Management and Outcomes of ST-Segment Elevation Myocardial Infarction in Hospitalized Frail Patients in the United States

https://doi.org/10.1016/j.amjcard.2022.04.006Get rights and content

Cardiovascular diseases and frailty are common conditions of aging populations and often coexist. In this study, we examined the in-hospital management, outcomes, and resource use of frail patients hospitalized for ST-segment elevation myocardial infarction (STEMI). This was a retrospective analysis of the 2005–2014 data from the Nationwide Inpatient Sample. Patients were classified into to versus ‘nonfrail’ using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnosis indicator. The primary outcome was STEMI management, whereas secondary outcomes were in-hospital mortality, length of stay, and cost. Outcomes were compared between frail and nonfrail patients using propensity score-matched analysis. There were 1,360,597 STEMI hospitalizations, of which 36,316 (2.7%) were frail. Propensity score-matched analysis showed that in in-hospital management options for STEMI, the odds of overall revascularization (odds ratio [OR], 0.60; 95% confidence interval [CI], 0.55 to 0.65), percutaneous coronary intervention (OR, 0.53; 95% CI, 0.49 to 0.57), and coronary angiography (OR, 0.59; 95% CI, 0.55 to 0.64) were significantly lower for frail patients. The odds of receiving coronary artery bypass grafting (OR, 1.66; 95% CI, 1.48 to 1.86) and overall hemodynamic support (OR, 1.26; 95% CI, 1.15 to 1.39) were significantly higher for frail patients. In-hospital mortality (18.7% vs 8.2%, p <0.001), length of stay (7.7 vs 3.7 days, p <0.001) and costs ($90,060 vs $63,507, p <0.001) were significantly higher in frail patients. Our findings suggest that collaborative efforts by cardiologists and cardiovascular surgeons for identifying frailty in patients with STEMI and incorporating frailty in risk estimation measures may improve management strategies, resource use and optimize patient outcomes.

Introduction

The older adult population in the United States has continued to increase over time, increasing the burden of managing associated conditions.1 Of particular concern is recognizing frailty, which includes clinical states resulting in depleting vitality, associated with age-related deterioration in physiologic reserves and functions.2 Frailty is associated with a greater risk for cardiovascular diseases and vice versa.3 In particular, the rates of major adverse cardiovascular events are significantly higher in frail patients with myocardial infarction (MI).4 Therefore, it is important to understand the impact of frailty on the management and outcomes, especially for invasive treatments involving complex medical and surgical procedures for MI. Although these procedures have become sophisticated and rigorous over the years, they have been under-recommended in the frail population because of the treatment-risk paradox.5 Therefore, we examined the differences in management, outcomes, and resource use between frail and nonfrail patients hospitalized for ST-segment elevation myocardial infarction (STEMI) using a national database.

Section snippets

Methods

We conducted a retrospective analysis of data from the Nationwide Inpatient Sample (NIS) database collected from 2005 to 2014. NIS is the largest all-payer inpatient database created by the Agency of Healthcare Research and Quality as a part of the Healthcare Cost and Utilization Project.6 NIS contains data from >35 million hospitalizations within the United States every year.

Adult patients 50 years and older and hospitalized during the study years with a primary diagnosis of STEMI were

Results

There were 1,360,597 STEMI hospitalizations from 2005 to 2014, of which 36,316 (2.7%) were frail. Table 1 lists the patient and hospital characteristics of the sample. Frail patients were significantly older than nonfrail patients. Most frail patients and nonfrail patients were men. In frail patients, the most were White, followed by Black, Hispanic, and other races, whereas in nonfrail patients, the most were White, followed by Hispanic, Black, and other races (Table 1). In the frail group,

Discussion

In our study, the prevalence of frailty in patients experiencing hospitalization for STEMI was 2.7%. The rates of CABG were significantly higher in frail patients, whereas the rates of PCI and coronary angiography were lower in frail patients. Frail patients also had higher rates of hemodynamic support such as IABP, pLVAD, and ECMO, and higher rates of hospital outcome and resource use such as in-hospital mortality, hospital length of stay, and hospitalization cost.

In our study, although only a

Disclosures

The authors have no conflicts of interest to declare.

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Funding: None.

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