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Defibrillator Use After Myocardial Infarction in Older Adults

Defibrillator Use After Myocardial Infarction in Older Adults

According to current estimates, more than 350,000 people experience sudden cardiac death in the United States each year. Patients with low ejection fraction (EF) are at risk for sudden cardiac death, and clinical trials have established that implantable cardioverter-defibrillators (ICDs) improve survival for these individuals. Guidelines recommend ICDs as primary prevention for patients with an EF of 35% or lower if they do not improve after being treated with optimal medical therapy for at least 40 days after a myocardial infarction (MI). Studies suggest that ICDs are underutilized in routine clinical practice, especially after a patient suffers an MI. The incidence of MI and the resulting sequelae from these events increase with age. The benefit of ICDs as primary prevention is controversial among older patients because this population is underrepresented in clinical trials. Clinicians may be uncertain about the efficacy of ICDs in an older patient population and must also consider treatment goals and procedural risks. These factors may discourage the use of ICDs among older adults.   A Closer Look In a retrospective study published in JAMA, Sean D. Pokorney, MD, MBA, and colleagues examined data from Medicare beneficiaries with an EF of 35% or less after MI. Participants were treated at 441 U.S. hospitals between 2007 and 2010, but were excluded if they had a prior ICD implant. The investigators evaluated the incidence and hospital variation of 1-year ICD implantation after MI among potentially eligible patients. They also examined factors that were linked to 1-year ICD implantation and compared 2-year mortality between patients with and without ICDs. The study was unique in that it evaluated the use...
A Qualitative Look at AMI in Younger Women

A Qualitative Look at AMI in Younger Women

Each year, more than 15,000 women younger than age 55 die from heart disease, ranking it among the leading causes of death in this age group. “Young women have twice the risk of dying during hospitalization for an acute myocardial infarction (AMI) as similarly aged men,” says Judith H. Lichtman, PhD, MPH. Research suggests that delays in recognizing AMI symptoms and seeking medical care may contribute to poorer outcomes for women, but most of these studies involve patients older than 55. Few studies have examined the perceptions and actions of women younger than 55 who experience AMI symptoms. “With a better understanding of the perspective of these women with regard to AMI symptoms and their interactions with healthcare providers, clinicians can gain valuable insights into factors that influence prompt care-seeking behaviors,” Dr. Lightman say. To address this research gap, Dr. Lichtman, and colleagues had a qualitative study published in Circulation: Cardiovascular Quality and Outcomes in which 30 younger women (aged 30 to 55) who were recently hospitalized with AMI described their experiences with AMI symptoms and their decision-making process to seek medical care. The purpose was to identify factors that may contribute to delays in recognizing symptoms and engaging the healthcare system. Important Themes According to the results, five themes characterized the experiences of women. First, prodromal symptoms varied substantially in both nature and duration. Second, women inaccurately assessed their personal risk of heart disease and commonly attributed symptoms to non-cardiac causes. Third, it appeared that competing and conflicting priorities influenced decisions about seeking acute care. Fourth, the healthcare system was not consistently responsive to women, which resulted in...
Strategies to Lower Death Risk After AMI

Strategies to Lower Death Risk After AMI

Research has shown that the risk of dying from an acute myocardial infarction (AMI) has been steadily decreasing across the United States in recent years. Despite this improvement, there is still substantial variation in 30-day risk-standardized mortality rates (RSMRs) from hospital to hospital. To investigate the causes of variation with RSMRs in these patients, my colleagues and I conducted a cross-sectional survey of 537 hospitals to see what strategies they employed. Published in the May 1, 2012 Annals of Internal Medicine, our findings were combined with data from CMS to determine the links between hospital strategies and mortality rates. 5 Key Hospital Strategies for AMI According to our analysis, five hospital strategies were associated with a clinically important reduced risk of death for patients hospitalized with an AMI: 1) Monthly meetings: Holding monthly meetings to review AMI cases between hospital clinicians and staff who transported patients to the hospital was associated with a 0.70 percentage-point decrease in the RSMR. 2) Cardiologists on site: Always having cardiologists on site lowered the RSMR by 0.54 percentage points. 3) Problem-solving culture: Fostering an organizational environment in which clinicians are encouraged to solve problems creatively lowered the RSMR by 0.84 percentage points. 4) Cross-training nurses: Avoiding cross-training nurses from ICUs for the cardiac catheterization laboratory lowered the RSMR by 0.44 percentage points. 5) Dual champions: Having both physician and nurse champions lowered the RSMR by 0.88 percentage points. Using all five of these strategies was associated with more than a 1% decrease in 30-day RSMRs when compared with hospitals that used none of the strategies. Only six of the hospitals reviewed in our...

Trends in Acute Kidney Injury in Patients With Acute Myocardial Infarction

Among patients hospitalized with an acute myocardial infarction (AMI), about 20% will develop an acute kidney injury (AKI). This complication has been linked to adverse long-term outcomes, including permanent renal impairment and end-stage renal disease. Minor increases in serum creatinine levels have also been associated with increased mortality, longer hospitalizations, and higher costs. “Experts are increasingly emphasizing the importance of preventing AKI and promptly recognizing it in patients hospitalized with AMI,” says Mikhail N. Kosiborod, MD. “A better understanding of trends may help determine if recent prevention efforts have been successful. This data can also be used to form initiatives aimed at preventing AKI.” Taking a Closer Look at AKI In the February 13, 2012 Archives of Internal Medicine, Dr. Kosiborod and colleagues analyzed data from a registry of patients admitted to 56 hospitals across the United States to examine trends in AKI from 2000 to 2008. AKI was defined as an increase of at least 0.3 mg/dL in creatinine levels or a relative increase of at least 50% during hospitalization. “The database used in our analysis had an extensive collection of laboratory data, including detailed assessments of renal function,” says Dr. Kosiborod. “Using this information, we wanted to understand the incidence trends in AKI and use of AKI prevention strategies among patients hospitalized with AMI.” According to findings, the incidence of AKI declined from 26.6% in 2000 to 19.7% in 2008 (Figure). In-hospital mortality also declined in patients who developed AKI, dropping from 19.9% in 2000 to 13.8% in 2008. This improvement occurred despite a concomitant increase in AKI risk factors, including chronic kidney disease, cardiogenic shock, diabetes,...

COPD in Patients Hospitalized With AMI

The gap in medical care between patients with and without COPD who are hospitalized with acute myocardial infarction (AMI) appears to have narrowed substantially between 1997 and 2007, according to Massachusetts researchers. However, those with COPD appear to be treated less aggressively and be at increased risk of adverse outcomes than those without COPD. In-hospital and 30-day mortality rates were 13.5% and 18.7% for those with COPD, compared with 10.1% and 13.2% rates for those without COPD, respectively. Outcomes did not improve over the 10 years studied despite increased use of evidence-based therapy for all patients with AMI. Abstract: Chest, June...
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