Objectives We sought to develop a long-term mortality risk prediction model and a simplified risk score for use in older patients with non–ST-segment elevation myocardial infarction (NSTEMI). ...Background Limited data are available regarding long-term mortality rates and concomitant risk predictors after acute myocardial infarction in contemporary community practice. Methods From the CRUSADE registry, a total of 43,239 (NSTEMI) patients aged ≥65 years treated at 448 hospitals in the United States from 2003 to 2006 were linked to Centers for Medicare and Medicaid Services data to track longitudinal all-cause mortality (median follow-up 453 days). Cox proportional hazard modeling was used to determine baseline independent demographic, clinical, and laboratory variables associated with long-term mortality. A simplified long-term mortality risk score was subsequently developed from these results. Results The median age of this population was 77 years, and mortality rates at 1, 2, and 3 years were 24.4%, 33.2%, and 40.3%, respectively. We identified 22 variables independently associated with long-term mortality in a full model (c-statistic 0.754 in the derivation sample and 0.744 in the validation sample). The CRUSADE long-term mortality risk score was limited to the 13 most clinically and statistically significant variables from the full model yet retained comparable discrimination in the derivation and validation samples (c-statistics 0.734 and 0.727, respectively) and had good calibration across the risk spectra. Conclusions Older patients face substantial long-term mortality risks after NSTEMI that can be accurately predicted from baseline characteristics. These prognostic estimates may support informed treatment decision-making and comparison of long-term provider outcomes.
...episodes of drug-induced TdP usually start with a short-long-short pattern of R-R cycles consisting of a short-coupled premature ventricular complex (PVC) followed by a compensatory pause and then ...another PVC that typically falls close to the peak of the T wave (2). ...TdP episodes usually show a warm-up phenomenon, with the first few beats of ventricular tachycardia exhibiting longer cycle lengths than subsequent arrhythmia complexes.
Treatments for non-ST-segment-elevation myocardial infarction (NSTEMI) reduce ischemic events but increase bleeding. Baseline prediction of bleeding risk can complement ischemic risk prediction for ...optimization of NSTEMI care; however, existing models are not well suited for this purpose.
We developed (n=71 277) and validated (n=17 857) a model that identifies 8 independent baseline predictors of in-hospital major bleeding among community-treated NSTEMI patients enrolled in the Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) Quality Improvement Initiative. Model performance was tested by c statistics in the derivation and validation cohorts and according to postadmission treatment (ie, invasive and antithrombotic therapy). The CRUSADE bleeding score (range 1 to 100 points) was created by assignment of weighted integers that corresponded to the coefficient of each variable. The rate of major bleeding increased by bleeding risk score quintiles: 3.1% for those at very low risk (score < or = 20); 5.5% for those at low risk (score 21-30); 8.6% for those at moderate risk (score 31-40); 11.9% for those at high risk (score 41-50); and 19.5% for those at very high risk (score >50; P(trend) <0.001). The c statistics for the major bleeding model (derivation=0.72 and validation=0.71) and risk score (derivation=0.71 and validation=0.70) were similar. The c statistics for the model among treatment subgroups were as follows: > or = 2 antithrombotics=0.72; <2 antithrombotics=0.73; invasive approach=0.73; conservative approach=0.68.
The CRUSADE bleeding score quantifies risk for in-hospital major bleeding across all postadmission treatments, which enhances baseline risk assessment for NSTEMI care.
Obesity and Age of First Non–ST-Segment Elevation Myocardial Infarction Mohan C. Madala, Barry A. Franklin, Anita Y. Chen, Aaron D. Berman, Matthew T. Roe, Eric D. Peterson, E. Magnus Ohman, Sidney ...C. Smith, Jr, W. Brian Gibler, Peter A. McCullough, for the CRUSADE Investigators Because excess adiposity is one of the most important determinants of adipokines and inflammatory factors associated with coronary plaque rupture, we hypothesized that obesity was associated with myocardial infarction at earlier ages. We retrospectively examined the relationship of body mass index (BMI) with patient age of first non–ST-segment elevation myocardial infarction (NSTEMI) in the CRUSADE (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. The age of first NSTEMI occurred 3.5, 6.8, 9.4, and 12.0 years earlier with ascending levels of adiposity (BMI 25.1 to 30.0, 30.1 to 35.0, 35.1 to 40.0, and >40.0 kg/m2 , respectively; referent 18.6 to 25.0 kg/m2 ); p < 0.0001 for each estimate. These data suggest that as the obesity pandemic worsens, NSTEMI might occur at increasingly younger ages.
Pay for performance has been promoted as a tool for improving quality of care. In 2003, the Centers for Medicare & Medicaid Services (CMS) launched the largest pay-for-performance pilot project to ...date in the United States, including indicators for acute myocardial infarction.
To determine if pay for performance was associated with either improved processes of care and outcomes or unintended consequences for acute myocardial infarction at hospitals participating in the CMS pilot project.
An observational, patient-level analysis of 105,383 patients with acute non-ST-segment elevation myocardial infarction enrolled 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 (ACC/AHA) Guidelines (CRUSADE) national quality-improvement initiative. Patients were treated between July 1, 2003, and June 30, 2006, at 54 hospitals in the CMS program and 446 control hospitals.
The differences in the use of ACC/AHA class I guideline recommended therapies and in-hospital mortality between pay for performance and control hospitals.
