An empirical approach for life expectancy estimation based on survival analysis among a post-acute myocardial infarction population.

Background: Practical communication of prognosis is pertinent in the clinical setting. Survival analysis techniques are standardly used in cohort studies; however, their results are not straightforward for interpretation as compared to the graspable notion of life expectancy (LE). The present study empirically examines the relationship between Cox regression coefficients (HRs), which reflect the relative risk of the investigated risk factors for mortality, and years of potential life lost (YPLL) values after acute myocardial infarction (AMI). Methods: This retrospective population-based study included patients aged 40-80 years, who survived AMI hospitalization from January 1, 2002, to October 25, 2017. A survival analysis approach assessed relationships between variables and the risk for all-cause mortality in an up to 21-year follow-up period. The total score was calculated for each patient as the summation of the Cox regression coefficients (AdjHRs) values. Individual LE and YPLL were calculated. YPLL was assessed as a function of the total score. Results: The cohort (n = 6316, age 63.0 ± 10.5 years, 73.4 % males) was randomly split into training (n = 4243) and validation (n = 2073) datasets. Sixteen main clinical risk factors for mortality were explored (total score of 0-14.2 points). After adjustment for age, sex and nationality, a one-point increase in the total score was associated with YPLL of ∼one year. A goodness-of-fit of the prediction model found 0.624 and 0.585 for the training and validation datasets respectively. Conclusions: This functional derivation for converting coefficients of survival analysis into the comprehensible form of YPLL/LE allows for practical prognostic calculation and communication.

Interaction between anemia and renal dysfunction in relation to long-term survival following acute myocardial infarction.

BACKGROUND: Anemia and chronic kidney disease (CKD) adversely affect prognosis following acute myocardial infarction (AMI). We aimed to assess their interaction regarding long-term survival post-AMI. METHODS: This is a single-center, retrospective analysis of consecutive AMI survivors. Stratified by admission-time anemia status and CKD grade, as determined by hemoglobin and creatinine levels, the cohort was evaluated for all-cause mortality at 10 years after hospital discharge. RESULTS: A total of 11,395 patients (69.1% males, mean age 65.8 ± 13.9 years, 49.6% with ST elevation MI) were included, of whom 29.9% had anemia and 15.9% - grade 3b or higher CKD. CKD was more advanced among anemic patients and the prevalence of anemia rose as CKD grade increased (p for trend < 0.001). At 10 years, 47.8% of patients died. Notwithstanding differences in baseline characteristics, presentation, and treatment between those with various anemia status and CKD grades, anemia presence (HR 1.40, 95% CI 1.32-1.49, p < 0.001) and increasing CKD grade (HR 1.10, 95% CI 1.02-1.20, p for trend < 0.001) were independently associated with a higher mortality risk. The incremental hazard imposed by either anemia or more advanced CKD was limited to patients with normal renal function and up to grade 3a (in the total cohort and the conservative treatment subgroup) or 4 (in the invasive revascularization subgroup) CKD. The added risk associated with increasing CKD grade also affected non-anemic individuals irrespective of the specific CKD grade. CONCLUSION: Anemia and more advanced CKD are associated with reduced long-term survival post-AMI, inflicting higher risk when conjoined in lower-grade CKD.

Healthcare Resources Utilization throughout the Last Year of Life after Acute Myocardial Infarction.

Healthcare resource utilization (HRU) peaks in the last year-of-life, and accounts for a substantial share of healthcare expenditure. We evaluated changes in HRU and costs throughout the last year-of-life among AMI survivors and investigated whether such changes can predict imminent mortality. This retrospective analysis included patients who survived at least one year following an AMI. Mortality and HRU data during the 10-year follow-up period were collected. Analyses were performed according to follow-up years that were classified into mortality years (one year prior to death) and survival years. Overall, 10,992 patients (44,099 patients-years) were investigated. Throughout the follow-up period, 2,885 (26.3%) patients died. The HRU parameters and total costs were strong independent predictors of mortality during a subsequent year. While a direct association between mortality and hospital services (length of in-hospital stay and emergency department visits) was observed, the association with ambulatory services utilization was reversed. The discriminative ability (c-statistics) of a multivariable model including the HRU parameters for predicting the mortality in the subsequent year, was 0.88. In conclusion, throughout the last year of life, hospital-centered HRU and costs of AMI survivors increase while utilization of ambulatory services decrease. HRUs are strong and independent predictors of an imminent mortality year among these patients.

The Association between Acute Myocardial Infarction-Related Outcomes and the Ramadan Period: A Retrospective Population-Based Study.

