Early Invasive Versus Initial Conservative Strategies for Women with Non–ST-Elevation Acute Coronary Syndromes: A Nationwide Analysis

doi:10.1016/j.amjmed.2017.01.049

The American Journal of Medicine

Volume 130, Issue 9, September 2017, Pages 1059-1067

https://doi.org/10.1016/j.amjmed.2017.01.049 Get rights and content

Abstract

Background

Studies conducted largely in men have shown improved outcomes with an early invasive strategy with non–ST-elevation acute coronary syndrome. In contrast, data have been less conclusive in women, with some trials demonstrating potential harm. This study aims to assess whether an early invasive strategy in women is associated with better outcomes in real-world data.

Methods

Women admitted with a primary diagnosis of non–ST-elevation myocardial infarction or unstable angina were identified from the National Inpatient Sample years 2012 and 2013. The incidence of in-hospital mortality in women with non–ST-elevation acute coronary syndrome undergoing an early invasive strategy versus an initial conservative strategy was compared using a propensity score–matched analysis.

Results

Among 372,080 women with non–ST-elevation acute coronary syndrome, 153,680 (41.3%) were managed with an early invasive strategy and 218,400 (58.7%) were managed with an initial conservative strategy. Propensity score–matched 19,965 women were treated with an early invasive strategy, and 20,009 women were treated with an initial conservative strategy. The risk of in-hospital mortality was lower with an early invasive strategy (2.1% vs 3.8%; odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.62). This benefit was noted in women presenting with non–ST-segment elevation myocardial infarction (OR, 0.52; 95% CI, 0.46-0.58) and was not observed in women with unstable angina (OR, 5.14; 95% CI, 0.47-56.9), P_interaction = .06. A propensity-adjusted analysis yielded similar results (OR, 0.51; 95% CI, 0.45-0.57).

Conclusions

In this large contemporary observational analysis of women with non–ST-elevation acute coronary syndrome, an early invasive strategy was associated with lower in-hospital mortality. This benefit was observed in women presenting with non–ST-elevation myocardial infarction but not with unstable angina. These findings provide evidence supporting the guideline recommendations for an early invasive strategy in women with non–ST-elevation acute coronary syndrome and high-risk features (eg, troponin positive).

Section snippets

Data Source

Data were obtained from the NIS database years 2012 and 2013. The NIS represents discharge data from approximately 20% stratified sample of US hospitals. The NIS is a part of the Healthcare Quality and Utilization Project, sponsored by the Agency for Healthcare Research and Quality.¹⁰ Starting from 2012, the NIS was redesigned to include a random sample of patient discharges rather than a random sample of hospitals retaining their discharges, which resulted in more precise national estimates.

Results

Among 372,080 women admitted with non–ST-elevation acute coronary syndrome in the NIS database years 2012 and 2013 (349,560 presented with non–ST-elevation myocardial infarction, and 22,520 presented with unstable angina), 153,680 (41.3%) were managed with an early invasive strategy and 218,400 (58.7%) were managed with an initial conservative strategy. Before propensity score matching, there were differences between the 2 groups in several of the baseline patient-related and hospital-related

Discussion

To the best of our knowledge, this is the largest study to compare an early invasive strategy with an initial conservative strategy exclusively in women. In this observational analysis on a large, real-world population of women with non–ST-elevation acute coronary syndrome admitted across the United States in 2012 and 2013, we demonstrated that an early invasive strategy was associated with a lower incidence of in-hospital mortality compared with an initial conservative strategy. This benefit

Conclusions

References (15)

A.A. Bavry et al.
Benefit of early invasive therapy in acute coronary syndromes: a meta-analysis of contemporary randomized clinical trials
J Am Coll Cardiol
(2006)
K.A. Fox et al.
Long-term outcome of a routine versus selective invasive strategy in patients with non-ST-segment elevation acute coronary syndrome a meta-analysis of individual patient data
J Am Coll Cardiol
(2010)
J. Alfredsson et al.
Impact of an invasive strategy on 5 years outcome in men and women with non-ST-segment elevation acute coronary syndromes
Am Heart J
(2014)
I.Y. Elgendy et al.
Meta-analysis of randomized trials of long-term all-cause mortality in patients with non-ST-elevation acute coronary syndrome managed with routine invasive versus selective invasive strategies
Am J Cardiol
(2017)
E.A. Amsterdam et al.
2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines
Circulation
(2014)
M. Roffi et al.
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)
Eur Heart J
(2016)
S.R. Mehta et al.
Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials
JAMA
(2005)

There are more references available in the full text version of this article.