Among treatments subject to financial incentives, there was a slightly higher rate of improvement for 2 of 6 targeted therapies at pay-for-performance vs control hospitals (odds ratio OR comparing adherence scores from 2003 through 2006 at half-year intervals for aspirin at discharge, 1.31; 95% confidence interval CI, 1.18-1.46 vs OR, 1.17; 95% CI, 1.12-1.21; P = .04) and for smoking cessation counseling (OR, 1.50; 95% CI, 1.29-1.73 vs OR, 1.28; 95% CI, 1.22-1.35; P = .05). There was no significant difference in a composite measure of the 6 CMS rewarded therapies between the 2 hospital groups (change in odds per half-year period of receiving CMS therapies: OR, 1.23; 95% CI, 1.15-1.30 vs OR, 1.17; 95% CI, 1.14-1.20; P = .16). For composite measures of acute myocardial infarction treatments not subject to incentives, rates of improvement were not significantly different (OR, 1.09; 95% CI, 1.05-1.14 vs OR, 1.08; 95% CI, 1.06-1.09; P = .49). Overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites (change in odds of in-hospital death per half-year period, 0.91; 95% CI, 0.84-0.99 vs 0.97; 95% CI, 0.94-0.99; P = .21).
Among hospitals participating in a voluntary quality-improvement initiative, the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction. Conversely, we did not find evidence that pay for performance had an adverse association with improvement in processes of care that were not subject to financial incentives. Additional studies of pay for performance are needed to determine its optimal role in quality-improvement initiatives.
Background Women with non–ST-segment elevation myocardial infarction (NSTEMI) who undergo coronary angiography have no obstructive coronary lesions more often than men. Sex-specific characteristics ...and outcomes of patients without obstructive coronary artery disease (CAD) have not been described previously. Methods Using data from NSTEMI patients enrolled in CRUSADE from 2001 to 2005, we evaluated differences in clinical features and in-hospital outcomes between men and women with no obstructive CAD. Results After excluding patients with missing catheterization and sex data (n = 1,494), previous coronary artery bypass grafting or percutaneous coronary intervention (47,907), catheterization contraindications (n = 6,588), and missing obstructive CAD status (n = 1,565), there were 55,514 patients (68.4%) with NSTE acute coronary syndromes (ACS) who underwent angiography (among women, 62.1% 21,294/34,290, and among men, 73% 34,220/46,875; P < .001). Among these, a total of 5,538 patients (10.0%) had nonnonobstructive CAD—15.1% (3,221/21,294) of women and 6.8% (2,317/34,220) of men ( P < .0001). In patients without obstructive CAD, women were as likely as men to have MI (troponin elevation in 89% vs 87%, P = .37). Women and men were equally likely to have larger troponin elevations (58.9% vs 58.6% with troponin >5× upper limit of normal, P = .69, respectively). In NSTEMI patients without obstructive CAD, in-hospital death (0.6% women vs 0.7% men) and cardiogenic shock (1.0% women vs 0.7% men) were infrequent. Conclusions Among NSTE ACS patients undergoing coronary angiography, absence of obstructive CAD is more common in women than men. Although nonobstructive CAD was twice as common among women with NSTEMI, sex differences in characteristics and outcomes were similar to those found with obstructive CAD. Unadjusted in-hospital outcomes of NSTEMI patients with nonobstructive CAD are favorable in both sexes. Whether the underlying pathophysiology of NSTE ACS without documentation of obstructive CAD is different between women and men requires further study.
Age is an important determinant of outcomes for patients with acute coronary syndromes (ACS); however, community practice reveals a disproportionately lower use of cardiovascular medications and ...invasive treatment even among elderly patients with ACS who would stand to benefit. Reasons include limited trial data to guide the care of older adults and uncertainty about benefits and risks, particularly with newer medications or invasive treatments and in the setting of advanced age or complex health status.
This 2-part American Heart Association scientific statement summarizes evidence on patient heterogeneity, clinical presentation, and treatment of non-ST-elevation ACS in relation to age (< 65, 65 to 74, 75 to 84, and > or = 85 years). In addition, we review methodological issues that influence the acquisition and application of evidence to the elderly patients treated in community practice. A writing group combining international cardiovascular and geriatric perspectives convened to summarize available data from trials (5 combined Virtual Coordinating Center for Global Collaborative Cardiovascular Research VIGOUR trials) and 3 registries (Global Registry of Acute Coronary Events, National Registry of Myocardial Infarction, and 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 national quality improvement initiative CRUSADE) to provide a conceptual framework for future work in the care of the elderly with acute cardiac disease. Treatment for non-ST-segment-elevation ACS (Part I) and ST-segment-elevation myocardial infarction (Part II) are reviewed. In addition, ethical considerations pertaining to acute care and secondary prevention are considered (Part II). The primary goal is to identify the areas in which sufficient evidence is available to guide practice, as well as to determine areas that warrant further study. Although treatment-related benefits should rise in an elderly population with high disease risk, data to assess these benefits are limited, outcomes of importance vary, and heterogeneity among the elderly increases treatment-related risks. Although a uniform approach to care in the oldest of the old is unlikely, understanding the major contributors to benefits and risks from treatment will advance the ability to apply guideline-based care in this subset of patients.
Although a few recent trials have described treatment effects in older patients, others continue to exclude patients on the basis of age. Going forward, prospective trials should enroll elderly subjects proportionate to their prevalence among the treated population to define risk and benefit. Findings from age subgroup analyses should be reported in a consistent manner across trials, including absolute and relative risks for efficacy and safety. Outcomes of particular relevance to the elderly, such as quality of life, physical function, and independence, should also be considered. Creatinine clearance should be calculated for every elderly patient to enable appropriate dosing. In addition, physicians need an understanding of conditions unique to older patients (eg, frailty, cognitive impairment) that influence treatment goals and outcomes. With these efforts, treatment risks can be minimized, and benefits can be placed in the health context of the elderly patient with ACS.
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