ST-Elevation Myocardial Infarction Diagnosed After Hospital Admission

Garberich, Ross; Traverse, Jay H.; Claussen, Michael; Rodriguez, Gilhen; Poulose, Anil; Chavez, Ivan; Rutten-Ramos, Stephanie; Hildebrandt, David; Henry, Timothy D.

doi:10.1161/circulationaha.113.005568

Cited by 42 publications

(73 citation statements)

References 14 publications

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“…This multi-center study confirms previously published studies 6,11,12 demonstrating increased mortality for patients who develop inpatient-onset STEMI compared to outpatient-onset STEMI. To the best of our knowledge, the present study is the largest of its kind and the only multi-center study specifically assessing the incidence and variables associated with outcomes of patients developing STEMI while hospitalized for a non-ACS condition.…”

Section: Commentsupporting

confidence: 90%

See 1 more Smart Citation

Association of Inpatient vs Outpatient Onset of ST-Elevation Myocardial Infarction With Treatment and Clinical Outcomes

Kaul

Federspiel

Dai

et al. 2014

JAMA

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Importance Reperfusion times for ST elevation myocardial infarction (STEMI) occurring in outpatients have improved significantly, but quality improvement efforts have largely ignored STEMI occurring in hospitalized patients (inpatient-onset STEMI). Objective To define the incidence and variables associated with treatment and outcomes of patients who develop STEMI during hospitalization for conditions other than acute coronary syndromes (ACS). Design, Setting and Participants STEMIs were identified in the 2008–2011 California State Inpatient Database. Exposure STEMI were classified as inpatient-onset or outpatient-onset based on present-on-admission codes. Patients who developed STEMI after being hospitalized for ACS were excluded from the analysis. Main Outcome Measures Regression models were used to evaluate associations between location of onset of STEMI, resource utilization and outcomes. Adjustments were made for patient age, sex, comorbidities and hospital characteristics. Results 62021 STEMIs were identified from 303 hospitals of which 3068 (4.9%) occurred in patients hospitalized for non-ACS indications. Inpatient-onset STEMI patients were older (71.5 ± 13.5 vs 64.9 ± 14.1 years; p < 0.001) and more frequently female (47.4% vs 32%; p < 0.001) than outpatient-onset STEMI. Inpatient-onset STEMI had higher in-hospital mortality (33.6% vs 9.2%; adjusted odds ratio (AOR) = 3.05; 95% CI, 2.76 to 3.38; p < 0.001), were less likely to be discharged home (33.7% vs 69.4%; AOR = 0.38; 95% CI, 0.34 to 0.42; p < 0.001), and were less likely to undergo cardiac catheterization (33.8% vs 77.8%; AOR = 0.19; 95% CI, 0.16 to 0.21; p < 0.001) or percutaneous coronary intervention (21.6% vs 65%; AOR = 0.23; 95% CI, 0.21 to 0.26; p < 0.001). Length of stay (13.4 ± 17.8 vs 4.7 ± 6.3 days; adjusted multiplicative effect (AME) = 2.51; 95% CI, 2.35 to 2.69; p < 0.001) and inpatient charges ($245000 ± 258700 vs $129000 ± 129800; AME = 2.09; 95% CI, 1.93 to 2.28; p < 0.001) were higher for inpatient-onset STEMI. Conclusions and Relevance Patients who developed STEMI while hospitalized for a non-ACS condition, compared to those with onset of STEMI as an outpatient, were less likely to undergo invasive testing or intervention and had a higher in-hospital mortality rate.

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Section: Commentsupporting

confidence: 90%

“…13 Recently, data from 3,795 consecutive STEMI patients treated at a single center between March 2003 and January 2013 were reported. 12 The 83 inpatient-onset STEMIs that were described had a higher 1-year mortality compared to outpatient-onset STEMIs that presented via emergency medical services (16.9% versus 10.3%).…”

Section: Commentmentioning

confidence: 94%

Association of Inpatient vs Outpatient Onset of ST-Elevation Myocardial Infarction With Treatment and Clinical Outcomes

Kaul

Federspiel

Dai

et al. 2014

JAMA

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“…3 Greater hospital delays to thrombolytic treatment for ischemic events with onset in the hospital compared to in the community have been observed for both stroke and ST elevation myocardial infarction. 3,29 This raises the interesting question, why would it take longer to respond to time critical ischemic emergencies in patients already hospitalized? There are a number of factors that could explain quality gaps for stroke ( Table 2).…”

