The Prevalence and Outcomes of In-Hospital Acute Myocardial Infarction in the Department of Veterans Affairs Health System

VA Puget Sound Health Care System, Washington, Washington, D.C., United States
Archives of Internal Medicine (Impact Factor: 17.33). 07/2006; 166(13):1410-6. DOI: 10.1001/archinte.166.13.1410
Source: PubMed


Most studies of the epidemiology and treatment of acute myocardial infarction (AMI) have focused on patients who experienced onset of their symptoms in the community and then presented to the hospital. There are, however, patients whose symptoms of AMI begin after hospitalization for other medical conditions. The purposes of this study were to determine the prevalence of in-hospital AMI in the Veterans Health Administration (VHA) and to compare baseline characteristics, treatments, and outcomes according to whether individuals presented with AMI or had an in-hospital AMI.
This was a retrospective cohort study of 7054 veterans who were hospitalized for AMI in 127 VHA medical centers between July 2003 and August 2004. The main outcome measure was 30-day mortality. Key covariates included age, body mass index, admission systolic blood pressure, heart rate, previous use of lipid-lowering drugs, elevated admission troponin value, prolonged and/or atypical chest pain on admission, and ST-segment elevation on the initial electrocardiogram.
There were 792 patients (11.2%) who had AMI while hospitalized for other medical conditions. These patients differed substantially from those who presented to the hospital with AMI. The odds of 30-day mortality were greater in the in-hospital group (odds ratio, 3.6; 95% confidence interval, 3.1-4.3; P<.001) and remained higher after statistical adjustment (odds ratio, 2.0; 95% confidence interval, 1.7-2.4; P<.001).
Although most attention has been paid to patients with AMI admitted via the community emergency medical system or through the emergency department, AMI occurring during hospitalization for other medical problems is an important clinical problem.

