMMARY: We report a 19-year-old male with a history of Factor V Leiden and recent neurosurgery treated with fondaparinux after developing HITT confirmed by the serotonin-release assay (SRA). The patient achieved full platelet recovery on fondaparinux and was successfully transitioned to warfarin therapy without further thrombotic nor bleeding complications. WHAT IS NEW AND CONCLUSION: This case demonstrates a clear example of success of fondaparinux use to treat SRA-confirmed HITT in the setting of complicating factors and adds to the existing literature supporting the use of fondaparinux for HIT.

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

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

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

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

Clinically significant ventricular arrhythmias and progression of depression and anxiety following an acute coronary syndrome.

BACKGROUND: Depression and anxiety are common and associated with worse clinical outcomes in patients who experience an acute coronary syndrome (ACS). We investigated the association between major ventricular arrhythmias (VAs) with the progression of depression and anxiety among hospital survivors of an ACS. METHODS: Patients were interviewed in hospital and by telephone up to 12 months after hospital discharge. The primary outcome was the presence of moderate/severe symptoms of depression and anxiety defined as a Patient Health Questionnaire (PHQ)-9 score ≥ 10 and a Generalized Anxiety Disorder (GAD)-7 score ≥ 10 at baseline and 1 month and PHQ-2 ≥ 3 and GAD-2 ≥ 3 at 3, 6, and 12 months. We used marginal models to examine the association between major VAs and the symptoms of depression or anxiety over time. RESULTS: The average age of the study population (n = 2074) was 61.1 years, 33.5% were women, and 78.3% were white. VAs developed in 105 patients (5.1%). Symptoms of depression and anxiety were present in 22.2% and 23.5% of patients at baseline, respectively, and declined to 14.1% and 12.6%, respectively, at 1-month post-discharge. VAs were not significantly associated with the progression of symptoms of depression (adjusted relative risk [aRR] = 1.29, 95% confidence interval [CI] = 0.94-1.77) and anxiety (aRR = 1.22, 95% CI = 0.86-1.72), or with change in average scores of PHQ-2 and GAD-2 over time, both before and after risk adjustment. CONCLUSION: The prevalence of symptoms of depression and anxiety was high after an ACS but declined thereafter and may not be associated with the occurrence of major in-hospital VAs.

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

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

Twenty-five year trends (1986-2011) in hospital incidence and case-fatality rates of ventricular tachycardia and ventricular fibrillation complicating acute myocardial infarction.

BACKGROUND: Long-term trends in the incidence rates (IRs) and hospital case-fatality rates (CFRs) of ventricular tachycardia (VT) and ventricular fibrillation (VF) among patients hospitalized with acute myocardial infarction (AMI) have not been recently examined. METHODS: We used data from 11,825 patients hospitalized with AMI at all 11 medical centers in central Massachusetts on a biennial basis between 1986 and 2011. Multivariable adjusted logistic regression modeling was used to examine trends in hospital IRs and CFRs of VT and VF complicating AMI. RESULTS: The median age of the study population was 71 years, 57.9% were men, and 94.7% were white. The hospital IRs declined from 14.3% in 1986/1988 to 10.5% in 2009/2011 for VT and from 8.2% to 1.7% for VF. The in-hospital CFRs declined from 27.7% to 6.9% for VT and from 49.6% to 36.0% for VF between 1986/1988 and 2009/2011, respectively. The IRs of both early (<48 hours) and late VT and VF declined over time, with greater declines in those of late VT and VF. The incidence rates of VT declined similarly for patients with either an ST-segment elevation myocardial infarction (STEMI) or non-STEMI, whereas they only declined in those with VF and a STEMI. CONCLUSIONS: The hospital IRs and CHRs of VT and VF complicating AMI have declined over time, likely because of changes in acute monitoring and treatment practices. Despite these encouraging trends, efforts remain needed to identify patients at risk for these serious ventricular arrhythmias so that preventive and treatment strategies might be implemented as necessary.

Hyperglycemia and risk of ventricular tachycardia among patients hospitalized with acute myocardial infarction.

BACKGROUND: Little is known about the association of hyperglycemia with the development of ventricular tachycardia (VT) in patients hospitalized with acute myocardial infarction (AMI) which we examined in the present study. The objectives of this community-wide observational study were to examine the relation between elevated serum glucose levels at the time of hospital admission for AMI and occurrence of VT, and time of occurrence of VT, during the patient's acute hospitalization. METHODS: We used data from a population-based study of patients hospitalized with AMI at all central Massachusetts medical centers between 2001 and 2011. Hyperglycemia was defined as a serum glucose level ≥ 140 mg/dl at the time of hospital admission. The development of VT was identified from physicians notes and electrocardiographic findings by our trained team of data abstractors. RESULTS: The average age of the study population was 70 years, 58.0% were men, and 92.7% were non-Hispanic whites. The mean and median serum glucose levels at the time of hospital admission were 171.4 mg/dl and 143.0, respectively. Hyperglycemia was present in 51.9% of patients at the time of hospital admission; VT occurred in 652 patients (15.8%), and two-thirds of these episodes occurred during the first 48 h after hospital admission (early VT). After multivariable adjustment, patients with hyperglycemia were at increased risk for developing VT (adjusted OR = 1.48, 95% CI = 1.23-1.78). The presence of hyperglycemia was significantly associated with early (multivariable adjusted OR = 1.39, 95% CI = 1.11-1.73) but not with late VT. Similar associations were observed in patients with and without diabetes and in patients with and without ST-segment elevation AMI. CONCLUSIONS: Efforts should be made to closely monitor and treat patients who develop hyperglycemia, especially early after hospital admission, to reduce their risk of VT.

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

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

Previous and New Onset Atrial Fibrillation and Associated Outcomes in Acute Coronary Syndromes (from the Global Registry of Acute Coronary Events).

Atrial fibrillation (AF) is a frequent complication of acute coronary syndromes (ACS) and is associated with an increased risk of in-hospital and long-term mortality. Our objective was to determine whether patients with previous AF and those who presented with or developed AF during their ACS hospitalization (new onset) have an associated increased risk of short- and mid-term cardiovascular events, death, or a composite. We included 7,228 patients from the Global Registry of Acute Coronary Events electrocardiogram core laboratory substudy, who presented with an ACS. Associated multivariable-adjusted risk of death and major adverse cardiovascular events (MACE) of death, re-infarction, or stroke in-hospital and at 6 months were estimated. New-onset AF and previous AF patients had higher rates of in-hospital mortality (14.9% and 10.9%, respectively) compared with patients without AF (3.8%; both p < 0.001). New-onset AF and previous AF patients had higher rates of 6-month mortality (22.3% and 21.3%, respectively) compared with patients without AF (7.0%; both p <0.001). After adjustment for clinical prognosticators, including those in the Global Registry of Acute Coronary Events risk model, new-onset AF was associated with higher mortality in-hospital (ORadj 1.87, 95% CI 1.30 to 2.70) and at 6 months (ORadj 1.75, 95% CI 1.29 to 2.39) as well as MACE at 6 months (ORadj 1.43, 95% CI 1.12 to 1.81) compared with patients without AF, but were at similar risk compared to those with previous AF (all p > 0.40). In conclusion, the risk of death and MACE after ACS in patients with new-onset and previous AF appears similar and significantly increased compared with patients without AF.

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

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