Outcomes associated with the high sensitivity cardiac troponin testing in patients presenting with non-cardiovascular disorders.

There are limited data regarding the utility of troponin testing in patients presenting with non-cardiovascular (CV) symptoms as the primary manifestation. The study population comprised 2057 patients who presented to the emergency department (ED) of a US healthcare system with non-CV symptoms as the primary manifestation between January and September 2018. We compared the effect of high-sensitivity cardiac troponin T (hs-cTnT) (n = 901) after its introduction vs. 4th generation cTnT (n = 1156) on the following outcomes measures: ED length of stay (LOS), coronary tests/procedures (angiography or stress test), and long-term mortality. Mean age was 64 ± 17 yrs., and 47% were female. Primary non-CV manifestations included pneumonia, obstructive pulmonary disease, infection, abdominal-complaint, and renal failure. Mean follow up was 9 ± 4 months. Patients' demographics and medical history were clinically similar between the two troponin groups. A second cTn test was obtained more frequently in the hs-cTnT than cTnT (84% vs. 32%; p < 0.001), possibly leading to a longer ED stay (8.1 ± 8.2 h vs 5.6 ± 3.4 h, respectively; p < 0.001). Coronary tests/procedures were performed at a significantly higher rate in the hs-cTnT than cTnT following the introduction of the hs-cTnT test (28% vs. 22%, p < 0.001). Multivariate analysis showed that following the introduction of hs-cTnT testing, there was a significant 27% lower risk of long-term mortality from ED admission through follow-up (HR = 0.73, 95%CI 0.54-0.98; p = 0.035). In conclusion, we show that in patients presenting primarily with non-CV disorders, the implementation of the hs-cTnT was associated with a higher rate of diagnostic coronary procedures/interventions, possibly leading to improved long-term survival rates.

Outcomes Associated with Introduction of the 5th Generation High-Sensitivity Cardiac Troponin in Patients Presenting with Cardiovascular Disorders.

BACKGROUND: The new high-sensitivity cardiac troponin T (hs-cTnT) is now widely used in the United States. OBJECTIVES: We aimed to examine outcomes associated with the introduction of the new 5th generation hs-cTnT assay among patients presenting to the emergency department (ED) with cardiovascular (CV) disorders. METHODS: The study comprised 5377 patients presenting to the ED with CV disorders between January and September 2018. Outcomes included rates of direct ED discharge, cardiac testing/procedures, and mortality. CV indications for troponin testing were categorized as rule-out acute coronary syndrome (RO-ACS) and other-CV (O-CV). RESULTS: Mean age was 62 ± 17 years, and 47% were female. Demographics and medical history did not differ significantly between the troponin groups. The use of hs-cTnT was associated with increased rates of direct discharge from the ED in the RO-ACS (48% vs. 37%; p < 0.01), but not in the O-CV (25% vs. 25%) cohort. Cardiac tests/procedures were more often performed after hs-cTnT vs. cTnT testing in both cohorts (45% vs. 41% for RO-ACS, and 33% vs. 28% for O-CV; p < 0.05 for both). Multivariate analysis demonstrated that hs-cTnT was not associated with a significant increase in postdischarge mortality in both cohorts (RO-ACS: hazard ratio = 1.47 [p = 0.13], O-CV: hazard ratio = 0.97 [p = 0.87]). CONCLUSIONS: Among patients with RO-ACS, hs-cTnT implementation resulted in increased rates of direct home discharge from the ED, without a significant increase in postdischarge mortality. Among patients presenting with O-CV indication, hs-cTnT implementation resulted in increased rates of cardiac testing procedures without an effect of ED discharge rates or long-term mortality.

Association between intensive care unit utilization for patients with non-ST-segment elevation myocardial infarction and patient experience.

Routine intensive care unit (ICU) utilization for patients with initially stable non-ST segment elevation myocardial infarction is not associated with improved short- or long-term patient outcomes; however, the association with patient experience has not been reported. Using Hospital Consumer Assessment of Healthcare Providers and Systems patient survey data linked to ICU use data from the National Cardiovascular Data Registry, we found no association between hospital-level ICU utilization and metrics of patient experience, including communication, staff responsiveness, and overall satisfaction.