Cited by (24)

Age-Stratified Sex-Related Differences in the Incidence, Management, and Outcomes of Acute Myocardial Infarction
2021, Mayo Clinic Proceedings
Citation Excerpt :
In the Role of Gender on Outcomes of Young AMI Patients (VIRGO) study, female sex was an independent risk factors for exceeding reperfusion guidelines; sex remained an important factor in exceeding STEMI reperfusion guidelines (OR=1.72; 95% CI, 1.28 to 2.33).30 In another nationwide study of young patients (age <60), women were less likely to receive reperfusion than men (adjusted OR=0.74; 95% CI, 0.73 to 0.75);3 several studies have shown that, in NSTEMI, women are less likely than men to receive early angiography ± revascularization.17,31,32 The novel finding in our study is its documentation of a clear association between female sex and less-invasive treatment of both STEMI and NSTEMI across all age groups.
To assess the impact of female sex on the incidence, management, and outcomes of myocardial infarction (MI) in different age groups.
Patients admitted with ST-elevation MI (STEMI) and non–ST-elevation MI (NSTEMI), between January 1, 2003, and December 31, 2015, were identified in the National Inpatient Sample. We compared STEMI and NSTEMI rates, management patterns, and in-hospital morbidity and mortality in men and women stratified into 4 age groups (<45, 45 to 64, 65 to 84, and ≥85 years of age).
A total of 6,720,639 weighted hospitalizations for MI (79.8% NSTEMI, and 20.2% STEMI) were included. The incidence rate of hospitalizations for MI was lower in women than men across all age groups. Women were less likely than men to undergo coronary angiography, revascularization, or to use circulatory-support devices. These differences were consistent across all age groups. Adjusted odds of death for women (vs men) varied by age: odds ratio (95% confidence interval) 1.08 (0.97 to 1.20), 1.05 (1.02 to 1.08), 0.92 (0.91 to 0.94), and 0.86 (0.85 to 0.88) for NSTEMI, and 1.15 (1.04 to 1.27), 1.22 (1.18 to 1.26), 1.09 (1.06 to 1.11), and 0.97 (0.94 to 0.99), for STEMI, in age groups (<45, 45 to 64, 65 to 84, and ≥85), respectively. The magnitude of differences in complications between men and women was higher in younger and middle-age patients.
Compared with men, women have lower incidence of MI and less likelihood of undergoing invasive treatment regardless of age. However, post-MI outcomes are age specific. The negative impact of female sex on most outcomes was most pronounced in young and middle-aged women.
Outcomes of Acute Myocardial Infarction in Patients with Rheumatoid Arthritis
2020, American Journal of Medicine
There is a paucity of data on the outcomes of acute myocardial infarction in patients with rheumatoid arthritis in the contemporary era.
We queried the National Inpatient Sample database (2002–2016) for hospitalizations with acute myocardial infarction. We described the trends and outcomes of acute myocardial infarction-rheumatoid arthritis compared with acute myocardial infarction-no rheumatoid arthritis.
The analysis included 9,359,546 hospitalizations with acute myocardial infarction, of whom 123,783 (1.3%) had rheumatoid arthritis. There was an increase in the number of hospitalizations with acute myocardial infarction-rheumatoid arthritis (P_trend < .001). There was an observed downtrend in mortality rates for acute myocardial infarction-rheumatoid arthritis (5.8% in 2002 vs 5.2% in 2016, P_trend = .01) corresponding to an increase in the utilization of percutaneous coronary intervention (P_trend < .001). In the overall cohort of acute myocardial infarction, rheumatoid arthritis was independently associated with lower rate of in-hospital mortality (adjusted odds ratio 0.90; 95% confidence interval, 0.81-0.99, P = .03). Compared with ST-elevation myocardial infarction (STEMI)-no rheumatoid arthritis, STEMI-rheumatoid arthritis was associated with lower in-hospital mortality and cardiac arrest, while it was associated with higher discharges to nursing facilities. No difference in mortality was observed among non-ST-elevation myocardial infarction (NSTEMI)-rheumatoid arthritis and NSTEMI-no rheumatoid arthritis, while NSTEMI-rheumatoid arthritis was associated with lower cardiac arrest, cardiogenic shock, and hemodialysis, at the expense of higher bleeding events and discharges to nursing facilities.
In this nationwide analysis, we found an increase in hospitalizations for acute myocardial infarction-rheumatoid arthritis. Among patients with acute myocardial infarction, rheumatoid arthritis was independently associated with lower in-hospital mortality, particularly in cases of STEMI.
Temporal Trends and Outcomes of Mechanical Complications in Patients With Acute Myocardial Infarction
2019, JACC: Cardiovascular Interventions
Citation Excerpt :
Then we identified hospitalizations using International Classification of Diseases-Ninth Revision diagnostics codes for STEMI and NSTEMI (Online Table 1). For NSTEMI, we used only cases with primary diagnosis codes of NSTEMI, to exclude MI secondary to other causes (8). We identified records with mechanical complications, including PMR, VSD, and FWR.
