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Background: It is unclear how the type of an atherosclerotic cardiovascular disease (ASCVD) event potentially influences patients' likelihood of smoking cessation., Methods: Using 2013 to 2018 data from the US based National Cardiovascular Data Registry Practice Innovation and Clinical Excellence outpatient cardiac registry, we identified patients who were current smokers at a clinic visit and followed them over time for a subsequent ASCVD event. Self-reported smoking status was assessed at each consecutive visit and used to determine smoking cessation after each interim ASCVD event (myocardial infarction, percutaneous coronary intervention, coronary artery bypass graft, stroke/transient ischemic attack, peripheral artery disease). We constructed separate multivariable Cox models with nonproportional hazards to examine the association of each interim ASCVD event with smoking cessation, compared with not having an interim ASCVD event. We estimated the relative association of ASCVD event type with smoking cessation using contrast tests. Analyses were stratified by presence versus absence of ASCVD at baseline., Results: Across 530 cardiology practices, we identified 1 933 283 current smokers (mean age 62±15, male 54%, ASCVD at baseline 50%). Among the 322 743 patients who had an interim ASCVD event and were still smoking, 41 336 (12.8%) quit smoking by their first subsequent clinic visit, which was higher among those with baseline ASCVD (13.4%) as compared with those without baseline ASCVD (11.5%). Each type of ASCVD event was associated with an increased likelihood of smoking. Patients who had an myocardial infarction, underwent coronary artery bypass graft (hazard ratio, 1.60 [95% CI, 1.55-1.65]), or had a stroke or transient ischemic attack were more likely to quit smoking as compared with those who underwent elective percutaneous coronary intervention or had a new diagnosis of peripheral artery disease (hazard ratio, 1.20 [95% CI, 1.17-1.22])., Conclusions: Only 13% of patients reported smoking cessation after an ASCVD event, with the type of event being associated with the likelihood of smoking cessation, prompting the need for patient-centered interventions., Competing Interests: Disclosures None.

Objective: This study aimed to assess whether an obesity paradox (lower event rates with higher body mass index [BMI]) exists in participants with advanced chronic kidney disease (CKD) and chronic coronary disease in the International Study of Comparative Health Effectiveness of Medical and Invasive Approaches (ISCHEMIA)-CKD, and whether BMI modified the effect of initial treatment strategy., Methods: Baseline BMI was analyzed as both a continuous and categorical variable (< 25, ≥ 25 to < 30, ≥ 30 kg/m 2 ). Associations between BMI and the primary outcome of all-cause death or myocardial infarction (D/MI), and all-cause death, cardiovascular death, and MI individually were estimated. Associations with health status were also evaluated using the Seattle Angina Questionnaire-7, the Rose Dyspnea Scale, and the EuroQol-5D Visual Analog Scale., Results: Body mass index ≥ 30 kg/m 2 vs < 25 kg/m 2 demonstrated increased risk for MI (hazard ratio [HR] [95% confidence interval] = 1.81 [1.12-2.92]) and for D/MI (HR 1.45 [1.06-1.96]) with a HR for MI of 1.22 (1.05-1.40) per 5 kg/m 2 increase in BMI in unadjusted analysis. In multivariate analyses, a BMI ≥ 30 kg/m 2 was marginally associated with D/MI (HR 1.43 [1.00-2.04]) and greater dyspnea throughout follow-up (P < .05 at all time points). Heterogeneity of treatment effect between baseline BMI was not evident for any outcome., Conclusions: In the ISCHEMIA-CKD trial, an obesity paradox was not detected. Higher BMI was associated with worse dyspnea, and a trend toward increased D/MI and MI risk. Larger studies to validate these findings are warranted., (Published by Elsevier Inc.)

Background: Whether initial invasive management in older vs younger adults with chronic coronary disease and moderate or severe ischemia improves health status or clinical outcomes is unknown., Objectives: The goal of this study was to examine the impact of age on health status and clinical outcomes with invasive vs conservative management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial., Methods: One-year angina-specific health status was assessed with the 7-item Seattle Angina Questionnaire (SAQ) (score range 0-100; higher scores indicate better health status). Cox proportional hazards models estimated the treatment effect of invasive vs conservative management as a function of age on the composite clinical outcome of cardiovascular death, myocardial infarction, or hospitalization for resuscitated cardiac arrest, unstable angina, or heart failure., Results: Among 4,617 participants, 2,239 (48.5%) were aged <65 years, 1,713 (37.1%) were aged 65 to 74 years, and 665 (14.4%) were aged ≥75 years. Baseline SAQ summary scores were lower in participants aged <65 years. Fully adjusted differences in 1-year SAQ summary scores (invasive minus conservative) were 4.90 (95% CI: 3.56-6.24) at age 55 years, 3.48 (95% CI: 2.40-4.57) at age 65 years, and 2.13 (95% CI: 0.75-3.51) at age 75 years (P interaction  = 0.008). Improvement in SAQ Angina Frequency was less dependent on age (P interaction  = 0.08). There were no age differences between invasive vs conservative management on the composite clinical outcome (P interaction  = 0.29)., Conclusions: Older patients with chronic coronary disease and moderate or severe ischemia had consistent improvement in angina frequency but less improvement in angina-related health status with invasive management compared with younger patients. Invasive management was not associated with improved clinical outcomes in older or younger patients. (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches [ISCHEMIA]; NCT01471522)., Competing Interests: Funding Support and Author Disclosures This project was supported in part by National Institutes of Health grants U01HL105907, U01HL105462, U01HL105561, and U01HL105565; and in part by Clinical Translational Science Award numbers 11UL1 TR001445 and UL1 TR002243 from the National Center for Advancing Translational Sciences. The contents of this project are solely the responsibility of the authors and do not necessarily represent official views of the National Center for Advancing Translational Sciences; the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the Department of Health and Human Services. Dr Nguyen is currently supported by the National Heart, Lung, and Blood Institute under Award Number T32HL110837. Dr Spertus has received grants from the National Heart, Lung, and Blood Institute during the conduct of the study; has received personal fees from Bayer, Novartis, AstraZeneca, Amgen, Janssen, and United Healthcare; has received grants from the American College of Cardiology, outside the submitted work; has a patent copyright to SAQ with royalties paid; is on the Board of Directors for Blue Cross Blue Shield of Kansas City; and has equity in Health Outcomes Sciences. Dr Newman, Dr Alexander, Mrs Stevens, Dr O'Brien, Dr Gamma, Dr Perna, Dr Garg, Dr Vertes, Dr Smanio, Dr Senior, Dr Held, and Dr Maron have received grants from the National Heart, Lung, and Blood Institute during the conduct of the study. Mr Jones reports employment by the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Chow holds the Saul and Edna Goldfarb Chair in Cardiac Imaging Research; receives research support from TD Bank, CV Diagnostix, AusculSciences, and Siemens Healthineers; and has equity interest in General Electric. Dr White has received grants from the National Heart, Lung, and Blood Institute during the conduct of the study; has received grant support paid to the institution and fees for serving on a steering committee for the ODYSSEY OUTCOMES trial from Sanofi and Regeneron Pharmaceuticals, for the ACCELERATE study from Eli Lilly, for the STRENGTH trial from Omthera Pharmaceuticals, for the HEART-FID study from American Regent, for the CAMELLIA-TIMI study from Eisai Inc, for the dal-GenE study from DalCor Pharma UK Inc, for the AEGIS-II study from CSL Behring, for the SCORED trial and the SOLOIST-WHF trial from Sanofi Australia Pty Ltd, and for the CLEAR Outcomes Study from Esperion Therapeutics Inc. Dr White was on the Advisory Board for Genentech, Inc; and has received lecture fees from AstraZeneca. Dr Boden has received grants from the National Heart, Lung, and Blood Institute during the conduct of the study; has received grants from AbbVie, Amarin, and Amgen; and has received personal fees from Amgen, the Cleveland Clinic Clinical Coordinating Center, and Janssen, outside the submitted work. Dr Mark has received grants from the National Heart, Lung, and Blood Institute during the conduct of the study; and has received grants from HeartFlow and Merck, outside the submitted work. Dr Reynolds has received funding for this research from the National Heart, Lung, and Blood Institute; and has received in-kind donations for unrelated research from Abbott Vascular, Siemens, and Philips. Dr Bangalore has received grants from the National Heart, Lung, and Blood Institute and Abbott Vascular; and serves on the advisory board for Abbott Vascular, Pfizer, Amgen, Biotronik, Meril, and Reata. Dr Chan has received funding from the American Heart Association; and is a consultant for Optum Rx. Dr Stone has received grants and personal fees from the National Heart, Lung, and Blood Institute during the conduct of the study; has received personal fees from Terumo, Amaranth, Shockwave, TherOx, Reva, Vascular Dynamics, Robocath, HeartFlow, Gore, Ablative Solutions, Matrizyme, Miracor, Neovasc, V-Wave, Abiomed, Claret, Sirtex, MAIA Pharmaceuticals, and Vectorious; has received personal fees and has equity/options from VALFIX, Ancora, Qool Therapeutics, SpectraWave, and Orchestra Biomed; has equity/options from Cagent, Applied Therapeutics, BioStar family of funds, MedFocus family of funds, and Aria; and has equity/options from Cardiac Success, outside the submitted work. Dr Hochman is Principal Investigator for the ISCHEMIA trial for which, in addition to support by a National Heart, Lung, and Blood Institute grant, devices and medications were provided by Abbott Vascular, Medtronic, Inc, Abbott Laboratories (formerly St Jude Medical, Inc), Royal Philips NV (formerly Volcano Corporation), Arbor Pharmaceuticals, LLC, AstraZeneca Pharmaceuticals, LP, Merck Sharp & Dohme Corp, Omron Healthcare, Inc, Sunovion Pharmaceuticals, Inc, Espero BioPharma, and Amgen, Inc, as well as financial donations from Arbor Pharmaceuticals LLC and AstraZeneca Pharmaceuticals LP. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Chronic stress in patients with cardiovascular disease (CVD), including peripheral artery disease (PAD), is independently associated worse outcomes. A model that can reliably identify factors associated with risk of chronic stress in patients with CVD is needed., Methods: In a prospective myocardial infarction (MI) registry (TRIUMPH), we constructed a logistic regression model using 27 patient demographic, socioeconomic, and clinical factors, adjusting for site, to identify predictors of chronic stress over 1 year. Stress at baseline and at 1-, 6- and 12-month follow-up was measured using the 4-item Perceived Stress Scale (PSS-4) [range 0-16, scores ≥6 depicting high stress]. Chronic stress was defined as at least 2 follow-up PSS-4 scores ≥6. We identified and validated this final model in another prospective registry of patients with symptomatic PAD, the PORTRAIT study., Results: Our derivation cohort consisted of 4,340 patients with MI (mean age 59.1 ± 12.3 years, 33% females, 30% non-white), of whom 30% had chronic stress at follow-up. Of the 27 factors examined, female sex, current smoking, socioeconomic status, and economic burden due to medical care were positively associated with chronic stress, and ENRICHD Social Support Instrument (ESSI) score and age were inversely related to chronic stress. In the validation cohort of 797 PAD patients (mean age 68.6±9.7 years, 42% females, 28% non-white, 18% chronic stress) the c-statistic for the model was 0.77 and calibration was excellent., Conclusions: We can reliably identify factors that are independently associated with risk of chronic stress in patients with CVD. As chronic stress is associated with worse outcomes in this population, our work identifies potential targets for interventions to as well as the patients that could benefit from these., Competing Interests: The authors have declared that no competing interests exist.