Section: Cumblermentioning

confidence: 99%

In-Hospital Ischemic Stroke

Cumbler

2015

The Neurohospitalist

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Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. These in-hospital strokes represent a unique population with different risk factors, more mimics, and substantially worsened outcomes compared to community-onset strokes. The fact that these strokes manifest during the acute care hospitalization, in patients with higher rates of thrombolytic contraindications, creates distinct challenges for treatment. However, the best evidence suggests benefit to treating appropriately selected in-hospital ischemic strokes with thrombolysis. Evidence points toward a ''quality gap'' for in-hospital stroke with longer in-hospital delays to evaluation and treatment, lower rates of evaluation for etiology, and decreased adherence to consensus quality process measures of care. This quality gap for in-hospital stroke represents a focused opportunity for quality improvement.

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“…1,[3][4][5] Patients who develop inpatient STEMI are older, often have atypical clinical presentation, and have more comorbidities. These patients are less likely to be recognized in a timely manner and to have longer ECG-to-reperfusion times.…”

Section: To the Editormentioning

confidence: 99%

Letter by Dai et al Regarding Article, “ST-Elevation Myocardial Infarction Diagnosed After Hospital Admission”

2015

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We read with interest the recent report by Garberich et al 1 describing data from a single-center registry of patients diagnosed with ST-segment-elevation myocardial infarction (STEMI) after hospital admission. This study confirmed that hospitalized patients who develop STEMI are older and have increased comorbidities, time to perfusion, and mortality compared with outpatients with STEMI. Inpatient STEMI is increasingly being recognized as an important challenge for optimizing acute coronary syndrome care, 2 and we would like to highlight 3 important issues raised by the study by Garberich et al.First, patients who developed STEMI while hospitalized with a primary cardiac diagnosis had better outcomes than patients initially admitted with a noncardiac diagnosis. Their study showed an 8-fold difference in mortality at 30 days (2.0% versus 17.7%; P=0.012) and a 5-fold difference at 1 year (6.1% versus 32.4%; P=0.002). We previously reported high in-hospital mortality rates in patients who developed STEMI while hospitalized for a noncardiac reason, both at our hospital (39.6% [inpatient] 4 Although Garberich et al reported overall lower mortality rates than in our studies, it is important to note that >90% of the patients in their study underwent primary percutaneous coronary intervention and that 54% of the patients in their study were admitted with a primary cardiac diagnosis. In our studies, we found that 30% to 70% of inpatients with STEMI were deemed not to be candidates for coronary angiography for various reasons 3,4 and that these patients have a much higher mortality. The present study, along with published data, presents a compelling picture that the development of STEMI in a patient hospitalized for a noncardiac condition is a lethal disease.Second, multiple studies have now reported significant differences between patients who develop inpatient and outpatient STEMI. 1,[3][4][5] Patients who develop inpatient STEMI are older, often have atypical clinical presentation, and have more comorbidities. These patients are less likely to be recognized in a timely manner and to have longer ECG-to-reperfusion times.Third, Garberich et al reported that implementation of a "level 1 MI program," a standard STEMI protocol for in-hospital STEMI, resulted in an important reduction in in-hospital mortality (from 15.4% to 5.3%, a 10.1% absolute and 66% relative reduction) with a moderate decrease in median reperfusion times (from 85 to 67 minutes). These data demonstrate that systems designed to improve the care of inpatient STEMI can have a significant beneficial impact on mortality. We congratulate the authors on this important finding. In our center, we have implemented a healthcare system-wide educational campaign to improve the awareness among staff of noncardiac units of the importance of early recognition of clinical signs of MI, early ECG acquisition, and rapid ECG interpretation and have formed a cardiac response team as key elements to improve inpatient STEMI care. DisclosuresNone.

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ST-Elevation Myocardial Infarction Diagnosed After Hospital Admission

Cited by 42 publications

References 14 publications

Association of Inpatient vs Outpatient Onset of ST-Elevation Myocardial Infarction With Treatment and Clinical Outcomes

Association of Inpatient vs Outpatient Onset of ST-Elevation Myocardial Infarction With Treatment and Clinical Outcomes

In-Hospital Ischemic Stroke

Letter by Dai et al Regarding Article, “ST-Elevation Myocardial Infarction Diagnosed After Hospital Admission”

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