Hospital participation in clinical trials for patients with acute myocardial infarction: Results from the National Cardiovascular Data Registry.

BACKGROUND: Little is known about the proportion of hospitals in the United States that offer clinical trial enrollment opportunities and how patient outcomes differ between hospitals that do and do not participate in clinical trials. METHODS: In the nationwide Chest Pain-MI registry, we described the proportion of hospitals that enrolled patients with acute myocardial infarction (MI) in clinical trials from 2009 to 2014. Hospital-level adherence to every eligible MI performance measure was compared between hospitals that did and did not enroll patients in clinical trials. Using linked Medicare data, we also compared 1-year major adverse cardiovascular events (MACE: death, MI, heart failure, or stroke) among patients ≥65 years old treated at trial versus nontrial hospitals. RESULTS: Among 766 hospitals, 430 (56.1%) enrolled ≥1 MI patient in a clinical trial during the study period, but the proportion of hospitals enrolling patients in clinical trials declined from 36.8% in 2009 to 26.6% in 2014. Complete adherence to performance measures was delivered to a greater proportion of patients at trial hospitals than nontrial hospitals (72.6% vs 64.9%, P < .001; adjusted OR 1.07, 95% CI 1.03-1.12). One-year MACE rates were also lower for trial hospitals (adjusted HR 0.96, 95% CI 0.93-0.99). CONCLUSIONS: Hospitals are becoming less likely to engage in clinical trials for patients with MI. Patients admitted to hospitals that participated in clinical trials more often received guideline-adherent care and had better long-term outcomes.

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.

Patterns of use of targeted temperature management for acute myocardial infarction patients following out-of-hospital cardiac arrest: Insights from the National Cardiovascular Data Registry.

Contemporary utilization patterns for targeted temperature management (TTM) among patients with acute myocardial infarction (MI) and out-of-hospital cardiac arrest (OHCA) have not been well characterized in the United States. In this nationwide evaluation of MI patients with OHCA (01/2015-03/2016; 691 hospitals), 34.1% (1792/5260) of OHCA patients received TTM. Patients who were treated with TTM had higher risk clinical features. A wide inter-hospital variation (ranging from 0% to 82%) in TTM use observed despite few differences in case mix.

Doing the right things and doing them the right way: association between hospital guideline adherence, dosing safety, and outcomes among patients with acute coronary syndrome.

BACKGROUND: Performance metrics currently focus on the measurement of the application of guideline-indicated medications without considering the appropriate dosing of these drugs. METHODS AND RESULTS: We studied 39 291 patients from the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines (CRUSADE) registry with non-ST-segment elevation acute coronary syndromes. We evaluated hospital variability in the composite use of American College of Cardiology/American Heart Association guideline-recommended therapies (adherence) and the proportion of treated patients with the recommended dose of heparins or a glycoprotein IIb/IIIa antagonist (safety), and its association with risk-adjusted in-hospital mortality and bleeding. The rates of composite guideline adherence (median, 85%; 25th, 75th percentile, 82, 88) and antithrombotic dosing safety (median, 53%; 25th, 75th percentile, 45%, 60%) varied among hospitals. Correlation between hospital composite adherence and safety metrics was significant but low (r=0.16, P=0.008). Risk-adjusted in-hospital mortality was inversely related to both guideline adherence (odds ratio-10% increment, 0.80; 95% confidence interval, 0.67-0.94) and safety metrics (odds ratio-10% increment, 0.90; 95% confidence interval, 0.83-0.98). Safety was inversely related to major bleeding (adjusted odds ratio-10% increment, 0.93; 95% confidence interval, 0.87-0.98). In comparison with hospitals with low adherence and safety (≤median performance) metrics, those with mixed performance metrics (high adherence and low safety, low adherence and high safety) had intermediate risk-adjusted mortality rates, whereas hospitals with above-average performance on both metrics (>median performance) had a trend for lowest risk adjusted mortality rates (odds ratio 0.83; 95% confidence interval, 0.68-1.01). Hospitals with high safety had lower bleeding rates in comparison to those with low safety. CONCLUSIONS: Guideline adherence and dosing safety appeared to provide independent and complementary information on hospital bleeding and mortality, supporting the need for broader metrics of quality that should include measures of both guideline-based care and safety.