The aim of this study was to examine the temporal trends and outcomes of mechanical complications after myocardial infarction in the contemporary era.
Data regarding temporal trends and outcomes of mechanical complications after ST-segment elevation myocardial infarction (STEMI) and non–ST-segment elevation myocardial infarction (NSTEMI) are limited in the contemporary era.
The National Inpatient Sample database (2003 to September 2015) was queried to identify all STEMI and NSTEMI hospitalizations. Temporal trends and outcomes of mechanical complications after STEMI and NSTEMI, including papillary muscle rupture, ventricular septal defect, and free wall rupture, were described.
The analysis included 3,951,861 STEMI and 5,114,270 NSTEMI hospitalizations. Mechanical complications occurred in 10,726 of STEMI hospitalizations (0.27%) and 3,041 of NSTEMI hospitalizations (0.06%), with no changes in trends (p = 0.13 and p = 0.83, respectively). The rates of in-hospital mortality in patients with mechanical complications were 42.4% after STEMI and 18.0% after NSTEMI, with no significant trend changes (p = 0.62 and p = 0.12, respectively). After multivariate adjustment, patients who had mechanical complications after myocardial infarction had higher in-hospital mortality, cardiogenic shock, acute kidney injury, hemodialysis, and respiratory complications compared with those without mechanical complications. Predictors of lower mortality in patients with mechanical complications who developed cardiogenic shock included surgical repair in the STEMI and NSTEMI cohorts and percutaneous coronary intervention in the STEMI cohort.
Contemporary data from a large national database show that the rates of mechanical complications are low in patients presenting with STEMI and NSTEMI. Post–myocardial infarction mechanical complications continue to be associated with high mortality rates, which did not improve during the study period.
Incidence and Outcomes of Non-ST Elevation Myocardial Infarction in Patients Hospitalized with Decompensated Diabetes
2018, American Journal of Cardiology
Citation Excerpt :
In this nationwide study, we found that ∼35% of patients admitted with decompensate diabetes and NSTEMI undergo an invasive ischemic evaluation before discharge, of whom only 42% undergo revascularization (73% percutaneous and 27% surgical). These rates are lower than the reported rates of invasive assessment of patients with NSTEMI in general (50% to 70%), but higher than the reported rates of invasive assessment in patients who suffer a NSTEMI in the setting of stroke or sepsis.13,16,17 The reason behind this underutilization of invasive management is multifactorial, and may be due to a combination of clinical, hospital-specific, and socioeconomic factors, and other variables that can not be ascertained in administrative databases (e.g., coronary lesion characteristics).
Single center studies suggested that non-ST elevation myocardial infarction (NSTEMI) in patients admitted with acute decompensated diabetes is associated with poor long-term prognosis. We hypothesize that acute decompensated diabetes is also associated with worse early morbidity and mortality in patients admitted with NSTEMI. Adult patients with a primary discharge diagnosis of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS) were identified in the national inpatient sample. We then assessed contemporary trends in the incidence and management patents of NSTEMI in patients admitted with DKA/HHS and compared in-hospital morbidity and mortality, resource utilization, and cost between DKA/HHS patients with and without NSTEMI. In 431,037 patients admitted with decompensated diabetes from 2003 to 2014, 13,069 (3.03%) suffered a NSTEMI during their hospitalization. Patients with NSTEMI were older and had higher prevalence of atherosclerotic and nonatherosclerotic comorbidities. After propensity score matching, NSTEMI was associated with a 60% increase in in-hospitalmortality (9.1% vs 5.5%; p < 0.001), higher incidences of stroke, acute kidney injury, blood transfusion, longer hospitalizations, and higher costs. A minority (35%) ofNSTEMI patients underwent invasive coronary assessment, and those had lower in-hospitalmortality compared with NSTEMI patients who did not undergo invasive assessment(3.3% vs 12.2%, adjusted OR 0.30, 95%CI 0.24 to 0.36, p < 0.001). About 3% of patients admitted with decompensated diabetes suffer a NSTEMI and those experience higher in-hospital morbidity and mortality, longer hospitalization, and higher cost.
Gender Impact on 30-Day Readmissions After Hospitalization With Acute Myocardial Infarction Complicated by Cardiogenic Shock (from the 2013 to 2014 National Readmissions Database)
2018, American Journal of Cardiology