Importance: Prior trials of invasive vs conservative management of chronic coronary disease (CCD) have not enrolled patients with severe chronic kidney disease (CKD). As such, outcomes across kidney function are not well characterized., Objectives: To evaluate clinical and quality-of-life (QoL) outcomes across the spectrum of CKD following conservative and invasive treatment strategies., Design, Setting, and Participants: Participants from the International Study of Comparative Health Effectiveness With Medical and Invasive Approaches (ISCHEMIA) and ISCHEMIA-Chronic Kidney Disease (CKD) trials were categorized by CKD stage: stage 1 (estimated glomerular filtration rate [eGFR] 90 mL/min/1.73m2 or greater), stage 2 (eGFR 60-89 mL/min/1.73m2), stage 3 (eGFR 30-59 mL/min/1.73m2), stage 4 (eGFR 15-29 mL/min/1.73m2), or stage 5 (eGFR less than 15 mL/min/1.73m2 or receiving dialysis). Enrollment took place from July 26, 2012, through January 31, 2018, with a median follow-up of 3.1 years. Data were analyzed from January 2020 to May 2021., Interventions: Initial invasive management of coronary angiography and revascularization with guideline-directed medical therapy (GDMT) vs initial conservative management of GDMT alone., Main Outcomes and Measures: The primary clinical outcome was a composite of death or nonfatal myocardial infarction (MI). The primary QoL outcome was the Seattle Angina Questionnaire (SAQ) summary score., Results: Among the 5956 participants included in this analysis (mean [SD] age, 64 [10] years; 1410 [24%] female and 4546 [76%] male), 1889 (32%), 2551 (43%), 738 (12%), 311 (5%), and 467 (8%) were in CKD stages 1, 2, 3, 4, and 5, respectively. By self-report, 18 participants (<1%) were American Indian or Alaska Native; 1676 (29%), Asian; 267 (5%), Black; 861 (16%), Hispanic or Latino; 18 (<1%), Native Hawaiian or Other Pacific Islander; 3884 (66%), White; and 13 (<1%), multiple races or ethnicities. There was a monotonic increase in risk of the primary composite end point (3-year rates, 9.52%, 10.72%, 18.42%, 34.21%, and 38.01% respectively), death, cardiovascular death, MI, and stroke in individuals with higher CKD stages. Invasive management was associated with an increase in stroke (3-year event rate difference, 1%; 95% CI, 0.3 to 1.7) and procedural MI (1.6%; 95% CI, 0.9 to 2.3) and a decrease in spontaneous MI (-2.5%; 95% CI, -3.9 to -1.1) with no difference in other outcomes; the effect was similar across CKD stages. There was heterogeneity of treatment effect for QoL outcomes such that invasive management was associated with an improvement in angina-related QoL in individuals with CKD stages 1 to 3 and not in those with CKD stages 4 to 5., Conclusions and Relevance: Among participants with CCD, event rates were inversely proportional to kidney function. Invasive management was associated with an increase in stroke and procedural MI and a reduced risk in spontaneous MI, and the effect was similar across CKD stages with no difference in other outcomes, including death. The benefit for QoL with invasive management was not observed in individuals with poorer kidney function.

Background: Patients with significant (≥50%) left main disease (LMD) have a high risk of cardiovascular events, and guidelines recommend revascularization to improve survival. However, the impact of intermediate LMD (stenosis, 25%-49%) on outcomes is unclear., Methods: Randomized ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) participants who underwent coronary computed tomography angiography at baseline were categorized into those with (25%-49%) and without (<25%) intermediate LMD. The primary outcome was a composite of cardiovascular mortality, myocardial infarction (MI), or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest. The primary quality of life outcome was the Seattle Angina Questionnaire summary score., Results: Among the 3699 participants who satisfied the inclusion criteria, 962 (26%) had intermediate LMD. Among invasive strategy participants with intermediate LMD on coronary computed tomography angiography, 49 (7.0%) had significant (≥50% stenosis) left main stenosis on invasive angiography. Patients with intermediate LMD had a higher risk of cardiovascular events in the unadjusted but not in the fully adjusted model compared with those without intermediate LMD. An invasive strategy increased procedural MI and decreased nonprocedural MI with no significant difference for other outcomes including the primary end point. There was no meaningful heterogeneity of treatment effect based on intermediate LMD status except for nonprocedural MI for which there was a greater absolute reduction with invasive management in the intermediate LMD group (-6.4% versus -2.0%; P interaction =0.049). The invasive strategy improved angina-related quality of life and the benefit was durable throughout follow-up without significant heterogeneity based on intermediate LMD status., Conclusions: In the ISCHEMIA trial, there was no meaningful heterogeneity of treatment benefit from an invasive strategy regardless of intermediate LMD status except for a greater absolute risk reduction in nonprocedural MI with invasive management in those with intermediate LMD. An invasive strategy increased procedural MI, reduced nonprocedural MI, and improved angina-related quality of life., Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT01471522.

Background: Many clinical investigations depend on participant self-report as a principal method of identifying health care events. If self-report is used as the trigger to collect and adjudicate medical records, any event that is not reported by the patient will be missed by the investigators, reducing the power of the study and misrepresenting the risk of its participants. We sought to determine the rates and predictors of underreporting hospitalization events during the follow-up period of a prospective study of patients hospitalized with an acute myocardial infarction., Methods and Results: The TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) registry, a longitudinal multicenter cohort study of people with acute myocardial infarction in the United States, queried patients for hospitalization events during interviews at 1, 6, and 12 months. To validate these self-reports, medical records for all events at every hospital where the patient reported receiving care were acquired for adjudication, not just those for the reported events. Of the 4340 participants in TRIUMPH, 1209 (28%) reported at least one hospitalization. After medical records abstraction and adjudication, we identified 1086 hospitalizations from 639 participants (60.2±12 years of age, 38.2% women). Of these hospitalizations, 346 (31.9%) were underreported by the participants. Rates of underreporting ranged from 22.5% to 55.6% based on different patient characteristics. The odds of underreporting were highest for those not currently working (adjusted odds ratio, 1.66 [95% CI, 1.04-2.63]), lowest for those married (adjusted odds ratio, 0.50 [95% CI, 0.33-0.76]), and increased the longer the elapsed time between the admission and the patient's follow-up interview (adjusted odds ratio per month, 1.16 [95% CI, 1.08-1.24]). There was a substantial within-individual variation on the accuracy of reporting., Conclusions: Hospitalizations after acute myocardial infarction are commonly underreported in interviews and should not be used alone to determine event rates in clinical studies.

Background: Long-term exposure to particulate matter <2.5 µm in diameter (PM 2.5 ) and ozone has been associated with the development and progression of cardiovascular disease and, in the case of PM 2.5 , higher cardiovascular mortality. Whether exposure to PM 2.5 and ozone is associated with patients' health status and quality of life is unknown. We used data from 2 prospective myocardial infarction (MI) registries to assess the relationship between long-term PM 2.5 and ozone exposure with health status outcomes 1 year after an MI., Methods and Results: TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction) and PREMIER (Prospective Registry Evaluating Myocardial Infarction: Events and Recovery) enrolled patients presenting with MI at 31 US hospitals between 2003 and 2008. One year later, patients were assessed with the disease-specific Seattle Angina Questionnaire, and 5-year mortality was assessed with the Centers for Disease Control's National Death Index. Individual patients' exposures to PM 2.5 and ozone over the year after their MI were estimated from the Environment Protection Agency's Fused Air Quality Surface Using Downscaling tool that integrates monitoring station data and atmospheric models to predict daily air pollution exposure at the census tract level. We assessed the association of exposure to ozone and PM 2.5 with 1-year health status and mortality over 5 years using regression models adjusting for age, sex, race, socioeconomic status, date of enrollment, and comorbidities. In completely adjusted models, higher PM 2.5 and ozone exposure were independently associated with poorer Seattle Angina Questionnaire summary scores at 1-year (β estimate per +1 SD increase =-0.8 [95% CI, -1.4 to -0.3; P=0.002] for PM 2.5 and -0.9 [95% CI, -1.3 to -0.4; P<0.001] for ozone). Moreover, higher PM 2.5 exposure, but not ozone, was independently associated with greater mortality risk (hazard ratio =1.13 per +1 SD [95% CI, 1.07-1.20; P<0.001])., Conclusions: In our study, greater exposure to PM 2.5 and ozone was associated with poorer 1-year health status following an MI, and PM 2.5 was associated with increased risk of 5-year death.

