Background Various national campaigns launched in recent years focused on young women with acute myocardial infarction (AMI). Contemporary longitudinal data about sex differences in clinical characteristics, hospitalization rates, length of stay (LOS), and mortality have not been examined. Objective To determine sex differences in clinical characteristics, hospitalization rates, LOS, and in-hospital mortality by age groups and race among young patients with AMI using a large national dataset of U.S. hospital discharges. Methods Using the National Inpatient Sample (NIS), we compared clinical characteristics, AMI hospitalization rates, LOS, and in-hospital mortality for patients with AMI across ages 30–54 years, dividing them into 5-year subgroups from 2001–2010, using survey data analysis techniques. Results We identified 230,684 hospitalizations with a principal discharge diagnosis of AMI in 30–54-year-old patients from NIS data, representing an estimated 1,129,949 hospitalizations in the U.S. from 2001–2010. No statistically significant declines in AMI hospitalization rates were observed in the age groups <55 years, or stratified by sex. Prevalence of comorbidities was higher in women and increased among both sexes through the study period. Women had longer LOS and higher in-hospital mortality than men across all age groups. However, observed inhospital mortality declined significantly for women from 2001 to 2010 (3.3% to 2.3%, relative change 30.5%, p-for-trend<0.0001); but not for men (2.0% to 1.8%, relative change 8.6%, p-for-trend=0.6). Conclusions AMI hospitalization rates for young people have not declined over the past decade. Young women with AMI have more comorbidity, longer LOS, and higher in-hospital mortality than young men.
BackgroundWe compared the clinical characteristics and outcomes of young patients with myocardial infarction with nonobstructive coronary arteries (MINOCA) versus obstructive disease (myocardial infarction due to coronary artery disease [MI‐CAD]) and among patients with MINOCA by sex and subtype.Methods and ResultsBetween 2008 and 2012, VIRGO (Variation in Recovery: Role of Gender on Outcomes of Young AMI Patients) prospectively enrolled acute myocardial infarction patients aged 18 to 55 years in 103 hospitals at a 2:1 ratio of women to men. Using an angiographically driven taxonomy, we defined patients as having MI‐CAD if there was revascularization or plaque ≥50% and as having MINOCA if there was <50% obstruction or a nonplaque mechanism. Patients who did not have an angiogram or who received thrombolytics before an angiogram were excluded. Outcomes included 1‐ and 12‐month mortality and functional (Seattle Angina Questionnaire [SAQ]) and psychosocial status. Of 2690 patients undergoing angiography, 2374 (88.4%) had MI‐CAD, 299 (11.1%) had MINOCA, and 17 (0.6%) remained unclassified. Women had 5 times higher odds of having MINOCA than men (14.9% versus 3.5%; odds ratio: 4.84; 95% confidence interval, 3.29–7.13). MINOCA patients were more likely to be without traditional cardiac risk factors (8.7% versus 1.3%; P<0.001) but more predisposed to hypercoaguable states than MI‐CAD patients (3.0% versus 1.3%; P=0.036). Women with MI‐CAD were more likely than those with MINOCA to be menopausal (55.2% versus 41.2%; P<0.001) or to have a history of gestational diabetes mellitus (16.8% versus 11.0%; P=0.028). The MINOCA mechanisms varied: a nonplaque mechanism was identified for 75 patients (25.1%), and their clinical profiles and management also varied. One‐ and 12‐month mortality with MINOCA and MI‐CAD was similar (1‐month: 1.1% and 1.7% [P=0.43]; 12‐month: 0.6% and 2.3% [P=0.68], respectively), as was adjusted 12‐month SAQ quality of life (76.5 versus 73.5, respectively; P=0.06).ConclusionsYoung patients with MINOCA were more likely women, had a heterogeneous mechanistic profile, and had clinical outcomes that were comparable to those of MI‐CAD patients.Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00597922.