Previous studies have suggested that women are more likely to have increased risk of readmissions after acute myocardial infarction (AMI); however, this difference has not been examined in the setting of AMI complicated by cardiogenic shock. Thus, we aimed to compare 30-day readmissions in women versus men initially admitted with AMI complicated with cardiogenic shock. In this observational study, we used the Nationwide Readmissions Databases years 2013 and 2014 to identify subjects who were initially hospitalized with a primary diagnosis of AMI complicated by cardiogenic shock, and discharged alive. The 30-day readmission rates between women and men were compared using a multivariate Cox regression model adjusting for variable co-morbidities, as well as a propensity-matched analysis. Of 1,116,933 patients who had AMI, 39,807 (3.6%) had cardiogenic shock and were discharged alive. The rates of in-hospital procedures such as percutaneous coronary intervention, coronary artery bypass grafting, and intra-aortic balloon placement were less frequent in women. Thirty-day readmissions were higher in women (20.7%) than in men (17.6%), after adjustment for various co-morbidities (hazards ratio 1.09, 95% confidence interval 1.00 to 1.19, p = 0.04), and in the propensity-matched analysis (hazards ratio 1.10, 95% confidence interval 1.01 to 1.21, p = 0.04). In conclusion, women are at a higher risk of 30-day readmissions after AMI complicated with cardiogenic shock.
Trends of Incidence, Clinical Presentation, and In-Hospital Mortality Among Women With Acute Myocardial Infarction With or Without Spontaneous Coronary Artery Dissection: A Population-Based Analysis
2018, JACC: Cardiovascular Interventions
Citation Excerpt :
The large sample size from the NIS database provided an excellent source for further evaluation of rare diseases, such as SCAD, in a high-risk patient population presenting with AMI. The NIS database had been used to evaluate outcomes of various special patient populations on a national scale, providing accurate estimates of both the clinical presentations and outcomes (28,33). First, being an administrative database, the data are subject to errors in coding or misdiagnosis.
The authors sought to determine the clinical characteristics and in-hospital survival of women presenting with acute myocardial infarction (AMI) and spontaneous coronary artery dissection (SCAD).
The clinical presentation and in-hospital survival of women with AMI and SCAD remains unclear.
The National Inpatient Sample (2009 to 2014) was queried for all women with a primary diagnosis of AMI and concomitant SCAD. Iatrogenic coronary dissection was excluded. The main outcome was in-hospital mortality. Propensity score matching and multivariable logistic regression analyses were performed.
Among 752,352 eligible women with AMI, 7,347 had a SCAD diagnosis. Women with SCAD were younger (61.7 vs. 67.1 years of age) with less comorbidity. SCAD was associated with higher incidence of in-hospital mortality (6.8% vs. 3.4%). In SCAD patients, a decrease in in-hospital mortality was evident with time (11.4% in 2009 vs. 5.0% in 2014) and concurred with less percutaneous coronary intervention (PCI) (82.5% vs. 69.1%). Propensity score yielded 7,332 SCAD and 14,352 patients without SCAD. The odds ratio (OR) of in-hospital mortality remained higher with SCAD after propensity matching (OR: 1.87, 95% confidence interval [CI]: 1.65 to 2.11) and on multivariable regression analyses (OR: 2.41, 95% CI: 2.07 to 2.80). PCI was associated with higher mortality in SCAD patients presenting with non–ST-segment elevation myocardial infarction (OR: 2.01; 95% CI: 1.00 to 4.47), but not with STEMI (OR: 0.62; 95% CI: 0.41 to 0.96).
Women presenting with AMI and SCAD appear to be at higher risk of in-hospital mortality. Lower rates of PCI were associated with improved survival, with evidence of worse outcomes when PCI was performed for SCAD in the setting of non with ST-segment elevation myocardial infarction.

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: Funding: None.

: Conflict of Interest: AAB declares honorarium from the American College of Cardiology.

: Authorship: All authors had access to the data and played a role in writing this manuscript.

: IYE and ANM equally contributed to this article.

View full text

Clinical research studyEarly Invasive Versus Initial Conservative Strategies for Women with Non–ST-Elevation Acute Coronary Syndromes: A Nationwide Analysis

Abstract

Background

Methods

Results

Conclusions

Section snippets

Data Source

Results

Discussion

Conclusions

J Am Coll Cardiol

J Am Coll Cardiol

Am Heart J

Am J Cardiol

2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Circulation

2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: Task force for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC)

Eur Heart J

Routine vs selective invasive strategies in patients with acute coronary syndromes: a collaborative meta-analysis of randomized trials

JAMA

Clinical research study
Early Invasive Versus Initial Conservative Strategies for Women with Non–ST-Elevation Acute Coronary Syndromes: A Nationwide Analysis