Non-eligibility for reperfusion therapy in patients presenting with ST-segment elevation myocardial infarction: Contemporary insights from the National Cardiovascular Data Registry (NCDR).

BACKGROUND: Reperfusion therapy is lifesaving in patients presenting with ST-segment elevation myocardial infarction (STEMI). Contemporary data describing the characteristics and outcomes of patients presenting with STEMI not receiving reperfusion therapy are lacking. METHODS: Using the ACTION Registry-GWTG database, we examined 219,726 STEMI patients (January 2007-December 2013) at 721 percutaneous coronary intervention (PCI)-capable hospitals in United States. Clinical characteristics and in-hospital outcomes were stratified by those who underwent reperfusion (n = 188,200; 86%), those who did not undergo reperfusion with a reason for ineligibility (n = 27,179; 12%), and those without reperfusion but had no reason for ineligibility (n = 4,347; 2%). RESULTS: Compared with STEMI patients receiving reperfusion therapy, the nonreperfusion groups were older, were more often female, and had higher rates of hypertension, diabetes, prior myocardial infarction, prior stroke, atrial fibrillation, and left bundle-branch block and heart failure on presentation. The major reason for reperfusion noneligibility was coronary anatomy not suitable for PCI (33%). Presence of 3-vessel coronary disease was more common in the nonreperfusion groups (with or without a documented reason) compared with reperfusion group (38% and 36% vs 26%, P < .001, respectively). In-hospital mortality was higher in patients not receiving reperfusion therapy with or without a documented reason compared with the reperfusion group (adjusted odds ratio [95% CI] 1.88 [1.78-1.99] and 1.37 [1.21-1.57], respectively). CONCLUSION: Most patients with STEMI not receiving reperfusion therapy had a documented reason. Coronary anatomy not suitable for PCI was the major contributor to ineligibility. In-hospital mortality was higher in patients not receiving reperfusion therapy.

The effect of high-risk ST elevation myocardial infarction transfer patients on risk-adjusted in-hospital mortality: A report from the American Heart Association Mission: Lifeline program.

BACKGROUND: Hospital mortality is an important quality measure for acute myocardial infarction care. There is a concern that despite risk adjustment, percutaneous coronary intervention hospitals accepting a greater volume of high-risk ST elevation myocardial infarction (STEMI) transfer patients may have their reported mortality rates adversely affected. METHODS: The STEMI patients in the National Cardiovascular Data RegistryAcute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines from April 2011 to December 2013 were included. High-risk STEMI was defined as having either cardiogenic shock or cardiac arrest on first medical contact. Receiving hospitals were divided into tertiles based on the ratio of high-risk STEMI transfer patients to the total number of STEMI patients treated at each hospital. Using the Action Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines in-hospital mortality risk model, we calculated the difference in risk-standardized in-hospital mortality before and after excluding high-risk STEMI transfers in each tertile. RESULTS: Among 119,680 STEMI patients treated at 539 receiving hospitals, 37,028 (31%) were transfer patients, of whom 4,500 (12%) were highrisk. The proportion of high-risk STEMI transfer patients ranged from 0% to 12% across hospitals. Unadjusted mortality rates in the low-, middle-, and high-tertile hospitals were 6.0%, 6.0%, and 5.9% among all STEMI patients and 6.0%, 5.5%, and 4.6% after excluding high-risk STEMI transfers. However, risk-standardized hospital mortality rates were not significantly changed after excluding high-risk STEMI transfer patients in any of the 3 hospital tertiles (low, -0.04%; middle, -0.05%; and high, 0.03%). CONCLUSIONS: Risk-adjusted in-hospital mortality rates were not adversely affected in STEMI-receiving hospitals who accepted more high-risk STEMI transfer patients when a clinical mortality risk model was used for risk adjustment.

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.

The association of in-hospital guideline adherence and longitudinal postdischarge mortality in older patients with non-ST-segment elevation myocardial infarction.