Health care may be burdensome and of uncertain benefit for older adults with multiple chronic conditions (MCCs). Aligning health care with an individual's health priorities may improve outcomes and reduce burden.OBJECTIVE To evaluate whether patient priorities care (PPC) is associated with a perception of more goal-directed and less burdensome care compared with usual care (UC).DESIGN, SETTING, AND PARTICIPANTS Nonrandomized clinical trial with propensity adjustment conducted at 1 PPC and 1 UC site of a Connecticut multisite primary care practice that provides care to almost 15% of the state's residents. Participants included 163 adults aged 65 years or older who had 3 or more chronic conditions cared for by 10 primary care practitioners (PCPs) trained in PPC and 203 similar patients who received UC from 7 PCPs not trained in PPC. Participant enrollment occurred between February 1, 2017, and March 31, 2018; follow-up extended for up to 9 months (ended September 30, 2018).INTERVENTIONS Patient priorities care, an approach to decision-making that includes patients' identifying their health priorities (ie, specific health outcome goals and health care preferences) and clinicians aligning their decision-making to achieve these health priorities. MAIN OUTCOMES AND MEASURES Primary outcomes included change in patients' OlderPatient Assessment of Chronic Illness Care (O-PACIC), CollaboRATE, and Treatment Burden Questionnaire (TBQ) scores; electronic health record documentation of decision-making based on patients' health priorities; medications and self-management tasks added or stopped; and diagnostic tests, referrals, and procedures ordered or avoided. RESULTSOf the 366 patients, 235 (64.2%) were female and 350 (95.6%) were white. Compared with the UC group, the PPC group was older (mean [SD] age, 74.7 [6.6] vs 77.6 [7.6] years) and had lower physical and mental health scores. At follow-up, PPC participants reported a 5-point greater decrease in TBQ score than those who received UC (ß [SE], -5.0 [2.04]; P = .01) using a weighted regression model with inverse probability of PCP assignment weights; no differences were seen in O-PACIC or CollaboRATE scores. Health priorities-based decisions were mentioned in clinical visit notes for 108 of 163 (66.3%) PPC vs 0 of 203 (0%) UC participants. Compared with UC patients, PPC patients were more likely to have medications stopped (weighted comparison, 52.0% vs 33.8%; adjusted odds ratio [AOR], 2.05; 95% CI, 1.43-2.95) and less likely to have self-management tasks (57.5% vs 62.1%; AOR, 0.59; 95% CI, 0.41-0.84) and diagnostic tests (80.8% vs 86.4%; AOR, 0.22; 95% CI, 0.12-0.40) ordered.CONCLUSIONS AND RELEVANCE This study's findings suggest that patient priorities care may be associated with reduced treatment burden and unwanted health care. Care aligned with patients' priorities may be feasible and effective for older adults with MCCs.TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03600389
Objectives To develop a values‐based, clinically feasible process to help older adults identify health priorities that can guide clinical decision‐making. Design Prospective development and feasibility study. Setting Primary care practice in Connecticut. Participants Older adults with 3 or more conditions or taking 10 or more medications (N=64). Intervention The development team of patients, caregivers, and clinicians used a user‐centered design framework—ideate → prototype → test →redesign—to develop and refine the value‐based patient priorities care process and medical record template with trained clinician facilitators. Measurements We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). Results We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. Conclusion Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.
Background Differences between sexes in cardiac risk factors, perceptions of cardiac risk, and healthcare provider discussions about risk with acute myocardial infarction (AMI) are not well studied. Objective We compared cardiac risk factor prevalence, risk perceptions, and healthcare provider feedback on heart disease and risk modification between young women and men hospitalized with AMI. Methods We studied 3,501 AMI patients aged 18-55 years enrolled in the VIRGO study in US and Spanish hospitals between 8/2008 to 1/2012, comparing the prevalence of 5 cardiac risk factors by sex. Modified Poisson regression was used to assess sex differences in self-perceived heart disease risk and self-reported provider discussions of risk and modification. Results Nearly all patients (98%) had ≥ 1 risk factor, and 64% had ≥ 3. Only 53% of patients considered themselves at-risk for heart disease, and even fewer reported being told they were at-risk (46%) or that their healthcare provider discussed heart disease and risk modification (49%). Women were less likely than men to be told they were at-risk (relative risk [RR] 0.89, 95% confidence interval [CI] 0.84-0.96) or have a provider discuss risk modification (RR 0.84, 95% CI 0.79-0.89); there was no difference between women and men for self-perceived risk. Conclusions Despite significant cardiac risk factors, only half of young AMI patients believed they were at-risk for heart disease before their event. Even fewer discussed their risks or risk modification with their healthcare providers; this problem was more pronounced among women.
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