Depressive Symptoms Moderate the Association Between Lifetime Discrimination and Inhibition Among Older Adults

Discrimination has been identified as a potentially modifiable environmental stressor that reduces cognitive function. As the burden of discrimination can extend from early to late life, understanding its role in cognition in late life is critical. Further, understanding the potential moderating influence of depressive symptoms, which are common among older adults, on the linkage between discrimination and cognition, may provide further insight into the potential patterns of psychosocial stress and negative affect that may promote cognitive decline and dementia. Thus, we sought to examine whether depressive symptoms moderate linear relations of lifetime discrimination to cognitive function in the domains of visuospatial, verbal, and working memory, executive function, and psychomotor ability, adjusting for age, sex, race, and education. Participants were 165 older adults (34% male) with a mean age of 68.43y. Participants completed a health screening, a battery of cognitive tests, a psychosocial assessment, and cardiovascular testing relevant to the larger study. Linear regression results showed a significant interaction between lifetime discrimination and depressive symptoms (p<.05) related to the Stroop interference score, a measure of inhibition. A probe of the interaction showed that greater lifetime discrimination was associated with better inhibition among participants with fewer depressive symptoms. This paradoxical finding is consistent with scant research that shows exposure to discrimination may heighten performance, and is more common among individuals that have achieved more, both educationally and vocationally. Greater depressive symptomatology may reduce this paradoxical association. Future research should explore this question both longitudinally and in a larger sample.

Differences in High‐ and Low‐Value Cardiovascular Testing by Health Insurance Provider

Background Quality of care incentives and reimbursements for cardiovascular testing differ between insurance providers. We hypothesized that there are differences in the use of guideline‐concordant testing between Medicaid versus commercial insurance patients <65 years, and between Medicare Advantage versus Medicare fee‐for‐service patients ≥65 years. Methods and Results Using data from the Colorado All‐Payer Claims Database from 2015 to 2018, we identified patients eligible to receive a high‐value test recommended by guidelines: assessment of left ventricular function among patients hospitalized with acute myocardial infarction or incident heart failure, or a low‐value test that provides minimal patient benefit: stress testing prior to low‐risk surgery or routine stress testing within 2 years of percutaneous coronary intervention or coronary artery bypass graft surgery. Among 145 616 eligible patients, 37% had fee‐for‐service Medicare, 18% Medicare Advantage, 22% Medicaid, and 23% commercial insurance. Using multilevel logistic regression models adjusted for patient characteristics, Medicaid patients were less likely to receive high‐value testing for acute myocardial infarction (odds ratio [OR], 0.84 [0.73–0.98]; P =0.03) and heart failure (OR, 0.59 [0.51–0.70]; P <0.01) compared with commercially insured patients. Medicare Advantage patients were more likely to receive high‐value testing for acute myocardial infarction (OR, 1.35 [1.15–1.59]; P <0.01) and less likely to receive low‐value testing after percutaneous coronary intervention/ coronary artery bypass graft (OR, 0.63 [0.55–0.72]; P <0.01) compared with Medicare fee‐for‐service patients. Conclusions Guideline‐concordant testing was less likely to occur among patients with Medicaid compared with commercial insurance, and more likely to occur among patients with Medicare Advantage compared with fee‐for‐service Medicare. Insurance plan features may provide valuable targets to improve guideline‐concordant testing.

Abstract 13645: Cardiologist Evaluation of Patients With Type 2 Myocardial Infarction

Introduction: Type 2 myocardial infarction (T2MI) is common and associated with recurrent cardiovascular events. How often T2MI patients are evaluated by a cardiologist and the association between these evaluations and diagnostic testing and treatments are unknown. Hypothesis: T2MI patients evaluated by a cardiologist are more likely to undergo cardiovascular testing and be placed on therapies for ischemic heart disease (IHD). Methods: We identified adjudicated patients with T2MI at Massachusetts General Hospital between October 2017 and May 2018. We examined baseline characteristics, diagnostic testing performed, and discharge medications, stratified by cardiologist evaluation during their admission. Results: We identified 359 patients with T2MI. During admission, 207 patients (57.7%) were evaluated by a cardiologist; 120 (33.4%) received a cardiology consultation and 87 (24.2%) were admitted to a cardiology service. Patients evaluated by a cardiologist were more likely to have hyperlipidemia (67.1% vs 52%, p=0.005), known CAD (58.9% vs. 38.8%, p<0.001), prior MI (27.1% vs. 14.5%, p=0.006), and HF (56.5% vs. 44.1%, p=0.03). Patients evaluated by a cardiologist were more likely to undergo stress testing (13.5% vs 3.3%, p=0.002), transthoracic echocardiography (80.2% vs. 50.7%, p<0.001), and coronary angiography (21.3% vs. 0%, p<0.001) during their index admission. There was no difference in mortality among those who were or were not evaluated by a cardiologist (11.6% vs. 9.2%, p=0.58). Patients evaluated by a cardiologist were more likely to be discharged on a statin (74.5% vs 64.5%, p=0.04) and a beta blocker (72% vs. 55.9%, p=0.002). Only new prescriptions of beta blockers were more commonly prescribed among those evaluated by a cardiologist (20.3% vs. 7.9%, p=0.002). Among those with available follow-up data (N=289), 111 patients (38.4%) had an outpatient cardiology follow-up visit within 6 months of discharge. Conclusions: Fewer than 60% of patients with T2MI were evaluated by a cardiologist during their admission and those that did were more likely to undergo further cardiovascular testing and to be discharged on therapies for IHD. Most T2MI patients did not have an outpatient cardiology follow-up visit after their event.

Implications of SARS-CoV-2-Associated Myocarditis in the Medical Evaluation of Athletes

Context: Myocarditis is a known cause of death in athletes. As we consider clearance of athletes to participate in sports during the COVID-19 pandemic, we offer a brief review of the myocardial effects of SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) through the lens of what is known about myocarditis and exercise. All athletes should be queried about any recent illness suspicious for COVID-19 prior to sports participation. Evidence Acquisition: The PubMed database was evaluated through 2020, with the following keywords: myocarditis, COVID-19, SARS-CoV-2, cardiac, and athletes. Selected articles identified through the primary search, along with position statements from around the world, and the relevant references from those articles, were reviewed for pertinent clinical information regarding the identification, evaluation, risk stratification, and management of myocarditis in patients, including athletes, with and without SARS-CoV-2. Study Design: Systematic review. Level of Evidence: Level 3. Results: Since myocarditis can present with a variety of symptoms, and can be asymptomatic, the sports medicine physician needs to have a heightened awareness of athletes who may have had COVID-19 and be at risk for myocarditis and should have a low threshold to obtain further cardiovascular testing. Symptomatic athletes with SARS-CoV-2 may require cardiac evaluation including an electrocardiogram and possibly an echocardiogram. Athletes with cardiomyopathy may benefit from cardiac magnetic resonance imaging in the recovery phase and, rarely, endocardial biopsy. Conclusion: Myocarditis is a known cause of sudden cardiac death in athletes. The currently reported rates of cardiac involvement of COVID-19 makes myocarditis a risk, and physicians who clear athletes for participation in sport as well as sideline personnel should be versed with the diagnosis, management, and clearance of athletes with suspected myocarditis. Given the potentially increased risk of arrhythmias, sideline personnel should practice their emergency action plans and be comfortable using an automated external defibrillator.