scholarly journals Influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction in the United States

PLoS ONE ◽  
2020 ◽  
Vol 15 (12) ◽  
pp. e0243810
Author(s):  
Saraschandra Vallabhajosyula ◽  
Vinayak Kumar ◽  
Pranathi R. Sundaragiri ◽  
Wisit Cheungpasitporn ◽  
Malcolm R. Bell ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Angiography ◽  
Hospital Mortality ◽  
The United States ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
Medicare Population ◽  
St Segment ◽  
Hospitalization Costs ◽  
Primary Payer

Background There are limited contemporary data on the influence of primary payer status on the management and outcomes of ST-segment elevation myocardial infarction (STEMI). Objective To assess the influence of insurance status on STEMI outcomes. Methods Adult (>18 years) STEMI admissions were identified using the National Inpatient Sample database (2000–2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured and others. Outcomes of interest included in-hospital mortality, use of coronary angiography and percutaneous coronary intervention (PCI), hospitalization costs, hospital length of stay and discharge disposition. Results Of the 4,310,703 STEMI admissions, Medicare, Medicaid, private, uninsured and other insurances were noted in 49.0%, 6.3%, 34.4%, 7.2% and 3.1%, respectively. Compared to the others, the Medicare cohort was older (75 vs. 53–57 years), more often female (46% vs. 20–36%), of white race, and with higher comorbidity (all p<0.001). The Medicare and Medicaid population had higher rates of cardiogenic shock and cardiac arrest. The Medicare cohort had higher in-hospital mortality (14.2%) compared to the other groups (4.1–6.7%), p<0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in uninsured (adjusted odds ratio (aOR) 1.14 [95% confidence interval {CI} 1.11–1.16]), and lower in Medicaid (aOR 0.96 [95% CI 0.94–0.99]; p = 0.002), privately insured (aOR 0.73 [95% CI 0.72–0.75]) and other insurance (aOR 0.91 [95% CI 0.88–0.94]); all p<0.001. Coronary angiography (60% vs. 77–82%) and PCI (45% vs. 63–70%) were used less frequently in the Medicare population compared to others. The Medicare and Medicaid populations had longer lengths of hospital stay, and the Medicare population had the lowest hospitalization costs and fewer discharges to home. Conclusions Compared to other types of primary payers, STEMI admissions with Medicare insurance had lower use of coronary angiography and PCI, and higher in-hospital mortality.

Abstract 13350: Primary Payer Status Influences Management and Outcomes in Non-ST Elevation Myocardial Infarction

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Viral K Desai ◽  
Vikas Singh ◽  
Saraschandra Vallabhajosyula
Keyword(s):  
Myocardial Infarction ◽  
Coronary Angiography ◽  
Hospital Mortality ◽  
Multivariable Analysis ◽  
St Segment Elevation ◽  
Discharge Disposition ◽  
Medicare Population ◽  
Hospitalization Costs ◽  
Primary Payer ◽  
The Impact