Background Although admission heart rate predicts higher mortality after acute myocardial infarction ( AMI ), less is known about discharge heart rate. We tested the hypothesis that higher discharge heart rate after AMI is related to increased long-term mortality independent of admission heart rate, and assessed whether β blockers modify this relationship. Methods and Results In 2 prospective US multicenter registries of AMI , we evaluated the associations of discharge and admission heart rate with 3-year mortality using Cox models. Among 6576 patients with AMI , discharge heart rate was modestly associated with initial heart rate ( r=0.28), comorbidities, and infarct severity. In this cohort, 10.7% did not receive β blockers at discharge. After full adjustment for demographic, psychosocial, and clinical covariates, discharge heart rate (hazard ratio [HR]=1.14 per 10 beats per minute [bpm]; 95% CI =1.07-1.21 per 10 bpm) was more strongly associated with risk of death than admission heart rate (HR=1.05 per 10 bpm; 95% CI=1.02-1.09 per 10 bpm) when both were entered in the same model ( P=0.043 for comparison). There was a significant interaction between discharge heart rate and β-blocker use ( P=0.004) on mortality, wherein risk of death was markedly higher among those with high discharge heart rate and not on β blockers (HR=1.35 per 10 bpm; 95% CI=1.19-1.53 per 10 bpm) versus those with a high discharge heart rate and on β blockers at discharge (HR=1.10 per 10 bpm; 95% CI=1.03-1.17 per 10 bpm). Conclusions Higher discharge heart rate after AMI was more strongly associated with 3-year mortality than admission heart rate, and the risk associated with higher discharge heart rate was modified by β blockers at discharge. These findings highlight opportunities for risk stratification and intervention that will require further investigation.

Outpatient cardiac rehabilitation (OCR) reinforces patients' efforts to quit smoking, but the association between participation in OCR and long-term smoking status after acute myocardial infarction (AMI) is unknown. We studied hospitalized smokers with confirmed AMI from two multicenter prospective registries (PREMIER, from January 1, 2003, to June 28, 2004, and TRIUMPH, from April 11, 2005, to December 31, 2008) to describe the association of OCR participation with smoking cessation. Eligible patients smoked at least 1 cigarette per day on average in the 30 days prior to enrollment and completed 12-month follow-up (N = 1307). Structured interviews were completed on subjects at baseline and during follow-up. OCR participation and abstinence from smoking within the prior 30-days (30-day point prevalence abstinence, PPA) were self-reported. We constructed a propensity model of OCR participation based on 22 baseline sociodemographic and clinical characteristics, and constructed hierarchical modified Poisson regression models of 30-day PPA at 12 months after matching on the propensity for OCR participation (with clinical site treated as a random effect). Seventy-four percent of subjects were referred to OCR at hospital discharge, but only 36% participated during follow-up. At 12-month follow-up, 30-day PPA was 57% in OCR participants, compared to 41% in matched OCR non-participants. Participation in OCR was a significant predictor of 30-day PPA at 12 months (adjusted RR 1.38, 95% CI 1.20-1.57). In conclusion, smokers who participated in OCR were significantly more likely to abstain from smoking 12 months after AMI hospitalization., (Published by Elsevier Inc.)

Importance: Black patients experience worse outcomes than white patients following acute myocardial infarction (AMI)., Objective: To examine the degree to which nonrace characteristics explain observed survival differences between white patients and black patients following AMI., Design, Setting, and Participants: This cohort study used the extensive socioeconomic and clinical characteristics from patients recovering from an AMI that were prospectively collected at 31 hospitals across the contiguous United States between 2003 and 2008 for the Prospective Registry Evaluating Myocardial Infarction: Events and Recovery registry and the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status registry. Survival was assessed using data from the National Death Index. Data were analyzed from December 2016 to July 2018., Main Outcomes and Measures: Patient characteristics were categorized into 8 domains, and the degree to which each domain discriminated self-identified black patients from white patients was determined by calculating propensity scores associated with black race for each domain as well as cumulatively across all domains. The final propensity score was associated with 1- and 5-year mortality rates., Results: Among 6402 patients (mean [SD] age, 60 [13] years; 2127 [33.2%] female; 1648 [25.7%] black individuals), the 5-year mortality rate following AMI was 28.9% (476 of 1648) for black patients and 18.0% (856 of 4754) for white patients (hazard ratio, 1.72; 95% CI, 1.54-1.92; P < .001). Most categories of patient characteristics differed substantially between black patients and white patients. The cumulative propensity score discriminated race, with a C statistic of 0.89, and the propensity scores were associated with 1- and 5-year mortality rates (hazard ratio for the 75th percentile of the propensity score vs 25th percentile, 1.72; 95% CI, 1.43-2.08; P < .001). Patients in the lowest propensity score quintile associated with being a black individual (regardless of whether they were of white or black race) had a 5-year mortality rate of 15.5%, while those in the highest quintile had a 5-year mortality rate of 31.0% (P < .001). After adjusting for the propensity associated with being a black patient, there was no significant mortality rate difference by race (adjusted hazard ratio, 1.09; 95% CI, 0.93-1.26; P = .37) and no statistical interaction between race and propensity score (P = .42)., Conclusions and Relevance: Characteristics of black patients and white patients differed significantly at the time of admission for AMI. Those characteristics were associated with an approximately 3-fold difference in 5-year mortality rate following AMI and mediated most of the observed mortality rate difference between the races.

Background: Anemia at discharge in patients with acute myocardial infarction is associated with poor prognosis; whether this differs in women and men or if there is a threshold value at which these relationships change is unknown., Hypothesis: Women have a lower discharge hemoglobin (Hb) at which outcomes worsen., Methods: We identified patients with acute myocardial infarction in the TRIUMPH registry between 2005 and 2008. In multivariable models, we evaluated the relationship between discharge Hb and 12-month mortality and tested whether this relationship varied by gender. We assessed whether the relationship with discharge Hb values was nonlinear using a restricted cubic spline term., Results: Of 4243 patients with AMI, 32.9% were female. Mean admission Hb was 12.9 ± 1.9 g/dL in women and 14.5 ± 2.0 g/dL in men, with mean discharge Hb 11.4 ± 1.8 g/dL and 12.9 ± 1.9 g/dL, respectively. Lower discharge Hb was independently associated with increased mortality (P < 0.05). In multivariable models, discharge Hb decline was similarly associated with increased 12-month mortality in women and men (per 1-g/dL decrease Hb; women HR: 1.24, 95% CI: 1.09-1.42, P < 0.01; and men HR: 1.25, 95% CI: 1.13-1.37, P < 0.01; P for gender interaction = 0.99). The relationship between discharge Hb and 12-month mortality was linear (P for nonlinear spline term = 0.12)., Conclusions: Lower discharge Hb levels were similarly associated with increased 12-month mortality in women and men. These relationships are linear without a clear threshold, suggesting any decline in discharge Hb is associated with poor outcomes., (© 2017 Wiley Periodicals, Inc.)

Background: Whereas composite end points are often used in clinical trials of percutaneous coronary interventions (PCI), the impact of individual components on subsequent survival is incompletely defined. We evaluated the association of subsequent acute coronary syndromes (ACS) and unplanned coronary revascularization post-PCI with long-term survival., Methods and Results: From 2009 to 2011, the KiCS-PCI (Keio interhospital Cardiovascular Studies) consecutively enrolled patients undergoing PCI in 14 Japanese teaching hospitals. We identified patients who experienced ACS or unplanned coronary revascularization following their index PCI and compared subsequent survival during the 2-year follow-up period using propensity-matched cohorts of patients who did and did not experience these events. Cox proportional hazard models were used to assess 2-year all-cause mortality. Because unstable angina is less severe than acute myocardial infarction, we also generated a separate propensity-matched cohort for UA post-PCI. Among 3348 PCI patients (mean age, 67.5±10.7 years; 79.7% male), 214 (6.4%) experienced a subsequent ACS (168 events [78.5%] were unstable angina), and 198 (5.9%) underwent unplanned revascularization. In the propensity-matched cohorts, patients with a subsequent ACS admission had an increased risk of mortality as compared with those without (hazard ratio, 4.73; 95% confidence interval=1.35-16.6; P =0.015), whereas those with an unplanned revascularization did not have significantly higher risk (hazard ratio, 2.97; 95% confidence interval=0.57-14.3; P =0.19). Among unstable angina events, no association with mortality was observed (hazard ratio, 1.39; 95% confidence interval=0.48-4.00; P =0.54)., Conclusions: In the KiCS-PCI registry, the incidence of a subsequent ACS was associated with higher mortality, but this association was less apparent after unplanned coronary revascularization or unstable angina. The prognostic implications of different outcomes in a composite end point should be considered when interpreting the results of clinical trials in PCI., (© 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.)

Background: Compared with men, women are at higher risk of rehospitalization in the first month after discharge for acute myocardial infarction (AMI). However, it is unknown whether this risk extends to the full year and varies by age. Explanatory factors potentially mediating the relationship between sex and rehospitalization remain unexplored and are needed to reduce readmissions. The aim of this study was to assess sex differences and factors associated with 1-year rehospitalization rates after AMI., Methods: We recruited 3536 patients (33% women) ≥18 years of age hospitalized with AMI from 24 US centers into the TRIUMPH study (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status). Data were obtained by medical record abstraction and patient interviews, and a physician panel adjudicated hospitalizations within the first year after AMI. We compared sex differences in rehospitalization using a Cox proportional hazards model, following sequential adjustment for covariates and testing for an age-sex interaction., Results: One-year crude all-cause rehospitalization rates for women were significantly higher than men after AMI (hazard ratio, 1.29 for women; 95% confidence interval, 1.12-1.48). After adjustment for demographics and clinical factors, women had a persistent 26% higher risk of rehospitalization (hazard ratio, 1.26; 95% confidence interval, 1.08-1.47). However, after adjustment for health status and psychosocial factors (hazard ratio, 1.14; 95% confidence interval, 0.96-1.35), the association was attenuated. No significant age-sex interaction was found for 1-year rehospitalization, suggesting that the increased risk applied to both older and younger women., Conclusions: Regardless of age, women have a higher risk of rehospitalization compared with men over the first year after AMI. Although the increased risk persisted after adjustment for clinical factors, the poorer health and psychosocial state of women attenuated the difference., (© 2017 American Heart Association, Inc.)