BACKGROUND: Prior work has demonstrated that adherence to American College of Cardiology/American Heart Association guideline recommendations is associated with decreased in-hospital mortality in non-ST-segment elevation myocardial infarction (NSTEMI) patients; however, it is unknown whether this association persists after hospital discharge in older, real-world populations. METHODS: We evaluated 32,646 NSTEMI patients ≥65 years treated at 243 US hospitals participating in CRUSADE from 2003 to 2006, linked to Medicare longitudinal claims data (followed to January 1, 2010). Hospital composite adherence examined the use of 13 individual American College of Cardiology/American Heart Association Class IA guideline-recommended interventions. Among patients who survived to hospital discharge, we used Cox proportional hazards modeling to examine the association between hospital composite adherence and 1- and 3-year mortality conditional on surviving initial hospitalization and adjusting for patient baseline clinical factors and hospital characteristics. RESULTS: The overall median composite guideline adherence to all 13 interventions was 77.4% with median (25th, 75th percentiles) hospital adherence ranging from 66.7% (61.9%, 70.1%) in the lowest adherence quartile to 85.8% (83.7%, 88.7%) in the highest adherence quartiles. Overall survival at 1 and 3 years was 80.0% and 62.8%, respectively. Relative to patients treated at the lowest adherence hospitals, those treated at the highest had similar adjusted mortality risk at 1 year but significantly lower 3-year mortality risk (adjusted hazard ratio [95% CI] 0.90 [0.82-0.99]). For every 10% increase in adherence to all 13 hospital composite therapies, there was a 5% reduction in 3-year mortality risk (0.95 [0.91-0.98]). CONCLUSIONS: Use of guideline-based therapies during acute hospitalization for NSTEMI was associated with significant decreases in mortality up to 3 years post-hospital discharge.

Cardiac arrest and clinical characteristics, treatments and outcomes among patients hospitalized with ST-elevation myocardial infarction in contemporary practice: A report from the National Cardiovascular Data Registry.

BACKGROUND: Cardiac arrest (CA) is a major complication of patients with ST-elevation myocardial infarction (STEMI). Its prevalence and prognostic impact in contemporary US practice has not been well assessed. METHODS: We evaluated STEMI patients included in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) from 4/1/11 to 6/30/12. Patient clinical characteristics, treatments, and inhospital outcomes were compared by the presence or absence of CA on first medical contact-either before hospital arrival or upon presentation to the ACTION hospital. RESULTS: Of the 49,279 STEMI patients included, 3,716 (7.5%) had CA. Cardiac arrest patients were more likely to have heart failure (15.5% vs 6.9%) and shock (42.9% vs 4.9%) on presentation and higher median (25th and 75th percentiles) ACTION Registry-GWTG mortality risk scores (42 [32, 54] vs 32 [26, 38]) than non-CA patients (all P < .001). Primary percutaneous coronary intervention was performed in most patients with and without CA (76.7% vs 79.1%). Inhospital mortality was significantly higher in patients with than without CA (28.8% vs 4.0%; P < .001), both in patients who presented with cardiogenic shock (46.9% vs 27.1%; P < .001) and those without shock (15.4% vs 2.9%; P < .001). The ACTION Registry-GWTG inhospital mortality model underestimated mortality risk in CA patients; however, prediction significantly improved after adding CA to the model. CONCLUSIONS: Almost 8% of STEMI patients present with CA. More than 25% die during the hospitalization, despite high use of primary percutaneous coronary intervention. Cardiogenic shock and CA frequently coexist. Our results suggest that development of systems of care and treatments for both STEMI and CA is needed to reduce the high mortality in these patients.

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.

Trends in outcomes among older patients with non-ST-segment elevation myocardial infarction.

