Elsevier

The American Journal of Cardiology

Volume 159, 15 November 2021, Pages 8-18
The American Journal of Cardiology

Predictors, Treatments, and Outcomes of Do-Not-Resuscitate Status in Acute Myocardial Infarction Patients (from a Nationwide Inpatient Cohort Study)

https://doi.org/10.1016/j.amjcard.2021.07.054Get rights and content

Little is known about how frequently do-not-resuscitate (DNR) orders are placed in patients with acute myocardial infarction (AMI), the types of patients in which they are placed, treatment strategies or clinical outcomes of such patients. Using the United States (US) National Inpatient Sample (NIS) database from 2015 to 2018, we identified 2,767,549 admissions that were admitted to US hospitals and during the hospitalization received a principle diagnosis of AMI, of which 339,270 (12.3%) patients had a DNR order (instigated both preadmission and during in-hospital stay). Patients with a DNR status were older (median age 83 vs 65, p < 0.001), more likely to be female (53.4% vs 39.3%, p < 0.001) and White (81.0% vs 73.3%, p < 0.001). Predictors of DNR status included comorbidities such as heart failure (OR: 1.47, 95% CI: 1.45 to 1.48), dementia (OR: 2.53, 95% CI: 2.50 to 2.55), and cancer. Patients with a DNR order were less likely to undergo invasive management or be discharged home (13.5% vs 52.8%), with only 1/3 receiving palliative consultation. In hospital mortality (32.7% vs 4.6%, p < 0.001) and MACCE (37.1% vs 8.8%, p < 0.001) were higher in the DNR group. Factors independently associated with in-hospital mortality among patients with a DNR order included a STEMI presentation (OR: 2.90, 95% CI: 2.84 to 2.96) and being of Black (OR: 1.29, 95% CI: 1.26 to 1.33), Hispanic (OR: 1.36, 95% CI: 1.32 to 1.41) or Asian/Pacific Islander (OR: 1.56, 95% CI:1.49-race. In conclusion, AMI patients with a DNR status were older, multimorbid, less likely to receive invasive management, with only one third of patients with DNR status referred for palliative care.

Section snippets

Methods

The National Inpatient Sample (NIS) is the largest all-payer inpatient health care database in the United States, developed by the Healthcare Cost and Utilization Project (HCUP) and sponsored by the Agency for Healthcare Research and Quality (AHRQ).6 The NIS dataset contains hospital information on between 7 and 8 million yearly hospital discharges from 2004 onwards. Since 2012, the NIS samples discharge from all hospitals participating in HUCP, approximating a 20% stratified sample of all

Results

Between October 2015 to December 2018, 2,959,244 patients were admitted to US hospitals and during the hospitalization received a diagnosis of an AMI. Applying relevant exclusion criteria (Figure 1) produced a study cohort consisting of 2,767,549 (6.0% excluded). Of these, 339,270 (12.3%) were in the DNR group. Differences in clinical characteristics at admission between the 2 groups are presented in Table 1. Patients with a DNR order were older (median age 83 vs 67, p < 0.001), more likely to

Discussion

The results of this analysis of greater than 2.5 million US patients who presented with AMI between 2015 and 2018 revealed several important findings. First, 1 in 8 patients hospitalized with AMI had a DNR order, with more common characteristics such as being older, female, of White race and presenting as a cardiac arrest or in cardiogenic shock, but less likely to present as a STEMI. Second, patients who received a DNR order had a high burden of comorbidities such as cerebrovascular disease,

Disclosures

Giuseppe Biondi-Zoccai has consulted for Cardionovum, Innovheart, Meditrial, Opsens Medical, and Replycare. Jessica Simon is Physician Consultant, Advance Care Planning and Goals of Care, Alberta Health Services, Calgary zone. All other authors have no conflicts of interest to disclose.

References (30)

  • NS Wenger et al.

    Epidemiology of do-not-resuscitate orders. Disparity by age, diagnosis, gender, race, and functional impairment

    Arch Intern Med

    (1995)
  • JE Zimmerman et al.

    The use and implications of do not resuscitate orders in intensive care units

    Jama

    (1986)
  • CJ Stolman et al.

    Evaluation of the do not resuscitate orders at a community hospital

    Arch Intern Med

    (1989)
  • EA Jackson et al.

    Do-not-resuscitate orders in patients hospitalized with acute myocardial infarction: the Worcester Heart Attack Study

    Arch Intern Med

    (2004)
  • SM Dunlay et al.

    Resuscitation preferences in community patients with heart failure

    Circ Cardiovasc Qual Outcomes

    (2014)
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