Background: Rehospitalizations after acute myocardial infarction for unplanned coronary revascularization and unstable angina (UA) are common. However, despite the inclusion of these events in composite end points of many clinical trials, their association with health status has not been studied., Methods and Results: We included 3283 patients with acute myocardial infarction enrolled in a prospective, 24-center US study who had rehospitalizations independently classified by experienced cardiologists. Health status was assessed using Seattle Angina Questionnaire and EuroQol-5D Visual Analog Scale. In the propensity-matched cohorts, 1-year health status was compared between those who did and did not experience rehospitalization for UA or revascularization using a hierarchical linear model. Overall, mean age was 59 years, 33% were women, and 70% were white. Rehospitalization rates for UA and unplanned revascularization at 1 year were 4.3% and 4.7%. One-year Seattle Angina Questionnaire summary scores were worse in patients with rehospitalizations for UA (mean difference, -10.1; 95% confidence interval, -12.4 to -7.9) and unplanned revascularization (mean difference, -5.7; 95% confidence interval, -8.8 to -2.5) when compared with patients without such rehospitalizations. Similarly, EuroQol-5D Visual Analog Scale scores were worse among patients with such readmissions. Individual Seattle Angina Questionnaire domains indicated worse 1-year angina and quality of life outcomes among patients rehospitalized for UA or unplanned revascularization., Conclusions: Within the first year after acute myocardial infarction, rehospitalizations for UA and unplanned revascularization are associated with worse health status. These findings highlight the impact of such events from a patient's perspective, beyond their economic impact and support the use of UA and unplanned revascularization as elements of composite end points., (© 2016 American Heart Association, Inc.)

Background: Rehospitalizations following acute myocardial infarction for unplanned coronary revascularization and unstable angina (UA) are often included as parts of composite end points in clinical trials. Although clearly costly, the clinical relevance of these individual components has not been described., Methods and Results: Patients enrolled in a prospective, 24-center, US acute myocardial infarction registry were followed for 1 year after an acute myocardial infarction for rehospitalizations, that were independently adjudicated by experienced cardiologists. Patients who did and did not experience UA or revascularization rehospitalization were propensity matched using greedy matching. Among 3283 patients with acute myocardial infarction who were included, mean age was 59 years, 33% were female, and 70% were white. Rehospitalization rates for UA and unplanned revascularization at 1 year were 5.0% and 4.1%, respectively. After propensity matching, we included 2433 patients in the UA rehospitalization group and 2410 in the unplanned revascularization group. Using weighted proportional hazards Cox regression, there was no significant association between a rehospitalization for UA and 5-year all-cause mortality (9.6% versus 13.8%; adjusted hazard ratio 0.87, 95% CI 0.60-1.16). Patients rehospitalized for unplanned revascularization had a lower 5-year mortality risk (7.0% versus 15.1%; hazard ratio 0.68, 95% CI 0.50-0.92) compared with those without such rehospitalizations. Nevertheless, patients with UA and unplanned revascularization had a substantially greater hazard of subsequent rehospitalizations compared with patients without such events (UA: hazard ratio 4.36, 95% CI 3.48-5.47; revascularization: hazard ratio 4.38, 95% CI 3.53-5.44)., Conclusions: Rehospitalizations for UA and unplanned revascularization in the year after an acute myocardial infarction are associated with higher risks of subsequent rehospitalizations but not with mortality., (© 2016 The Authors and Eli Lilly and Company. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Although patients with diabetes mellitus experience high rates of adverse events after acute myocardial infarction (AMI), including death and recurrent ischemia, some diabetic patients are likely at low risk, whereas others are at high risk. We sought to develop prediction models to stratify risk after AMI in patients with diabetes mellitus., Methods and Results: We developed prediction models for long-term mortality and angina among 1613 patients with diabetes mellitus discharged alive after AMI from 24 US hospitals and then validated the models in a separate, multicenter registry of 786 patients with diabetes mellitus. Event rates in the derivation cohort were 27% for 5-year mortality and 27% for 1-year angina. Parsimonious prediction models demonstrated good discrimination (c-indices=0.78 and 0.69, respectively) and excellent calibration. Within the context of the predictors we estimated, the strongest predictors for mortality were higher creatinine, not working at the time of the AMI, older age, lower hemoglobin, left ventricular dysfunction, and chronic heart failure. The strongest predictors for angina were angina burden in the 4 weeks before the AMI, younger age, history of prior coronary bypass graft surgery, and non-white race. The lowest and highest deciles of predicted risk ranged from 4% to 80% for mortality and 12% to 59% for angina. The models also performed well in external validation (c-indices=0.78 and 0.73, respectively)., Conclusions: We found a wide range of risk for adverse outcomes after AMI in diabetic patients. Predictive models can identify patients with diabetes mellitus for whom closer follow-up and aggressive secondary prevention strategies should be considered., (© 2016 American Heart Association, Inc.)

Background: Drug-eluting stents (DES) reduce restenosis, as compared with bare-metal stents (BMS); however, the relationship between stent type and health status is unknown. We examined whether stent type was associated with health status outcomes in patients undergoing percutaneous coronary intervention (PCI)., Methods and Results: We evaluated 6- and 12-month health status in 2,694 patients with acute myocardial infarction (AMI) enrolled in the TRIUMPH and PREMIER registries who underwent PCI with DES (n = 1,361) or BMS (n = 1,333). Health status was assessed with the Seattle Angina Questionnaire, Medical Outcomes Study Short Form-12, and Patient Health Questionnaire depression scale. Propensity matching was performed to account for baseline differences in patient characteristics, resulting in a comparison cohort of 784 patients treated with DES and 784 patients treated with BMS. Both groups experienced significant improvements in health status at 6 and 12 months after PCI. Drug-eluting stent use was associated with a small improvement in Seattle Angina Questionnaire quality of life and functional limitation scores at 6 months (3.6 [95% CI 0.96-6.21], P = .007, and 3.8 [1.55-6.01], P < .001, respectively), but not at 12 months (2.3 [-0.46 to 5.03], P = .10, and 0.3 [-2.04 to 2.48], P = .85, respectively)., Conclusions: In patients with AMI undergoing PCI, DES use was associated with transient but unsustained health status benefits over 12 months after AMI., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Renin-angiotensin system (RAS) inhibitor use after acute myocardial infarction (AMI) is a quality indicator, but there may also be reasons not to use this therapy. We sought to determine how chronic kidney disease (CKD) and acute kidney injury (AKI) affected RAS inhibitor prescription after AMI in patients with and without decreased ejection fraction (EF)., Methods: Participants from the TRIUMPH registry were categorized by admission estimated glomerular filtration rate (eGFR in mL/min per 1.73 m(2); severe [<30], moderate [30-59], mild [60-89], and no [≥90] CKD) and occurrence of AKI (an increase in creatinine ≥0.3 mg/dL or ≥50%). Renin-angiotensin system inhibitor prescriptions at discharge were compared across categories of CKD, AKI, and decreased EF (<40% vs ≥40%) using a hierarchical modified Poisson model., Results: Among 4,223 AMI patients (mean age 59.0 years, 67.0% male, 67.3% white), RAS inhibitor use decreased significantly with lower eGFR (P < .001), but there was no effect of decreased EF on this relationship (interaction P = .40). Without AKI, severe and moderate CKD were associated with significantly less RAS inhibitor use: relative risks (RRs) 0.67 (95% CIs, 0.58-0.78) and 0.94 (0.90-0.99), respectively. When AKI occurred, CKD was associated with less RAS inhibitor use: RRs 0.84 (0.76-0.93) for mild CKD, 0.78 (0.68-0.88) for moderate CKD, and 0.50 (0.42-0.61) for severe CKD. Ejection fraction <40% was associated with use (RR 1.11, 1.03-1.18), independent of renal function., Conclusions: Chronic kidney disease and AKI are associated with fewer RAS inhibitor prescriptions at discharge, but in both AKI and non-AKI patients, eGFR was more strongly associated with use than EF., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Smoking cessation after acute myocardial infarction (AMI) decreases the risk of recurrent AMI and mortality by 30% to 50%, but many patients continue to smoke. The association of smoking with angina and health-related quality of life (HRQOL) after AMI is unclear., Methods and Results: Patients in 2 US multicenter AMI registries (n=4003) were assessed for smoking and HRQOL at admission and 1, 6, and 12 months after AMI. Angina and HRQOL were measured with the Seattle Angina Questionnaire and Short Form-12 Physical and Mental Component Scales. At admission, 29% never had smoked, 34% were former smokers (quit before AMI), and 37% were active smokers, of whom 46% quit by 1 year (recent quitters). In hierarchical, multivariable, regression models that adjusted for sociodemographic, clinical and treatment factors, never and former smokers had similar and the best HRQOL in all domains. Recent quitters had intermediate HRQOL levels, with angina and Short Form-12 Mental Component Scale scores similar to never smokers. Persistent smokers had worse HRQOL in all domains compared with never smokers and worse Short Form-12 Mental Component Scale scores than recent quitters., Conclusions: Smoking after AMI is associated with more angina and worse HRQOL in all domains, whereas smokers who quit after AMI have similar angina levels and mental health as never smokers. These observations may help encourage patients to stop smoking after AMI.