OBJECTIVES: The objective of this study is to assess trends in evidence-based therapy use and short- and long-term mortality over time among older patients with non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: With the prevalence of national quality improvement efforts, the use of evidence-based therapies has improved over time among patients with NSTEMI, yet it is unclear whether these improvements have been associated with significant change in short- and long-term mortality for older patients. METHODS: We linked detailed clinical data for 28,603 NSTEMI patients aged ≥65 years at 171 hospitals in the Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines Registry with longitudinal Centers for Medicare & Medicaid claims data and compared trends in annual unadjusted and risk-adjusted inhospital and long-term mortality from 2003 to 2006. RESULTS: The median age of our NSTEMI study population was 77 years, 48% were female, and 87% were white. Overall, inhospital and 1-year mortality rates were 6.0% and 24.5%, respectively. When compared with patients treated in 2003, NSTEMI patients treated in 2006 were more likely to receive guideline-recommended inhospital medications and early invasive treatment. Inhospital mortality decreased significantly over the study period (5.5% vs 7.2% [adjusted odds ratio 0.82, 95% CI 0.67-1.00, P = .045] for 2006 vs 2003), but there was no significant change in 1-year mortality from the index admission (24.0% vs 26.0% [adjusted hazard ratio 0.99, 95% CI 0.90-1.08] for 2006 vs 2003). CONCLUSIONS: Between 2003 and 2006, there was a significant reduction in inhospital mortality that corresponded to an increase in the use of evidence-based NSTEMI care. Nevertheless, long-term outcomes have not changed over time, suggesting a need for improved care transition and longitudinal secondary prevention.

The association of myocardial infarction process of care measures and in-hospital mortality: a report from the NCDR®.

BACKGROUND: The Center for Medicare and Medicaid Services (CMS) publicly reports "core process of care measures" along with 30-day mortality rates for patients with acute myocardial infarction; the American College of Cardiology/American Heart Association has a similar but expanded set of performance measures. METHODS: We sought to determine whether hospital-level adherence with these process performance measures was associated with risk-adjusted in-hospital mortality among 96,340 ST-segment elevation myocardial infarction (STEMI) and 145,832 non-STEMI (NSTEMI) patients in the National Cardiovascular Data Registry® ACTION Registry-Get With the Guidelines™ admitted from January 2007 to March 2011 from 372 US sites. Hospitals were grouped based on risk-adjusted in-hospital mortality: low (20%), middle (60%), and high mortality (20%). RESULTS: The mean (SD) mortality from low to high hospital mortality groups for STEMI was 4.9% (0.9%), 5.8% (0.3%), and 7.0% (0.5%); and that for NSTEMI was 3.3% (0.2%), 4.0% (0.2%), and 4.9% (0.3%). Adherence to individual process measures was high, with composite measure adherences exceeding 88%. Composite adherence for both CMS and American College of Cardiology/American Heart Association performance measures was inversely associated with risk-adjusted hospital mortality. However, the association was low for STEMI hospitals and not significant for NSTEMI hospitals. Variation tended to be higher for CMS measures for higher-mortality hospitals. CONCLUSIONS: Although process performance was associated with hospital mortality, the association was low for STEMI and nonsignificant for NSTEMI hospitals, thus supporting the need to measure complementary metrics of acute myocardial infarction quality of care.

Influence of heart failure symptoms and ejection fraction on short- and long-term outcomes for older patients with non-ST-segment elevation myocardial infarction.

BACKGROUND: Symptomatic heart failure (HF) and reduced ejection fraction (REF) are both associated with mortality, but the long-term outcomes associated with the development of HF in older non-ST-segment elevation myocardial infarction (NSTEMI) patients with preserved systolic function and REF are uncertain. METHODS: We analyzed a total of 26,291 NSTEMI patients ≥65 years discharged alive in the CRUSADE Registry who had linked Medicare data. We evaluated 30-day and 1-year risks of mortality and HF readmission in 4 cohorts of patients stratified by symptomatic HF and ejection fraction: (1) no HF-PEF, (2) no HF-REF, (3) HF-PEF, and (4) HF-REF. RESULTS: A total of 14,280 NSTEMI patients (54.3%) had no HF-PEF, 3,345 (12.7%) had no HF-REF, 4,913 (18.7%) had HF-PEF, and 3,753 (14.3%) had HF-REF. Compared with no HF-PEF patients, the 30-day mortality risk was higher among patients with no HF-REF (4.9% vs 1.7%, adjusted hazard ratio 2.11, 95% CI 1.69-2.63), HF-PEF (5.9% vs 1.7%, adjusted hazard ratio 1.99, 95% CI 1.64-2.41), and highest among those with HF-REF (9.3% vs 1.7%, adjusted hazard ratio 2.70, 95% CI 2.23-3.26). Similar relationships were noted in the adjusted 1-year mortality and the risks of 30-day and 1-year HF readmission. CONCLUSIONS: Symptomatic HF and REF during the index NSTEMI hospitalization are both associated with an increased risk of short- and long-term mortality as well as HF readmission with an apparent additive prognostic impact of both factors.