Introduction: Multiple previous studies have shown that insurance status of the patient impacts the management and overall outcomes of patients presenting with acute myocardial infarction. There are limited data on the impact of primary payer status in patients with non ST segment elevation myocardial infarction (NSTEMI). Hypothesis: Primary payer status influences management and overall outcomes independent of the clinical and hospital-based characteristics in NSTEMI patients. Methods and Results: Adult (>18 years) NSTEMI admissions were identified using the National Inpatient Sample database (2000-2017). Expected primary payer was classified into Medicare, Medicaid, private, uninsured, and others. Outcomes of interest included in-hospital mortality, use of coronary angiography, early coronary angiography and percutaneous coronary intervention (PCI), resource utilization, and discharge disposition. Of the 7,290,565 NSTEMI admissions, Medicare, Medicaid, private, uninsured, and other insurances were noted in 62.9%, 6.1%, 24.1%, 4.6%, and 2.3%, respectively. Compared to others, the Medicare cohort was older (76 vs. 53-60 years), more often female (48% vs. 25-44%), of white race, and with higher comorbidity (all p <0.001). The Medicare cohort had higher in-hospital mortality (5.6%) compared to the other groups (1.9-3.4%), p <0.001. In a multivariable analysis (Medicare referent), in-hospital mortality was higher in other (adjusted odds ratio (aOR) 1.15 [95% confidence interval {CI} 1.11-1.19]; p <0.001), and lower in Medicaid (aOR 0.95 [95% CI 0.92-0.97]; p <0.001), private (aOR 0.77 [95% CI 0.75-0.78]; p <0.001) and uninsured cohorts (aOR 0.97 [95% CI 0.0.94-1.00]; p =0.06). Coronary angiography (overall 52% vs. 65-74%; early 15% vs. 22-27%) and PCI (27% vs. 35-44%) were used less frequently in the Medicare population. The Medicare population had longer lengths of hospital stay, lowest hospitalization costs and fewer discharges to home. Conclusions: Compared to other types of primary payers, NSTEMI admissions with Medicare insurance had lower use of coronary angiography and PCI and higher in-hospital mortality.

scholarly journals Cardiogenic shock in patients presenting with acute left main coronary artery occlusion

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
M Braga ◽  
J Calvao ◽  
J C Silva ◽  
A Campinas ◽  
A Alexandre ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery ◽  
Coronary Angiography ◽  
Hospital Mortality ◽  
Cardiogenic Shock ◽  
Left Main Coronary Artery ◽  
Left Main ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment

Abstract Background and purpose Acute myocardial infarction (AMI) due to left main coronary artery (LMCA) occlusion is a rare event, often catastrophic. Limited data are available about management and outcomes of patients with acute LMCA occlusion, including those presenting with cardiogenic shock (CS) at hospital admission. This study sought to describe patients with AMI due unprotected LMCA occlusion presenting with CS and to evaluate their in-hospital outcomes and 1-year mortality. Methods In this retrospective 2-center study, we identified 7630 patients with ST-segment elevation myocardial infarction (STEMI) or hight risk non-ST segment elevation myocardial infarction who underwent to emergent coronary angiography between January 2008 and December 2020. Among this cohort, we analysed 94 patients who presented with unprotected LMCA occlusion (Thrombolysis In Myocardial Infarction – TIMI ≤2) and divided them in 2 groups according to presence of signs of cardiogenic shock at admission: CS and no-CS. Results Of 94 patients with AMI due LMCA occlusion, 52 patients presented with CS (53.3%). Mean age was 62.8±11.5 years in CS and 62.0±15.9 years in no-CS patients, p=0.766. In both groups, most patients were male. STEMI presentation was more frequent in CS group (80.4% vs. 52.4%, p=0.004). Severe systolic dysfunction of left ventricle was more frequent in CS patients (81.1% vs. 33.3%, p&lt;0.001). Compared to no-CS patients, CS group shown more often TIMI=0 (67.3% vs. 26.2%, p&lt;0.001), collateral coronary circulation Rentrop 0–1 (95.3% vs. 75.0%, p=0.008), and slow-reflow/no-reflow phenomena (30.6% vs 3.8%, p=0.019) in emergent coronary angiography. The need of invasive mechanical ventilation (68.9% vs. 21.4%, p&lt;0.001), and haemodialysis (20.5% vs. 2.4%, p=0.010) were more prevalent in CS patients. Likewise, mechanical circulatory support (MCS) was more frequently used in patients presented with CS (52.9% vs. 26.2%, p=0.009). In subgroup analysis, MCS implantation was not a survival predictor in CS patients (Odds ratio: 3.9 [95% confidence interval: 0.4 to 36.3], p=0.229). Ultimately, in-hospital mortality (78.8% vs. 16.7%, p&lt;0.001) was higher in CS patients. On the other hand, in hospital survivors, there was no significant differences in 1-year mortality (11.1% vs. 23.5%, p=0.42) between both groups. Conclusions Nearly half of patients with AMI due LMCA occlusion presented with CS signs at first medical evaluation. This subgroup of patients had higher in-hospital mortality compared to those without CS, despite MCS implantation. Whether the use of a specific MCS device or whether early use of MCS can change the outcome remains to be elucidated. CS patients who survive to index-hospitalization, had similar long-term outcomes compared to no-CS patients. Further studies are imperative in this population to refine initial medical treatment in order to improve their prognosis. FUNDunding Acknowledgement Type of funding sources: None.

