CLINICAL
NEWS JOURNAL WRAP
Kim Eagle, MD, and the editors of ACC.org’s Journal Scans,
present relevant articles taken from various journals.
ICDs in Older Patients After MI
Following a myocardial infarction
(MI), only one in 10 patients aged 65
or older with an ejection fraction of
35% or less had an implantable cardioverter-defibrillator (ICD) inserted
within 1 year, and, on average, patients
who received an ICD had a significantly lower mortality rate than those
who did not—15.3 vs. 26.4 events per
100 patient-years, according to a study
published June 23 in the Journal of the
American Medical Association.
Using data from the ACC’s ACTION Registry-GWTG linked with
Medicare data, researchers assessed
records from 10,318 patients at 242
hospitals between Jan. 2, 2007, and
Sept. 30, 2010. The median age of
patients was 78, and the majority
(75%) underwent in-hospital revascularization.
Results showed that the cumulative ICD implantation rate within 1
year of the cardiac event was 8.1%,
and median time from admission to
implantation was 137 days. For patients who had undergone revascularization, the timeframe was 115 days.
Based on their findings, the
authors identified patient factors associated with a greater likelihood of
ICD implantation within 1 year of the
MI: younger, male patients who had
prior coronary artery bypass graft
procedures, larger infarcts, in-hospital
cardiogenic shock, and cardiology
follow-up within 2 weeks after hospital discharge. Those patients with a
lower likelihood of ICD implantation
were older, female, and had end-stage
renal disease.
Researchers also found significant
variation in hospital ICD implantation
rates. After adjusting for differences
in the patient mix across hospitals,
the study showed that among 242
hospitals, the median estimated
1-year ICD implantation rate was
7.4%. Patients in hospitals in the 90th
percentile of 1-year ICD implantation
(11.5%) were 2.4-fold more likely to
receive an ICD than hospitals in the
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10th percentile (4.8%).
The authors conclude that moving forward, “Additional research is
needed to determine evidence-based
approaches to increase ICD implantation among eligible patients.”
Sean Pokorney, MD, MBA, a cardiology fellow in the Division of Cardiology at Duke University Medical
Center, Durham, NC, and the study’s
lead author, notes that the study’s
findings are surprising and raise “concerns about gaps in care that occur
during the transition from inpatient
care to outpatient care.” He adds that
the study “should raise awareness of
the need to be vigilant about identifying patients who are candidates for
primary prevention ICDs.”
In an accompanying editorial,
Robert G. Hauser, MD, a cardiologist
with the Minneapolis Heart Institute
at Abbott Northwestern Hospital,
Minneapolis, MN, agrees that it is
“concerning that so few potentially
ICD-eligible patients are undergoing
implantation, especially considering that ICDs significantly improve
survival.” He suggests that the reason
for the problem is the fragmented
health care system in which “overly
burdened primary care physicians are
expected to connect all the clinical
and diagnostic information without
the essential tools and necessary
facts.”
“Even though the use of ICDs for
primary prevention may not seem to
make as much sense for an 80-yearold patient as it does for a patient
in his or her 50s or 60s,” continues
Hauser. “An older patient at risk for
sudden cardiac death should have the
same opportunity to choose potentially lifesaving therapy. [This study]
can help physicians and their patients
be better informed during discussions
about the risks and benefits of ICDs
in older persons.”
Pokorney SD, Miller AL, Chen AY,
et al. JAMA. 2015;313(24):2433-40.
More Women Readmitted After MI
A recent study in Circulation has
found that women have higher rates
of 30-day readmission than men after
acute myocardial Infarction (AMI).
Researchers used data from the
Health Care Cost and Utilization
Project—State Inpatient Dataset
of California from January 2007,
to November 2009, to evaluate
sex differences in the rate, timing
and principal diagnosis of 30-day
readmission following AMI, and to
examine the association of sex with
30-day readmissions, while assessing whether or not these is an agesex interaction.
A total of 42,518 hospitalizations
from 40,851 patients aged 18-65
years with AMI were examined.
Women were more likely to be older
and African American or Hispanic,
and be covered by Medicare or
Medicaid. Women also had a higher
frequency of unfavorable cardiovascular risk factors and comorbidities
compared to men.
The number of patients with at
least one readmission for the population was 4,775 (11.2%). The 30day all-cause readmission rate was
higher for women (15.5% vs. 9.7%).
The higher rates for women existed
regardless of age, race and payer
status. There was no difference in the
readmission risk between men and
women, with both sexes having the
highest risk 2-4 days after discharge
and declining thereafter. In both
women and men, 42% of readmissions occurred in the first week
following AMI. Women were more
likely to present for readmission
with non-cardiac diagnoses.
According to the authors, a large
proportion of the association of sex
on readmissions was explained by
socio-demographic differences. The
higher comorbidity burden women
faced also added to the vulnerability for readmission. However, the
fact that this higher risk existed
in women even after adjusting
for covariates suggests that there
are other factors that predispose
younger women to readmission.
The authors suggest that these differences may include differences in
comorbidities and/or consequences
of the AMI, as well as social and/or
psychosocial factors.
Researchers also note that
women are more prone to complications after hospitalization for AMI.
They suggest that women may
focus less on their own recovery
following AMI due to the work and
home roles. As the typical family
caregiver, women may not have a
caregiver of their own. Additionally,
“Women may be more susceptible to
the disruption of the hospitalization
itself and have more stressful and
difficult experiences than man,” the
authors said. “This excess allostatic
load may lead to greater vulnerability after discharge.”
Moving forward, the authors
suggest that “health care providers
should be made aware of this disparity, and research efforts be directed
toward identifying risk factors or
opportunities in care that differ between groups and that may mediate
the observed disparities in the risk
of readmission, which may inform
effective interventions.” They add
that “there may need to be a continued focus on safe discharge planning and early ambulatory interventions following hospital discharge,”
especially for the high-risk group of
young women.
In an ACC.org Journal Scan,
Elizabeth A. Jackson, MD, recommends that further research “related
to factors associated with readmission among young women may help
promote interventions that translate
into reduced readmission rates.” ■
Dreyer RP, Ranasinghe I, Wang Y,
et al. Circulation. doi: 10.1161/
CIRCULATIONAHA.114.014776.
July 2015