Risk Prediction in Male Adolescents With Congenital Long QT Syndrome: Implications for Sex-Specific Risk Stratification in Potassium Channel-Mediated Long QT Syndrome.

BACKGROUND: Sex-specific risk management may improve outcomes in congenital long QT syndrome (LQTS). We recently developed a prediction score for cardiac events (CEs) and life-threatening events (LTEs) in postadolescent women with LQTS. In the present study, we aimed to develop personalized risk estimates for the burden of CEs and LTEs in male adolescents with potassium channel-mediated LQTS. METHODS AND RESULTS: The prognostic model was derived from the LQTS Registry headquartered in Rochester, NY, comprising 611 LQT1 or LQT2 male adolescents from age 10 through 20 years, using the following variables: genotype/mutation location, QTc-specific thresholds, history of syncope, and ß-blocker therapy. Anderson-Gill modeling was performed for the end point of CE burden (total number of syncope, aborted cardiac arrest, and appropriate defibrillator shocks). The applicability of the CE prediction model was tested for the end point of the first LTE (excluding syncope and adding sudden cardiac death) using Cox modeling. A total of 270 CEs occurred during follow-up. The genotype-phenotype risk prediction model identified low-, intermediate-, and high-risk groups, comprising 74%, 14%, and 12% of the study population, respectively. Compared with the low-risk group, high-risk male subjects experienced a pronounced 5.2-fold increased risk of recurrent CEs (P<0.001), whereas intermediate-risk patients had a 2.1-fold (P=0.004) increased risk . At age 20 years, the low-, intermediate-, and high-risk adolescent male patients had on average 0.3, 0.6, and 1.4 CEs per person, respectively. Corresponding 10-year adjusted probabilities for a first LTE were 2%, 6%, and 8%. CONCLUSIONS: Personalized genotype-phenotype risk estimates can be used to guide sex-specific management in male adolescents with potassium channel-mediated LQTS.

Short-term outcomes of acute myocardial infarction in patients with acute kidney injury: a report from the national cardiovascular data registry.

BACKGROUND: Acute kidney injury (AKI) is a risk factor for long-term adverse outcomes, including acute myocardial infarction and death. However, the relationship between severity of AKI and in-hospital outcomes in the setting of acute myocardial infarction has not been well documented. METHODS AND RESULTS: The study population (n = 59,970) was drawn from the Acute Coronary Treatment and Intervention Outcomes Network (ACTION) Registry-Get With the Guidelines (GWTG), a nationwide sample of myocardial infarction patients admitted to 383 hospitals in the United States between July 2008 and September 2009. AKI was defined using absolute changes in serum creatinine (SCr; peak SCr minus admission SCr) and categorized as no AKI (SCr change, <0.3 mg/dL), mild AKI (SCr change, 0.3-<0.5 mg/dL), moderate AKI (SCr change, 0.5-<1.0 mg/dL), and severe AKI (SCr change, ≥1.0 mg/dL). Overall, 16.1% had AKI, including 6.5% with mild AKI, 5.6% with moderate AKI, and 4.0% with severe AKI. In-hospital mortality rates for those with mild, moderate, and severe AKI were 6.6%, 14.2%, and 31.8% compared with 2.1% in those without AKI. The odds ratios for in-hospital death were 2.4 (95% confidence interval, 2.0-2.7), 4.5 (95% confidence interval, 3.9-5.1), and 12.6 (95% confidence interval, 11.1-14.3) for mild, moderate, and severe AKI compared with those without AKI. Although patients with AKI were less likely to undergo early invasive care or to receive antiplatelet therapies, rates of major bleeding ranged from 8.4% (no AKI) to 32.7% (severe AKI). CONCLUSION: AKI is common and associated with mortality and bleeding, underscoring the importance of efforts to identify risk factors and to prevent AKI in acute myocardial infarction care.