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    • "All patients with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9CM) diagnosis codes 410.xx (acute myocardial infarction) and 411.xx (other acute and subacute forms of ischemic heart disease) were identified from the VA Patient Treatment File, and their records were manually abstracted by trained abstractors using standard reporting forms. Additional details of the study methods have been published [31]. "
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    ABSTRACT: Background Chronic kidney disease (CKD) is associated with worse outcomes among patients with acute coronary syndrome (ACS). Less is known about the impact of CKD on longitudinal outcomes among clopidogrel treated patients following ACS. Methods Using a retrospective cohort design, we identified patients hospitalized with ACS between 10/1/2005 and 1/10/10 at Department of Veterans Affairs (VA) facilities and who were discharged on clopidogrel. Using outpatient serum creatinine values, estimated glomerular filtration rate [eGFR (1.73 ml/min/m2)] was calculated using the CKD-EPI equation. The association between eGFR and mortality, hospitalization for acute myocardial infarction (AMI), and major bleeding were examined using Cox proportional hazards models. Results Among 7413 patients hospitalized with ACS and discharged taking clopidogrel, 34.5% had eGFR 30–60 and 11.6% had eGFR < 30. During 1-year follow-up after hospital discharge, 10% of the cohort died, 18% were hospitalized for AMI, and 4% had a major bleeding event. Compared to those with eGFR > =60, individuals with eGFR 30–60 (HR 1.45; 95% CI: 1.18-1.76) and < 30 (HR 2.48; 95% CI: 1.97-3.13) had a significantly higher risk of death. A progressive increased risk of AMI hospitalization was associated with declining eGFR: HR 1.20; 95% CI: 1.04-1.37 for eGFR 30–60 and HR 1.47; 95% CI: 1.22-1.78 for eGFR < 30. eGFR < 30 was independently associated with over a 2-fold increased risk in major bleeding (HR 2.09; 95% CI: 1.40-3.12) compared with eGFR > = 60. Conclusion Lower levels of kidney function were associated with higher rates of death, AMI hospitalization, and major bleeding among patients taking clopidogrel after hospitalization for ACS.
    BMC Nephrology 05/2013; 14(1):107. DOI:10.1186/1471-2369-14-107 · 1.69 Impact Factor
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    • "They found significantly higher mortality for inpatient MI (66% versus 22%) and concluded that it was the result of atypical presentation, higher comorbidity, and delayed recognition. More recently, Maynard et al6 reported that in‐hospital mortality was much higher (27.3% versus 8.6%) for 792 patients who experienced an acute inpatient MI (9.5% who had a STEMI) compared with 6262 patients with acute MI who presented as outpatients to the Department of Veterans Affairs Health System. Patients with inpatient MI were older, more likely to have atypical symptoms, and had higher rates of renal disease, cerebrovascular disease, congestive heart failure, diabetes mellitus, chronic obstructive pulmonary disease, dementia, and cancer than patients who presented to the VA system with an outpatient MI. "
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    ABSTRACT: Major advances have been made in the treatment of ST-elevation myocardial infarction (STEMI) in outpatients. In contrast, little is known about outcomes in STEMI that occur in patients hospitalized for a noncardiac condition. This was a retrospective, single-center study of inpatient STEMIs from January 1, 2007, to July 31, 2011. Forty-eight cases were confirmed to be inpatient STEMIs of a total of 139 410 adult discharges. These patients were older and more often female and had higher rates of chronic kidney disease and prior cerebrovascular events compared with 227 patients with outpatient STEMIs treated during the same period. Onset of inpatient STEMI was heralded most frequently by a change in clinical status (60%) and less commonly by patient complaints (33%) or changes on telemetry. Coronary angiography and percutaneous coronary intervention were performed in 71% and 56% of patients, respectively. The median time to obtain ECG (41 [10, 600] versus 5 [2, 10] minutes; P<0.001), ECG to angiography time (91 [26, 209] versus 35 [25, 46] minutes; P<0.001) and ECG to first device activation (FDA) (129 [65, 25] versus 60 [47, 76] minutes; P<0.001) were longer for inpatient versus outpatient STEMI. Survival to discharge was lower for inpatient STEMI (60% versus 96%; P<0.001), and this difference persisted after adjusting for potential confounders. Patients who develop a STEMI while hospitalized for a noncardiac condition are older and more often female, have more comorbidities, have longer ECG-to-FDA times, and are less likely to survive than patients with an outpatient STEMI.
    Journal of the American Heart Association 02/2013; 2(2):e000004. DOI:10.1161/JAHA.113.000004 · 4.31 Impact Factor
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    • "We applied a logistic regression model for 30-day mortality that was developed and validated expressly for VA patients using earlier versions of EPRP data. [15] The model includes history of cancer, history of dementia, history of heart failure, history of stroke within 5 years, history of lipid disorder or prescriptions for lipid medications, age, elevated initial troponin, creatinine, heart rate, systolic blood pressure, chest and/or shoulder pain, and presentation at night. Analyses were run with and without a cluster correction for medical center. "
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    ABSTRACT: Mortality from acute myocardial infarction (AMI) is declining worldwide. We sought to determine if mortality in the Veterans Health Administration (VHA) has also been declining. We calculated 30-day mortality rates between 2004 and 2006 using data from the VHA External Peer Review Program (EPRP), which entails detailed abstraction of records of all patients with AMI. To compare trends within VHA with other systems of care, we estimated relative mortality rates between 2000 and 2005 for all males 65 years and older with a primary diagnosis of AMI using administrative data from the VHA Patient Treatment File and the Medicare Provider Analysis and Review (MedPAR) files. Using EPRP data on 11,609 patients, we observed a statistically significant decline in adjusted 30-day mortality following AMI in VHA from 16.3% in 2004 to 13.9% in 2006, a relative decrease of 15% and a decrease in the odds of dying of 10% per year (p = .011). Similar declines were found for in-hospital and 90-day mortality.Based on administrative data on 27,494 VHA patients age 65 years and older and 789,400 Medicare patients, 30-day mortality following AMI declined from 16.0% during 2000-2001 to 15.7% during 2004-June 2005 in VHA and from 16.7% to 15.5% in private sector hospitals. After adjusting for patient characteristics and hospital effects, the overall relative odds of death were similar for VHA and Medicare (odds ratio 1.02, 95% C.I. 0.96-1.08). Mortality following AMI within VHA has declined significantly since 2003 at a rate that parallels that in Medicare-funded hospitals.
    BMC Cardiovascular Disorders 09/2009; 9(1):44. DOI:10.1186/1471-2261-9-44 · 1.88 Impact Factor
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