scholarly journals Electroangiographic Correlation of Simultaneous ST-Segment Elevations of Anterior and Inferior Segment: Who Is the Culprit?

2021 ◽  
pp. 263246362110155
Author(s):  
Pankaj Jariwala ◽  
Shanehyder Zaidi ◽  
Kartik Jadhav
Keyword(s):  
Myocardial Infarction ◽  
Coronary Angiography ◽  
Coronary Arteries ◽  
Index Case ◽  
St Segment Elevation ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment ◽  
Inferior Segment ◽  
The Right ◽  
Proximal Occlusion

Simultaneous ST-segment elevation (SST-SE) in anterior and inferior leads in the setting of ST-segment elevation myocardial infarction is often confounding for a cardiologist and further more challenging is the angiographic localization of the culprit vessel. SST-SE can be fatal as it jeopardizes simultaneously a larger area of myocardium. This phenomenon could be due to “one lesion, one artery,” “two lesions, one artery,” “two lesions, two arteries,” or combinations in two different coronary arteries. We have discussed an index case where we encountered a phenomenon of SST-SE and coronary angiography demonstrated “two lesions, one artery” (proximal occlusion and distal critical diffuse stenoses of the wrap-around left anterior descending [LAD] artery) and “two lesions, two (different coronary) arteries” (previously mentioned stenoses of the LAD artery and critical stenosis of the posterolateral branch of the right coronary arteries). We have also described in brief the possible causes of this phenomena and their electroangiographic correlation of the culprit vessels.

Unstable Angina and Other Acute Coronary Syndromes

2013 ◽  
Author(s):  
R Scott Wright ◽  
Joseph G Murphy
Keyword(s):  
Myocardial Infarction ◽  
Coronary Artery ◽  
Risk Stratification ◽  
Unstable Angina ◽  
The United States ◽  
Cardiac Biomarkers ◽  
St Segment Elevation ◽  
Coronary Syndrome ◽  
Segment Elevation Myocardial Infarction ◽  
St Segment

Patients with coronary artery disease (CAD) present clinically when their disease enters an unstable phase known as an acute coronary syndrome (ACS), in which the cap of a previously stable atheromatous coronary plaque ruptures or erodes, which in turn activates a thrombotic cascade that may lead to coronary artery occlusion, myocardial infarction (MI), cardiogenic shock, and patient death. There are nearly 2 million episodes of ACS in the United States annually; it is the most common reason for hospitalization with CAD and is the leading cause of death in the developed world. ACS patients include those with unstable angina (UA), non–ST segment elevation myocardial infarction (non-STEMI), and ST segment elevation myocardial infarction (STEMI) and patients who die suddenly of an arrhythmia precipitated by coronary occlusion. The distinction among various ACS subgroups reflects varying characteristics of clinical presentation (presence or absence of elevated cardiac biomarkers) and the type of electrocardiographic (ECG) changes manifested on the initial ECG at the time of hospitalization. This chapter focuses on UA and non-STEMI. A graph outlines mortality risks faced by patients with varying degrees of renal insufficiency. An algorithm describes the suggested management of patients admitted with UA or non-STEMI. Tables describe the risk stratification of the patient with chest pain, categories of Killip class, examination findings of a patient with high-risk ACS, diagnosis of MI, causes of troponin elevation other than ischemic heart disease, initial risk stratification of ACS patients, and long-term medical therapies and goals in ACS patients. This review contains 2 highly rendered figures, 11 tables, and 76 references.

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