Background: Prior studies have demonstrated that patients with high-risk acute myocardial infarction (AMI) are less likely to receive guideline-directed medications during hospitalisation. It is unknown if this paradox persists following discharge. We aimed to assess if persistence with guideline-directed medications post discharge varies by patients' risk following AMI., Methods: Data were analysed from two prospective, multicentre US AMI registries. The primary outcome was persistence with all prescribed guideline-directed medications (aspirin, β-blockers, statins, angiotensin-antagonists) at 1, 6 and 12 months post discharge. The association between risk and medication persistence post discharge was assessed using multivariable mixed-effect models., Results: Among 6434 patients with AMI discharged home, 2824 were considered low-risk, 2014 intermediate-risk and 1596 high-risk for death based upon their Global Registry of Acute Coronary Event (GRACE) 6-month risk score. High-risk was associated with a lower likelihood of receiving all appropriate therapies at discharge compared with low-risk patients (relative risk (RR) 0.90; 95% CI 0.87 to 0.94). At 12 months, the rate of persistence with all prescribed therapies was 61.5%, 57.9% and 45.9% among low-risk, intermediate-risk and high-risk patients, respectively. After multivariable adjustment, high-risk was associated with lower persistence with all prescribed medications (RR 0.87; 95% CI 0.82 to 0.92) over follow-up. Similar associations were seen for individual medications. Over the 5 years of the study, persistence with prescribed therapies post discharge improved modestly among high-risk patients (RR 1.05; 95% CI 1.03 to 1.08 per year)., Conclusions: High-risk patients with AMI have a lower likelihood of persistently taking prescribed medications post discharge as compared with low-risk patients. Continued efforts are needed to improve the use of guideline-directed medications in high-risk patients., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Diabetes mellitus (DM) is common in patients hospitalized with an acute myocardial infarction (AMI), representing in some cases the first opportunity to recognize and treat DM. We report the incidence of new DM and its recognition among patients with AMI., Methods and Results: Patients in a 24-site US AMI registry (2005-08) had glycosylated hemoglobin assessed at a core laboratory, with results blinded to clinicians and local clinical measurements left to the discretion of the treating providers. Among 2854 AMI patients without known DM on admission, 287 patients (10%) met criteria for previously unknown DM, defined by a core laboratory glycosylated hemoglobin of ≥6.5%. Among these, 186 (65%) were unrecognized by treating clinicians, receiving neither DM education, glucose-lowering medications at discharge, nor documentation of DM in the chart (median glycosylated hemoglobin of unrecognized patients, 6.7%; range, 6.5-12.3%). Six months after discharge, only 5% of those not recognized as having DM during hospitalization had been initiated on glucose-lowering medications versus 66% of those recognized (P<0.001)., Conclusions: Underlying DM that has not been previously diagnosed is common among AMI patients, affecting 1 in 10 patients, yet is recognized by the care team only one third of the time. Given its frequency and therapeutic implications, including but extending beyond the initiation of glucose-lowering treatment, consideration should be given to screening all AMI patients for DM during hospitalization. Inexpensive, ubiquitous, and endorsed as an acceptable screen for DM, glycosylated hemoglobin testing should be considered for this purpose., (© 2015 American Heart Association, Inc.)

Background: Rehospitalizations for acute coronary syndromes (ACS) and coronary revascularization after an acute myocardial infarction (AMI) are not only common and costly but can also impact patients' quality of life. In contrast to mortality and all-cause readmissions, little insight is available into risk factors associated with ACS and revascularization after AMI., Methods and Results: In a multicenter AMI registry, we examined the rates and predictors of rehospitalizations for ACS and revascularization within the year after AMI among 3283 patients. Staged revascularization procedures were excluded. Kaplan-Meier estimated rates of rehospitalization due to ACS and revascularization were 6.8% and 4.1%, respectively. In hierarchical, multivariable models, the strongest predictors of rehospitalization for ACS were coronary artery bypass graft prior to AMI hospitalization (hazard ratio [HR] 2.12, 95% CI 1.45 to 3.10), female sex (HR 1.67, 95% CI 1.23 to 2.25), and in-hospital PCI (HR 1.85, 95% CI 1.28 to 2.69). The strongest predictors of subsequent revascularization were multivessel disease (HR 2.89, 95% CI 1.90 to 4.39) and in-hospital percutaneous coronary intervention with a bare metal stent (HR 2.08, 95% CI 1.19 to 3.63). The Global Registry of Acute Coronary Events mortality risk score was not associated with the risk of rehospitalization for ACS or revascularization., Conclusions: Unique characteristics are associated with admissions for ACS and revascularization, as compared with survival. These multivariable risk predictors may help identify patients at high risk for ACS and revascularization, in whom intensification of secondary prevention therapies or closer post-AMI follow-up may be warranted., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Health disparities by socioeconomic status (SES) exist for many outcomes, including patients' subjective health status after myocardial infarction (MI). The Reserve Capacity Model (RCM), a theoretical means to understand such disparities, was tested to examine the possible mediating effects of cognitive-emotional factors on the association between SES and health status. Data from 2,348 post-MI patients in PREMIER were used. Indicators of SES were collected during hospitalization via personal interviews, while participants completed measures of stress and reserves at 1 month, depressive symptoms at 6 months, and health status at 1 year through telephone interviews. Structural equation model results provide partial support for the RCM, as cognitive-emotional factors partially mediated the association between SES and mental health status. For physical health status, results supported direct rather than indirect effects of SES. Findings suggest psychosocial interventions with patients of low SES will have their greatest effects on appraisals of psychological health status.

Background: Despite calls to expand measurement of acute myocardial infarction (AMI) outcomes to include symptom burden, little has been done to describe hospital-level variation in this patient-centered outcome, or its association with mortality. Understanding the relationship between symptoms and longer-term mortality could inform the importance of these outcomes for monitoring quality of care., Methods and Results: Among 4316 patients with AMI treated at 24 hospitals participating in the Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study, we assessed risk-standardized 1-year symptom burden as measured by the Seattle Angina Questionnaire Angina Frequency Score and mortality attributed to the hospital that provided AMI care. Median odds ratios were used to assess outcome variation and reflect the relative odds of an outcome for 2 patients with identical covariates at different, randomly selected, hospitals. We then evaluated the correlation between hospital-level mortality and angina. Finally, we determined the extent to which variation in mortality and angina was explained by achievement of AMI performance measures. We observed hospital variation in risk-adjusted 1-year mortality (range, 4.9%-8.6%; median odds ratio, 1.30; P=0.01) and angina (range, 17.7%-29.4%; median odds ratio, 1.34; P<0.001). At the hospital level, mortality and angina at 1 year were weakly correlated (r=0.40; 95% confidence interval, 0.00-0.68; P=0.05). Accounting for the quality of AMI care did not attenuate variation in risk-adjusted 1-year mortality or angina., Conclusions: Symptom burden and mortality vary at the hospital level after AMI and are only weakly correlated. These findings suggest that symptom burden should be considered a separate quality domain that is not well captured by current quality metrics., (© 2014 American Heart Association, Inc.)

Background: Many clinical trials use composite end points to reduce sample size, but the relative importance of each individual end point within the composite may differ between patients and researchers., Methods and Results: We asked 785 cardiovascular patients and 164 clinical trial authors to assign 25 "spending weights" across 5 common adverse events comprising composite end points in cardiovascular trials: death, myocardial infarction, stroke, coronary revascularization, and hospitalization for angina. We then calculated end point ratios for each participant's ratings of each nonfatal end point relative to death. Whereas patients assigned an average weight of 5 to death, equal or greater weight was assigned to myocardial infarction (mean ratio, 1.12) and stroke (ratio, 1.08). In contrast, clinical trialists were much more concerned about death (average weight, 8) than myocardial infarction (ratio, 0.63) or stroke (ratio, 0.53). Both patients and trialists considered revascularization (ratio, 0.48 and 0.20, respectively) and hospitalization (ratio, 0.28 and 0.13, respectively) as substantially less severe than death. Differences between patient and trialist end point weights persisted after adjustment for demographic and clinical characteristics (P<0.001 for all comparisons)., Conclusions: Patients and clinical trialists did not weigh individual components of a composite end point equally. Whereas trialists are most concerned about avoiding death, patients place equal or greater importance on reducing myocardial infarction or stroke. Both groups considered revascularization and hospitalization as substantially less severe. These findings suggest that equal weights in a composite clinical end point do not accurately reflect the preferences of either patients or trialists., (© 2014 American Heart Association, Inc.)

Background: Before outcomes-based measures of quality can be used to compare and improve care, they must be risk-standardized to account for variations in patient characteristics. Despite the importance of health-related quality of life (HRQL) outcomes among patients with acute myocardial infarction (AMI), no risk-standardized models have been developed., Methods and Results: We assessed disease-specific HRQL using the Seattle Angina Questionnaire at baseline and 1 year later in 2693 unselected AMI patients from 24 hospitals enrolled in the Translational Research Investigating Underlying disparities in acute Myocardial infarction Patients' Health status (TRIUMPH) registry. Using 57 candidate sociodemographic, economic, and clinical variables present on admission, we developed a parsimonious, hierarchical linear regression model to predict HRQL. Eleven variables were independently associated with poor HRQL after AMI, including younger age, previous coronary artery bypass graft surgery, depressive symptoms, and financial difficulties (R(2)=20%). The model demonstrated excellent internal calibration and reasonable calibration in an independent sample of 1890 AMI patients in a separate registry, although the model slightly overpredicted HRQL scores in the higher deciles. Among the 24 TRIUMPH hospitals, 1-year unadjusted HRQL scores ranged from 67-89. After risk-standardization, HRQL score variability narrowed substantially (range=79-83), and the group of hospital performance (bottom 20%/middle 60%/top 20%) changed in 14 of the 24 hospitals (58% reclassification with risk-standardization)., Conclusions: In this predictive model for HRQL after AMI, we identified risk factors, including economic and psychological characteristics, associated with HRQL outcomes. Adjusting for these factors substantially altered the rankings of hospitals as compared with unadjusted comparisons. Using this model to compare risk-standardized HRQL outcomes across hospitals may identify processes of care that maximize this important patient-centered outcome.

Objective: The prevalence of insulin resistance (IR) is increasing worldwide because of increasing age, obesity, and physical inactivity. Emerging evidence supports a direct proatherogenic effect of IR on the coronary vasculature, but the relation between IR and angiographic atherosclerosis in a real-world clinical setting is uncertain. In this work, we assessed whether IR is independently associated with clinically significant angiographic atherosclerosis in nondiabetic individuals., Approach and Results: We examined the association between IR and the extent of coronary atherosclerosis determined by angiography in 1073 nondiabetic patients surviving acute myocardial infarction. Patients were divided into quartiles on the basis of the homeostasis model assessment grading of IR, and associations between IR and multivessel coronary artery disease, defined as ≥ 2 arteries with ≥ 70% stenosis (or ≥ 50% left main stenosis), were analyzed in bivariate and multivariable modeling. Overall, the cohort had a median age of 56 years; 28.9% women and 21.8% nonwhite. The crude prevalence of multivessel coronary artery disease was 37.8%, 42.3%, 47.2%, and 48.0% for homeostasis model assessment grading of IR quartiles 1, 2, 3, and 4, respectively (P(trend) = 0.009). In multivariable modeling, compared with quartile 1, both quartile 3 (relative risk [95% confidence interval], 1.31 [1.07-1.60]) and quartile 4 (1.29 [1.03-1.60]) were independently associated with multivessel coronary artery disease. Covariates in the model included patient demographic and clinical characteristics and metabolic factors (low-density lipoprotein-cholesterol, high-density lipoprotein-cholesterol, triglyceride, glycosylated hemoglobin, and high-sensitivity C-reactive protein)., Conclusions: We demonstrate an independent association between IR and multivessel coronary artery disease in nondiabetic postmyocardial infarction patients. Our findings strengthen the experimental evidence for a direct atherogenic effect of IR independent of glucose control and other components of the metabolic syndrome.