Admission international normalized ratio levels, early treatment strategies, and major bleeding risk among non-ST-segment-elevation myocardial infarction patients on home warfarin therapy: insights from the National Cardiovascular Data Registry.

BACKGROUND: Non-ST-segment-elevation myocardial infarction patients on home warfarin pose treatment concerns because of their potential increased risk of bleeding. Expert opinion from the American College of Cardiology/American Heart Association guidelines suggest holding anticoagulants and initiating antiplatelet therapy among therapeutically anticoagulated non-ST-segment-elevation myocardial infarction patients. Yet, little is known about contemporary treatment patterns and bleeding risks in this population. METHODS AND RESULTS: We stratified 5787 non-ST-segment-elevation myocardial infarction patients on home warfarin therapy using data from the National Cardiovascular Data Registry Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines by admission international normalized ratio (INR) levels: subtherapeutic (INR <2), therapeutic (INR, 2-3), and supratherapeutic (INR >3). Multivariable logistic generalized estimating equations models were constructed to examine the associations between admission INR level, early antithrombotic treatment and invasive therapy, and risk of in-hospital major bleeding. Among these patients, 46%, 35%, and 19% had subtherapeutic, therapeutic, and supratherapeutic admission INR levels, respectively. Risk of major bleeding was higher among patients with therapeutic (15%; adjusted odds ratio, 1.25; 95% confidence interval [CI], 1.03-1.50) and supratherapeutic (22%; odds ratio, 1.60; 95% CI, 1.30-1.97) anticoagulation compared with the subtherapeutic group (12%). Among patients with admission INR ≥2, 45% were treated with early (within 24 hours) heparin, 35% with early clopidogrel, 14% with early glycoprotein IIb/IIIa inhibitor, and 36% with early invasive strategy. Early antithrombotic treatment was associated with increased bleeding risk (odds ratio, 1.40 [95% CI, 1.14-1.72] for heparin; 1.50 [95% CI, 1.22-1.84] for clopidogrel; and 1.82 [95% CI, 1.43-2.32] for glycoprotein IIb/IIIa inhibitor); however, an early invasive strategy was not (odds ratio, 1.09; 95% CI, 0.86-1.37). No significant interactions were observed between INR level and use of each early treatment in its association with bleeding. CONCLUSIONS: National patterns of early antithrombotic treatment for non-ST-segment-elevation myocardial infarction patients on home warfarin diverge from expert opinion provided by current practice guidelines. Early antithrombotic treatment was associated with increased bleeding risk regardless of admission INR level.

Balancing the risk of mortality and major bleeding in the treatment of NSTEMI patients - a report from the National Cardiovascular Data Registry.

OBJECTIVES: We sought to describe real-world patterns of care in NSTEMI patients across different risk profiles for bleeding and mortality. BACKGROUND: The NCDR ACTION Registry-GWTG in-hospital mortality and major bleeding risk scores were developed to assess patient risk and optimize treatment decisions. However, little is known about the alignment of contemporary clinical management patterns with these risk estimates. METHODS: We studied 61,366 NSTEMI patients in the NCDR ACTION-Registry-GWTG from January 2007 to March 2009, stratifying them into four groups based on estimated risk of mortality and major bleeding. RESULTS: There were 24,709 (40.3%) patients in each of the concordant risk groups (low:low; high:high) and 5974 (9.7%) in each of the discordant risk groups (low:high; high:low). Subjects at high estimated risk for both mortality and major bleeding were least likely to receive guideline-based adjunctive pharmacotherapy or to undergo angiography within 48 hours but most likely to receive an excess dose of an antithrombotic agent. Patients at low estimated risk for mortality and bleeding received the most intensive adjunctive therapy and were most likely to undergo invasive angiography. CONCLUSION: There are significant differences in contemporary patterns of care across varying risk profiles of mortality and major bleeding. Despite practice patterns which seem to emphasize avoiding harm with reduced use of antithrombotic therapy, patients at high risk for major bleeding continue to receive excess doses of antithrombotic therapy. Additional performance improvement efforts are needed to optimize outcomes in NSTEMI patients with high risk for both bleeding and mortality.