The occurrence of ST-elevation myocardial infarction (STEMI) in a patient hospitalized for a noncardiac condition (inpatient STEMI; IPS) has a mortality rate that is 4– 10 fold higher than observed in patients with out-of-hospital onset STEMI (outpatient STEMI; OPS). ,, IPS are associated with longer delays in recognition, less utilization of standard therapies, longer lengths of stay, and more resource utilization than OPS. , Patients with IPS are much less likely to undergo percutaneous coronary intervention (PCI) than OPS although previous studies have shown that in-hospital mortality is significantly lower in IPS patients treated with PCI than in those who do not receive PCI. In the study by Dai et al, the benefits of PCI persisted after multivariable adjustment analysis, and were observed even in the highest risk group although these patients were less likely to undergo coronary angiography and PCI than patients at lower risk. ,
One reason that patients with IPS may be denied invasive therapies is that they are older than patients with OPS ,, and advanced age is associated with a higher risk of complications with PCI, including bleeding and acute kidney injury. It is possible that risks outweigh benefits in older individuals and that the survival benefit seen with PCI in IPS is limited to younger patients. This is an important question since there are more than 13 million hospitalizations for adults aged 65 years and older in the United States every year.
To determine whether the benefit of PCI in IPS extends across all age groups, a retrospective analysis of adult patients diagnosed with STEMI within the New York (NY) Planning and Research Cooperative System (SPARCS) database, covering the period 2011 to 2018 was performed. The methods have been previously described. To differentiate between outpatient-onset and inpatient-onset STEMI, diagnostic codes present on admission were used. Patients who were admitted with a cardiac diagnosis, were transferred from another hospital, were discharged on the same day as hospitalization or who did not reside in the state of NY were excluded. Treatment with PCI and use of diagnostic left heart cardiac catheterization were identified using ICD-9/10 procedure codes 00.66, 36.01, 36.02, 36.05, 36.06, 36.07, 36.09, 37.22, 37.23, 88.5x.
STEMI patients were categorized into three age cohorts: < 65 years, 65−74 years, and ≥ 75 years. Demographics and comorbidities were compared between IPS and OPS using t-tests for continuous variables and ꭓ 2 tests for categorical variables. Overall mortality outcomes were compared between age cohorts using chi-square. A logistic regression was created to evaluate risk factors for 30-day mortality. All inferential statistics were two-tailed and used α=0.05.
A total of 64,960 STEMI cases were identified in the state of NY between 2011 and 2018 with 4.4% being inpatient-onset. The mean (STD) age was higher for IPS patients compared to OPS (73.5 ± 13.3 vs 64.6 ± 14.2 years; p <0.001). Individuals ≥75 years accounted for 51.6% of IPS but only 19.7% of OPS whereas individuals younger < 65 years accounted for 24.4% of IPS and 53% of OPS ( Figure 1 A). Patients with IPS were more frequently female, and more likely to have diabetes mellitus (DM), hypertension, heart failure, chronic obstructive pulmonary disease (COPD), chronic kidney disease (CKD), and prior stroke than OPS, whereas hyperlipidemia, obesity, and tobacco use disorder were more common in the OPS group. The prevalence of females, White, hypertension, CKD, and COPD increased with age in both IPS and OPS groups with IPS having a higher prevalence of these risk factors compared to OPS in each age group. Smoking and obesity decreased as a function of age for both IPS and OPS ( Table 1 ).
Prevalence of IPS and OPS by age (A), 30 day and one-year mortality of IPS and OPS by age (B), use of coronary angiography and PCI in IPS vs OPS (C) and 30 day mortality with and without use of PCI in IPS (D). IPS = inpatient onset STEMI; OPS = outpatient onset STEMI.
Table 1
Comparison of demographics, comorbidities, treatment and mortality by age of inpatient-onset STEMI and outpatient-onset STEMI
| < 65 years | 65– 74 years | ≥ 75 years | ||||
|---|---|---|---|---|---|---|
| IPS | OPS | IPS | OPS | IPS | OPS | |
| N | 699 | 32,699 | 696 | 13,483 | 1,485 | 15,898 |
| Female (%) | 38.8% | 22.4% | 42.5% | 33.7% | 57.8% | 55.9% |
| Race/ ethnicity | ||||||
| White | 58.8% | 63.1% | 66.1% | 68.2% | 75.2% | 75.0% |
| Black | 18.3% | 9.8% | 12.4% | 8.1% | 8.5% | 6.7% |
| Hispanic | 9.9% | 8.7% | 7.2% | 8.2% | 6.4% | 6.6% |
| Asian | 2.3% | 3.8% | 4.6% | 3.1% | 2.8% | 2.3% |
| Other | 10.7% | 14.6% | 9.8% | 12.4% | 6.9% | 9.3% |
| Comorbid conditions | ||||||
| Diabetes Mellitus | 36.5% | 29.8% | 39.7% | 35.9% | 34.7% | 31.7% |
| Hypertension | 60.8% | 61.3% | 70.0% | 72.6% | 76.4% | 78.9% |
| Obesity | 18.5% | 17.4% | 12.5% | 13.3% | 5.0% | 5.9% |
| Hyperlipidemia | 29.2% | 59.5% | 42.2% | 59.7% | 41.2% | 53.0% |
| Chronic kidney disease | 22.6% | 6.3% | 22.4% | 13.6% | 30.1% | 23.9% |
| COPD | 16.9% | 7.0% | 24.9% | 12.7% | 21.4% | 14.0% |
| Current or former smoker | 29.8% | 48.6% | 23.4% | 32.7% | 13.9% | 16.3% |
| Treatments | ||||||
| Diagnostic cardiac catheterization | 26.9% | 85.9% | 25.1% | 78.9% | 16.2% | 55.0% |
| Percutaneous coronary intervention | 18.0% | 80.3% | 16.1% | 70.3% | 9.3% | 45.3% |
| Outcomes | ||||||
| In-hospital mortality | 33.0% | 3.9% | 40.7% | 8.2% | 43.7% | 17.6% |
| 30-day mortality | 39.9% | 4.9% | 47.3% | 10.9% | 54.3% | 25.7% |
| 30-day mortality with PCI | 16.7% | 2.4% | 16.1% | 4.8% | 22.9% | 10.3% |
| 30-day mortality without PCI | 50.0% | 14.8% | 53.3% | 25.6% | 56.9% | 37.6% |
| 1-year mortality | 48.2% | 6.8% | 55.9% | 15.4% | 67.3% | 38.2% |
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