Background: Elevated blood glucose is associated with higher mortality in patients with acute myocardial infarction (AMI). Although clinical guidelines recommend targeted glucose control in this group, clinical trials have yielded inconclusive results. Our objective was to understand how this lack of evidence impacts the management of severe hyperglycemia in routine practice., Methods: We examined insulin use among 4,297 AMI admissions with a mean hospitalization blood glucose of ≥200 mg/dL across 55 US hospitals from 2000 to 2008. Temporal trends and interhospital variation in 2 measures of insulin use during hospitalization-any (subcutaneous, intravenous [IV], short acting, long acting) and IV insulin-were examined using hierarchical Poisson regression models., Results: Of the 4,297 admissions, 2,618 (61%) received any insulin and 538 (13%) received IV insulin. After multivariable adjustment, a slight increase in insulin use was observed per admission year (relative risk [RR] 1.06, 95% CI 1.01-1.11). There was a modest (albeit nonsignificant) increase in IV insulin use seen before May 2004 (RR 1.18, 95% CI 0.96-1.47), with no significant change thereafter (RR 0.99, 95% CI 0.92-1.09). Marked variability in insulin use was observed across hospitals (median rate ratio 1.5 [any insulin] and 1.8 [IV insulin]), which did not change over time., Conclusions: Insulin use among patients with AMI and severe hyperglycemia has remained low over the past decade, with substantial and persistent interhospital variation. These observations reflect marked clinical uncertainty with regard to glucose management in AMI, underscoring the imperative for a definitive clinical trial in this field., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: Previous studies have described an "obesity paradox" with heart failure, whereby higher body mass index (BMI) is associated with lower mortality. However, little is known about the impact of obesity on survival after acute myocardial infarction., Methods: Data from 2 registries of patients hospitalized in the US with acute myocardial infarction between 2003-2004 (PREMIER) and 2005-2008 (TRIUMPH) were used to examine the association of BMI with mortality. Patients (n=6359) were categorized into BMI groups (kg/m(2)) using baseline measurements. Two sets of analyses were performed using Cox proportional hazards regression with fractional polynomials to model BMI as categorical and continuous variables. To assess the independent association of BMI with mortality, analyses were repeated, adjusting for 7 domains of patient and clinical characteristics., Results: Median BMI was 28.6. BMI was inversely associated with crude 1-year mortality (normal, 9.2%; overweight, 6.1%; obese, 4.7%; morbidly obese; 4.6%; P <.001), which persisted after multivariable adjustment. When BMI was examined as a continuous variable, the hazards curve declined with increasing BMI and then increased above a BMI of 40. Compared with patients with a BMI of 18.5, patients with higher BMIs had a 20% to 68% lower mortality at 1 year. No interactions between age (P=.37), sex (P=.87), or diabetes mellitus (P=.55) were observed., Conclusions: There appears to be an "obesity paradox" among patients after acute myocardial infarction such that higher BMI is associated with lower mortality, an effect that was not modified by patient characteristics and was comparable across age, sex, and diabetes subgroups., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Mean blood glucose (BG) during acute myocardial infarction (AMI) is an important predictor of inpatient mortality but does not capture glucose variability (GV), which has been shown to be independently associated with mortality in critically ill patients. Whether GV is associated with in-hospital mortality during AMI, after accounting for mean BG, is unknown., Methods and Results: We analyzed 18 563 consecutive patients with AMI with ≥3 BGs in the first 48 hours admitted to 61 US hospitals from 2000 to 2008. Five different GV metrics were compared for their ability to predict in-hospital mortality (range, standard deviation, mean amplitude of glycemic excursions, mean absolute glucose change, and average daily risk range) using hierarchical logistic regression models that sequentially adjusted for mean BG, hypoglycemia (<70 mg/dL), and multiple patient characteristics. In unadjusted analyses, range and average daily risk range had the highest C-indices (0.620 for range, 0.635 for average daily risk range; both P<0.0001). Greater GV was associated with higher mortality for all metrics (eg, mortality was 3.8%, 5.5%, 7.1%, and 11.3% for increasing quartiles of range, P<0.0001); however, the association between GV and mortality for each metric was no longer significant after multivariable adjustment. In contrast, mean BG remained an important predictor of survival (P<0.001, all models)., Conclusions: Although greater GV is associated with increased risk of in-hospital mortality in patients with AMI in unadjusted analyses, GV is no longer independently predictive after controlling for multiple patient factors, including mean BG. These findings suggest that GV does not provide additional prognostic value above and beyond already recognized risk factors for mortality during AMI.

Objective: To examine changes in social support during early recovery after acute myocardial infarction (AMI) and determine whether these changes influence outcomes within the first year., Methods: Among 1951 AMI patients enrolled in a 19-center prospective study, we examined changes in social support between baseline (index hospitalization) and 1 month post-AMI to longitudinally assess their association with health status and depressive symptoms within the first year. We further examined whether 1-month support predicted outcomes independent of baseline support. Hierarchical repeated-measures regression evaluated associations, adjusting for site, baseline outcome level, baseline depressive symptoms, sociodemographic characteristics, and clinical factors., Results: During the first month of recovery, 5.6% of patients had persistently low support, 6.4% had worsened support, 8.1% had improved support, and 80.0% had persistently high support. In risk-adjusted analyses, patients with worsened support (vs. persistently high) had greater risk of angina (relative risk=1.46), lower disease-specific quality of life (β=7.44), lower general mental functioning (β=4.82), and more depressive symptoms (β=1.94) (all p≤.01). Conversely, patients with improved support (vs. persistently low) had better outcomes, including higher disease-specific quality of life (β=6.78), higher general mental functioning (β=4.09), and fewer depressive symptoms (β=1.48) (all p≤.002). In separate analyses, low support at 1 month was significantly associated with poorer outcomes, independent of baseline support level (all p≤.002)., Conclusion: Changes in social support during early AMI recovery were not uncommon and were important for predicting outcomes. Intervening on low support during early recovery may provide a means of improving outcomes., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: To evaluate the relationship between A1C and glucose therapy intensification (GTI) in patients with diabetes mellitus (DM) hospitalized for acute myocardial infarction (AMI)., Research Design and Methods: A1C was measured as part of routine care (clinical A1C) or in the core laboratory (laboratory A1C, results unavailable to clinicians). GTI predictors were identified using hierarchical Poisson regression., Results: Of 1,274 patients, 886 (70%) had clinical A1C and an additional 263 had laboratory A1C measured. Overall, A1C was <7% in 419 (37%), 7-9% in 415 (36%), and >9% in 315 patients (27%). GTI occurred in 31% of patients and was more frequent in those with clinical A1C both before (34 vs. 24%, P < 0.001) and after multivariable adjustment (relative risk 1.34 [95% CI 1.12-1.62] vs. no clinical A1C)., Conclusions: Long-term glucose control is poor in most AMI patients with DM, but only a minority of patients undergo GTI at discharge. Inpatient A1C assessment is strongly associated with intensification of glucose-lowering therapy.

Context: Clinical practice guidelines recommend maintaining serum potassium levels between 4.0 and 5.0 mEq/L in patients with acute myocardial infarction (AMI). These guidelines are based on small studies that associated low potassium levels with ventricular arrhythmias in the pre-β-blocker and prereperfusion era. Current studies examining the relationship between potassium levels and mortality in AMI patients are lacking., Objective: To determine the relationship between serum potassium levels and in-hospital mortality in AMI patients in the era of β-blocker and reperfusion therapy., Design, Setting, and Patients: Retrospective cohort study using the Cerner Health Facts database, which included 38,689 patients with biomarker-confirmed AMI, admitted to 67 US hospitals between January 1, 2000, and December 31, 2008. All patients had in-hospital serum potassium measurements and were categorized by mean postadmission serum potassium level (<3.0, 3.0-<3.5, 3.5-<4.0, 4.0-<4.5, 4.5-<5.0, 5.0-<5.5, and ≥5.5 mEq/L). Hierarchical logistic regression was used to determine the association between potassium levels and outcomes after adjusting for patient- and hospital-level factors., Main Outcome Measures: All-cause in-hospital mortality and the composite of ventricular fibrillation or cardiac arrest., Results: There was a U-shaped relationship between mean postadmission serum potassium level and in-hospital mortality that persisted after multivariable adjustment. Compared with the reference group of 3.5 to less than 4.0 mEq/L (mortality rate, 4.8%; 95% CI, 4.4%-5.2%), mortality was comparable for mean postadmission potassium of 4.0 to less than 4.5 mEq/L (5.0%; 95% CI, 4.7%-5.3%), multivariable-adjusted odds ratio (OR), 1.19 (95% CI, 1.04-1.36). Mortality was twice as great for potassium of 4.5 to less than 5.0 mEq/L (10.0%; 95% CI, 9.1%-10.9%; multivariable-adjusted OR, 1.99; 95% CI, 1.68-2.36), and even greater for higher potassium strata. Similarly, mortality rates were higher for potassium levels of less than 3.5 mEq/L. In contrast, rates of ventricular fibrillation or cardiac arrest were higher only among patients with potassium levels of less than 3.0 mEq/L and at levels of 5.0 mEq/L or greater., Conclusion: Among inpatients with AMI, the lowest mortality was observed in those with postadmission serum potassium levels between 3.5 and <4.5 mEq/L compared with those who had higher or lower potassium levels.

Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 United States centers from 2003 through 2004, to assess the association of living alone with outcomes after AMI. Outcome measurements included 4-year mortality, 1-year readmission, and 1-year health status using the Seattle Angina Questionnaire (SAQ) and the Short Form-12 Physical Health Component scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs 14.5%, p <0.001) but comparable rates of 1-year readmission (41.6% vs 38.3%, p = 0.79). Living alone was associated with lower unadjusted quality of life (mean SAQ -2.40, 95% confidence interval [CI] -4.44 to -0.35, p = 0.02) but had no impact on Short Form-12 Physical Health Component (-0.45, 95% CI -1.65 to 0.76, p = 0.47) compared to patients who did not live alone. After multivariable adjustment, patients who lived alone had a comparable risk of mortality (hazard ratio 1.35, 95% CI 0.94 to 1.93) and readmission (hazard ratio 0.99, 95% CI 0.76 to 1.28) as patients who lived with others. Mean quality-of-life scores remained lower in patients who lived alone (SAQ -2.91, 95% CI -5.56 to -0.26, p = 0.03). In conclusion, living alone may be associated with poorer angina-related quality of life 1 year after MI but is not associated with mortality, readmission, or other health status measurements after adjusting for other patient and treatment characteristics., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Black patients with myocardial infarction (MI) have worse outcomes than white patients, including higher mortality rates, more angina, and worse quality of life. The Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study was designed to examine whether racial differences in socioeconomic, clinical, genetic, metabolic, biomarker, or treatment characteristics mediate observed disparities in outcomes., Methods and Results: Between April 11, 2005, and December 31, 2008, 31 567 patients with MI were prospectively screened; 6152 had an eligible MI, and 4340 (71%) were enrolled from 24 US centers. Consenting patients had detailed chart abstractions of their medical history and processes of inpatient care, supplemented with a detailed baseline interview. Detailed genetic and metabolic data were obtained at hospital discharge in 2979 (69%) and 3013 patients (69%), respectively. In a subset of patients, blood and urine samples were obtained at 1 month (obtained in 27% of survivors) and blood samples at 6 months (obtained in 19% of survivors). Centralized follow-up interviews sought to quantify patients' postdischarge care and outcomes, with a focus on their health status (symptoms, function, and quality of life). At 1, 6, and 12 months, 23%, 27%, and 24%, respectively, were lost to follow-up. Vital status was available for 99% of patients at 12 months., Conclusions: TRIUMPH is a novel MI registry with detailed information on patients' sociodemographic, clinical, treatment, health status, metabolic, and genetic characteristics. The wealth of patient data collected in TRIUMPH will provide unique opportunities to examine factors that may mediate racial differences in mortality and health status after MI and the complex interactions between genetic and environmental determinants of post-MI outcomes.

Background and Objectives: African-American race and decreased kidney function have been associated with higher mortality after acute myocardial infarction (AMI). However, whether there are racial differences in the prevalence or prognostic importance of renal insufficiency in AMI is unknown., Design, Setting, Participants & Measurements: Among 1847 AMI patients enrolled in the multicenter Prospective Registry Evaluating Myocardial Infarction Event and Recovery (PREMIER) study, estimated glomerular filtration rate (eGFR) was used to stratify prognosis and to examine potential interactions among eGFR, race, and mortality. Multivariable proportional hazards regression was used to examine the effect of race and eGFR on 3.5-year all-cause mortality., Results: Race and eGFR were significantly associated with mortality. After adjustment for eGFR alone, differences in mortality by race were substantially attenuated (unadjusted hazard ratio [HR] for African Americans=1.56 [95% confidence interval {CI}=1.2 to 2.1]; eGFR-adjusted HR=1.32 [95% CI=0.99 to 1.75]). A similar magnitude of attenuation in racial differences in survival was observed after adjustment for all covariates except eGFR (HR=1.29 [95% CI=0.96 to 1.72]). A final model adjusting for all covariates only slightly attenuated the association further. No interaction between race and eGFR was detected., Conclusions: Renal insufficiency, which may represent chronic kidney disease, is a prognostically important comorbidity in African Americans after AMI. However, the effect of decreased eGFR on mortality is comparable between races, suggesting that preventing renal insufficiency in African Americans could be an important target to reduce racial disparities in post-AMI survival., (© 2011 by the American Society of Nephrology)

Although medical co-morbidities commonly affect clinical outcomes after acute myocardial infarction (AMI), current performance measures of AMI quality focus exclusively on the management of the AMI itself. However, patients with AMIs frequently present with other co-morbidities, such as diabetes mellitus (DM), that also warrant assessment and management. To date, the quality of DM evaluation in patients presenting with AMIs has not been described. From January 2003 to June 2004, the Prospective Registry Evaluating Myocardial Infarction Patients: Events and Recovery-Quality Improvement (PREMIER-QI) enrolled 3,953 patients with AMIs at 19 centers in the United States. The frequency of glycosylated hemoglobin (HbA(1c)) assessment, either during the hospitalization or documented in the chart from the preceding 3 months, was prospectively evaluated. Among 1,168 patients with AMIs with preexisting DM, only 47% had recent HbA(1c) levels available, with marked variability in HbA(1c) assessment among hospitals (range 7% to 81%). Among those with available HbA(1c) levels, 39% had good control (HbA(1c) <7%), 36% had suboptimal control (HbA(1c) 7% to 9%), and 25% had poor control (HbA(1c) >9%). Patients with suboptimal and poor control were more likely to have their DM treatment intensified than those without HbA(1c) assessment (for HbA(1c) 7% to 9%, rate ratio 1.38, 95% confidence interval 1.03 to 1.85; for HbA(1c) >9%, rate ratio 2.20, 95% confidence interval 1.68 to 2.88). Similarly, patients with DM who had HbA(1c) measured were more likely to receive instructions on DM disease management before discharge. In conclusion, the assessment of chronic glycemic control is highly variable among patients with AMIs and DM. Because much of this variability occurs at the hospital level, the evaluation of DM control could represent an additional quality indicator and an opportunity to advance patient-centered AMI care., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Prior studies have associated low social support (SS) with increased rehospitalization and mortality after acute myocardial infarction. However, relatively little is known about whether similar patterns exist for other outcomes, such as health status and depressive symptoms, and whether these patterns vary by sex., Methods and Results: Using data from 2411 English- or Spanish-speaking patients with acute myocardial infarction enrolled in a 19-center prospective study, we examined the association of SS (low, moderate, high) with health status (angina, disease-specific quality of life, general physical and mental functioning) and depressive symptoms over the first year of recovery. Overall and sex-stratified associations were evaluated using mixed-effects Poisson and linear regression, adjusting for site, baseline health status, baseline depressive symptoms, and demographic and clinical factors. Patients with the lowest SS (relative to those with the highest) had increased risk of angina (relative risk, 1.27; 95% confidence interval [CI], 1.10, 1.48); lower disease-specific quality of life (mean difference [beta]=-3.33; 95% CI, -5.25, -1.41), lower mental functioning (beta=-1.72; 95% CI, -2.65, -0.79), and more depressive symptoms (beta=0.94; 95% CI, 0.51, 1.38). A nonsignificant trend toward lower physical functioning (beta=-0.87; 95% CI, -1.95, 0.20) was observed. In sex-stratified analyses, the relationship between SS and outcomes was stronger for women than for men, with a significant SS-by-sex interaction for disease-specific quality of life, physical functioning, and depressive symptoms (all P<0.02)., Conclusions: Lower SS is associated with worse health status and more depressive symptoms over the first year of acute myocardial infarction recovery, particularly for women.

Background: We assessed the degree to which differences in guideline-based medical therapy for acute myocardial infarction (AMI) contribute to the higher mortality associated with kidney disease., Methods: In the PREMIER registry, we evaluated patients from 19 US centers surviving AMI. Cox regression evaluated the association between estimated glomerular filtration rate (GFR) and time to death over two years, adjusting for demographic and clinical variables. The contribution of variation in guideline-based medical therapy to differences in mortality was then assessed by evaluating the incremental change in the hazard ratios after further adjustment for therapy., Results: Of 2426 patients, 26% had GFR > or = 90, 44% had GFR = 60- < 90, 22% had GFR = 30- < 60, and 8% had GFR < 30 ml/min/1.73 m2. Greater degrees of renal dysfunction were associated with greater 2-year mortality and lower rates of guideline-based therapy among eligible patients. For patients with severely decreased GFR, adjustment for differences in guideline-based therapy did not significantly attenuate the relationship with mortality (HR 3.82, 95% CI 2.39-6.11 partially adjusted; HR = 3.90, 95% CI 2.42-6.28 after adjustment for treatment differences)., Conclusion: Higher mortality associated with reduced GFR after AMI is not accounted for by differences in treatment factors, underscoring the need for novel therapies specifically targeting the pathophysiological abnormalities associated with kidney dysfunction to improve survival.

Background: Both angina and dyspnea are prevalent symptoms among post-myocardial infarction (MI) patients. Given their frequent overlap, little is known about the degree to which these symptoms provide independent information in this population., Methods: Using the multicenter Prospective Registry Evaluating Myocardial Infarction: Events and Recovery (PREMIER), 1,835 patients were administered the Rose Dyspnea Scale (scores range 0-4; higher scores indicate worse dyspnea), Seattle Angina Questionnaire (SAQ; lower scores indicate worse angina), and 12-item Short Form physical component (PCS; lower scores indicate worse physical health status) at 1 and 12 months post-MI. Multivariable regression was used to examine the association between dyspnea and quality of life (QOL) in both cross-sectional and longitudinal analyses as well as its association with rehospitalizations and mortality., Results: At 1-month follow-up, 863 patients (47%) reported dyspnea, and 340 (19%) noted moderate to severe dyspnea. After adjusting for sociodemographic and clinical factors including SAQ angina frequency, higher dyspnea scores remained strongly associated with worse QOL in both cross-sectional (1-U dyspnea increase = 2.5-point PCS decrease and 2.4-point SAQ QOL decrease) and longitudinal analyses (1-U dyspnea increase from 1 month to 1 year = 3.8-point PCS decrease and 3.5-point SAQ QOL decrease), and with increased risk of 1-year rehospitalization (hazard ratio 1.15/1 U of dyspnea, 95% CI 1.07-1.24) and 3-year mortality (hazard ratio 1.34/1 U of dyspnea, 95% CI 1.19-1.51; P < .001 for all analyses)., Conclusions: Among post-MI patients, dyspnea is common and strongly associated with impaired QOL, more frequent rehospitalization, and reduced survival--independent of both clinical factors and angina. These findings suggest that dyspnea is an important component of disease-specific health status for post-MI patients, and its assessment should be strongly considered in both research studies and clinical practice.

Background: Elevated blood glucose levels on admission are associated with increased mortality in patients with acute myocardial infarction. Whether glucose normalization after admission is associated with improved survival remains controversial. In addition, whether outcomes differ in patients who have spontaneous resolution of hyperglycemia vs those who achieve normoglycemia after treatment with insulin is also unknown., Methods: We studied 7820 hyperglycemic (admission glucose level, > or =140 mg/dL [to convert glucose to millimoles per liter, multiply by 0.0555]) patients with acute myocardial infarction hospitalized between January 1, 2000, and December 31, 2005, in 40 US hospitals. Patients were stratified according to their mean glucose levels after admission and were divided into those who did and did not receive insulin therapy. Multivariable logistic regression models were developed to examine whether lower glucose levels after admission are independently associated with better survival. Propensity-matching methods were then used to compare in-hospital mortality in patients who did and did not receive insulin therapy., Results: After multivariable adjustment, lower mean postadmission glucose levels were associated with better survival (for mean postadmission glucose levels of 110 to <140, 140 to <170, 170 to <200, and > or =200 mg/dL, the odds ratios [95% confidence intervals] were 2.1 [1.3-3.5], 5.3 [3.0-8.6], 6.9 [4.1-11.4], and 13.0 [8.0-21.3], respectively, vs <110 mg/dL). Similar results were seen in patients who did and did not receive insulin therapy (P =.74 for insulin therapy x postadmission glucose level interaction). In propensity-matched analysis, mortality rates were similar between insulin-treated and non-insulin-treated patients across the spectrum of mean postadmission glucose levels (range, P = .15 to P = .91)., Conclusions: Glucose normalization after admission is associated with better survival in hyperglycemic patients hospitalized with acute myocardial infarction whether or not they receive insulin therapy. A strategy of intentional glucose lowering with insulin therapy needs to be further tested in future randomized controlled trials.

Background: Little information is available about factors associated with racial differences across a broad spectrum of post-myocardial infarction outcomes, including patients' symptoms and quality of life., Objective: To determine racial differences in mortality, rehospitalization, angina, and quality of life after myocardial infarction and identify the factors associated with these differences., Design: Prospective cohort study., Setting: 10 hospitals in the United States., Patients: 1849 patients who had myocardial infarction, 28% of whom were black., Measurements: Demographic, economic, clinical, psychosocial, and treatment characteristics and outcomes were prospectively collected. Outcomes included time to 2-year all-cause mortality, 1-year rehospitalization, and Seattle Angina Questionnaire-assessed angina and quality of life., Results: Black patients had higher unadjusted mortality (19.9% vs. 9.3%; P < 0.001) and rehospitalization rates (45.4% vs. 40.4%; P = 0.130), more angina (28.0% vs. 17.8%; P < 0.001), and worse mean quality of life (80.6 [SD, 22.5] vs. 85.9 [SD, 17.2]; P < 0.001). After adjustment for patient characteristics, black patients trended toward greater mortality (hazard ratio, 1.29 [95% CI, 0.92 to 1.81]; P = 0.142), fewer rehospitalizations (hazard ratio, 0.82 [CI, 0.66 to 1.02]; P = 0.071), and higher likelihood of angina at 1 year (odds ratio, 1.41 [CI, 1.03 to 1.94]; P = 0.032) but similar quality of life (mean difference, -0.6 [CI, -3.4 to 2.2]). Adjustment for site of care further attenuated mortality differences (hazard ratio, 1.04 [CI, 0.71 to 1.52]; P = 0.84). Adjustment for treatments had minimal effect on any association., Limitation: Residual confounding and missing data may have introduced bias., Conclusion: Although black patients with myocardial infarction have worse outcomes than white patients, these differences did not persist after adjustment for patient factors and site of care. Further adjustment for treatments received minimally influenced observed differences. Strategies that focus on improving baseline cardiac risk and hospital factors may do more than treatment-focused strategies to attenuate racial differences in myocardial infarction outcomes., Funding: The National Heart, Lung, and Blood Institute Specialized Center of Clinically Oriented Research in Cardiac Dysfunction and Disease, CV Therapeutics, and Cardiovascular Outcomes.

Background: Providing patients with documented discharge instructions is a performance measure of health care quality. It is not well known how often cardiac patients comply with the list of instructions or what their association is with health status outcomes after an acute myocardial infarction., Methods: Acute myocardial infarction patients (N = 2,498) were prospectively enrolled into a 19-center study and asked, at 1 month, if they had recalled receiving instructions at discharge on any of the 13 secondary prevention behaviors (eg, exercise, medications, diet, and smoking). Adherence, defined as the percentage of relevant activities patients reported adhering to at 1 month, was grouped into 4 categories: poor (0%-49%), partial (50%-74%), careful (75%-99%), and very careful (100%)., Results: A total of 2,046 patients completed 1-month interviews and received instruction on at least 1 risk factor management (RFM) behavior. Very careful adherence at 1-month was reported most frequently with "taking medications as prescribed" (94%). In multivariable-adjusted models, patients who reported being poorly adherent were 58% more likely to report angina at 1 year as compared with those who very carefully followed RFM (relative risk 1.58, 95% CI 1.05-2.37). There was no independent association between RFM behavior and quality of life, physical functioning, rehospitalization, or mortality., Conclusions: There is substantial variation in the types of RFM to which acute myocardial infarction patients adhere. In aggregate, stronger adherence was associated with less angina at 1 year. More research is needed to understand adherence patterns and its association with outcomes.

Background: Although a variety of prognostic tools have been shown to predict rehospitalization and mortality in heart failure patients, their utility in assessing future costs is less clear. We assessed whether health status assessment with the Kansas City Cardiomyopathy Questionnaire (KCCQ) predicts future costs in stable heart failure outpatients with left ventricular dysfunction after myocardial infarction., Methods and Results: We evaluated 12-month cost utilization data from 1516 heart failure outpatients enrolled in the Quality-of-Life Substudy of the Eplerenone Post-Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS). Multivariable hierarchical models assessed whether the KCCQ (categorized as 0 to <25, 25 to <50, 50 to <75, and 75 to 100) was an independent predictor of future resource use. At baseline, 685 patients (45.2%) had good health status (KCCQ scores > or =75), whereas 510 (33.6%), 262 (17.3%), and 59 (3.9%) had fair (KCCQ, 50 to 74), poor (KCCQ, 25 to 49), and the worst (KCCQ <25) health status, respectively. After multivariable adjustment, compared with patients with good health status, patients with fair health status incurred incremental 1-year costs of $1520 (cost ratio, 1.23; 95% confidence interval, 1.05 to 1.43), whereas patients with poor and the worst health status incurred incremental 1-year costs of $4265 (cost ratio, 1.63; 95% confidence interval, 1.34 to 1.99) and $8999 (cost ratio, 2.34; 95% confidence interval, 1.62 to 3.38), respectively (P<0.0001 for association with KCCQ). Further adjustment for New York Heart Association class led to only partial attenuation of this relationship (P=0.0002)., Conclusions: Health status assessment predicts resource use and costs over the next year in stable heart failure outpatients with left ventricular dysfunction after myocardial infarction.

Background: Older age is a risk factor for higher mortality after acute myocardial infarction (AMI), but the association with health status outcomes is largely unexplored., Methods: In a prospective cohort of 2498 patients in the PREMIER study, we compared health-related quality of life (HRQL) and burden of angina symptoms among survivors of AMI by age strata (age groups > or = 75, 65-74, 50-64, and 19-49 years) using the Seattle Angina Questionnaire. Multivariable analyses assessed the relationship between age and 1-year HRQL and angina burden, adjusting for differences in clinical characteristics, treatment, and baseline health status., Results: Older patients comprised a majority: 20.1% were > or = 75 years of age, 41.7% were 65 to 74 years of age, 20.7% were 50 to 64 years of age, and 17.4% were < 50 years of age. At 12 months, older patients had higher mortality (17.0% vs 8.7% vs 6.1% vs 3.2% for age groups > or = 75, 65-74, 50-64, 19-49; P < .001). Among survivors of AMI, increasing age was associated with less angina and better HRQL. By 12 months, older patients reported less angina (10.9% vs 12.7% vs 19.3% vs 23.4% for age groups > or = 75, 65-74, 50-64, 19-49; P < .0001) and better HRQL (scores 89.1 vs 88.1 vs 82.5 vs 80.0, respectively; P < .0001), which persisted after adjustment for baseline angina, HRQL, and other demographic, clinical, disease severity, and treatment differences., Conclusions: Although older patients have higher mortality after AMI, those who survive experience fewer symptoms and better HRQL at 1 year than younger patients. Angina remains present in a number of patients across the spectrum of age, supporting strategies to systematically assess and treat symptoms after AMI.

Background: Early outpatient follow-up after acute myocardial infarction (AMI) is recommended in guidelines, but its relationship with the use of evidence-based therapies is unknown., Methods: We evaluated 1516 patients hospitalized with AMI from the multicenter Prospective Registry Evaluating Outcomes After Myocardial Infarction: Events and Recovery registry. Early follow-up was defined as patient- reported visits with a primary care physician or cardiologist within 1 month after discharge. The primary outcomes were use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and statins in eligible patients at 6 months. Multivariable analyses assessed the association between early follow-up and medication use at 6 months, adjusting for patient and clinical characteristics. Secondary analyses compared medication use at 6 months for patients receiving collaborative follow-up from a single provider vs those receiving follow-up from both provider types., Results: Among the cohort, 34% reported no outpatient follow-up during the month following discharge. Rates of medication prescription among appropriate candidates were similar at hospital discharge for both follow-up groups. Compared with those not receiving early follow-up, those receiving early follow-up were more likely to be prescribed beta-blockers (80.1% vs 71.3%; P = .001), aspirin (82.9% vs 77.1%; P = .01), or statins (75.9% vs 68.6%; P = .005) at 6 months. In multivariable analyses, a persistent relationship remained between early follow-up and beta-blocker use (risk ratio, 1.08; 95% confidence interval, 1.02-1.15). In secondary analyses, statin use was higher in patients receiving collaborative follow-up (risk ratio, 1.11; 95% confidence interval, 1.01-1.22)., Conclusions: Early outpatient follow-up and collaborative follow-up after AMI is associated with higher rates of evidence-based medication use. Although further studies should assess whether this relationship is causal, these results support current guideline recommendations for follow-up after AMI.