Fasting throughout the Muslim month of Ramadan may impact cardiovascular health. This study examines the association between the Ramadan period and acute myocardial infarction (AMI)-related outcomes among a Muslim population. The data were retrospectively extracted from a tertiary hospital (Beer-Sheva, Israel) database from 2002-2017, evaluating Muslim patients who endured AMI. The study periods for each year were: one month preceding Ramadan (reference period (RP)), the month of Ramadan, and two months thereafter (1840 days in total). A comparison of adjusted incidence rates between the study periods was performed using generalized linear models; one-month post-AMI mortality data were compared using a generalized estimating equation. Out of 5848 AMI hospitalizations, 877 of the patients were Muslims. No difference in AMI incidence between the Ramadan and RP was found (p = 0.893). However, in the one-month post-Ramadan period, AMI incidence demonstrably increased (AdjIRR = 3.068, p = 0.018) compared to the RP. Additionally, the highest risk of mortality was observed among the patients that underwent AMI in the one-month post-Ramadan period (AdjOR = 1.977, p = 0.004) compared to the RP. The subgroup analyses found Ramadan to differentially correlate with AMI mortality with respect to smoking, age, sex, diabetes mellitus, and hypertension, suggesting the Ramadan period is a risk factor for adverse AMI-related outcomes among select Muslim patients.

Norton Scale Score and long-term healthcare services utilization after acute myocardial infarction.

AIMS: Many patients admitted with acute myocardial infarction (AMI) have considerable multimorbidity, sometimes associated with functional limitations. The Norton Scale Score (NSS) evaluates clinical aspects of well-being and predicts numerous clinical outcomes. We evaluated the association between NSS and long-term healthcare utilization (HU) following a non-fatal AMI. METHODS AND RESULTS: A retrospective observational study including AMI survivors during 1 January 2004 to 31 December 2015 with a filled NSS report. Data were recouped from the electronic medical records of the hospital and two Health Maintenance Organizations. Norton Scale Score ≤16 or >16 was defined as low or high respectively. The outcome was annual HU, encompassing length of hospital stay (LOS), emergency department (ED) visits, primary care, and other ambulatory service utilization during up to 10 years of follow-up. HU costs were compared between groups. Two-level models were built: unadjusted and adjusted for patients' baseline characteristics. The study included 4613 patients, 784 (17%) had low NSS. Patients with low NSS compared with patients with high NSS were older, had a higher rate of multimorbidity, and had significantly lower coronary angiography and revascularization rates. In addition, low NSS patients presented higher annual HU costs (4879 vs. 3634 Euro, P <0.001), primarily due to LOS, ED visits, and less frequent ambulatory services usage. CONCLUSION: In patients after non-fatal AMI, low NSS is a signal for higher long-term costs reflecting the presence of expensive comorbidities. Management disparity and impaired mobility may offset the real need of these patients. Therefore, the specific proactive nursing intervention in that population is recommended.

When More Means Less: The Prognosis of Recurrent Acute Myocardial Infarctions.

Recurrent acute myocardial infarctions (AMI) are common and associated with dismal outcomes. We evaluated the clinical characteristics and the prognosis of AMI survivors according to the number of recurrent AMIs (ReAMI) and the time interval of events (TI). A retrospective analysis of patients who survived following hospitalization with an AMI throughout 2002-2017 was conducted. The number of ReAMIs for each patient during the study period was recorded and classified based on following: 0 (no ReAMIs), 1, 2, ≥3. Primary outcome: all-cause mortality up to 10 years post-discharge from the last AMI. A total of 12,297 patients (15,697 AMI admissions) were analyzed (age: 66.1 ± 14.1 years, 68% males). The mean number of AMIs per patient was 1.28 ± 0.7; the rates of 0, 1, 2, ≥3 ReAMIs were 81%, 13.4%, 3.6% and 1.9%, respectively. The risk of mortality increased in patients with greater number of AMIs, HR = 1.666 (95% CI: 1.603-1.720, p < 0.001) for each additional event (study group), attenuated following adjustment for potential confounders, AdjHR = 1.135 (95% CI: 1.091-1.181, p < 0.001). Increased risk of mortality was found with short TI (<6-months), AdjHR = 2.205 (95% CI: 1.418-3.429, p < 0.001). The risk of mortality following AMI increased as the number of ReAMIs increased, and the TI between the events shortened. These findings should guide improved surveillance and management of this high-risk group of patients (i.e., ReAMI).

Heterogenicity of diabetes as a risk factor for all-cause mortality after acute myocardial infarction: Age and sex impact.

AIM: Type 2 diabetes mellitus (T2DM) is a risk factor for mortality after acute myocardial infarction (AMI). We studied the impact of T2DM related to sex and age on post-AMI long-term mortality. METHODS: A retrospective study included post-AMI patients. Data were obtained from electronic medical records. We defined the study groups by T2DM, stratified by age-sex. OUTCOME: up-to-10 years post-discharge all-cause mortality. RESULTS: 16,168 patients were analyzed, 40.3% had T2DM. Ten-year mortality rates were 50.3% with T2DM vs. 33.1% without T2DM, adjHR = 1.622 (p < 0.001). Females (adjHR = 1.085, p = 0.052) and increased age (adjHR = 1.056 for one-year increase, p < 0.001) were associated with a higher risk of mortality (borderline statistical significance for sex). The relationship between T2DM and mortality was stronger in females than in males at < 50 and 60-69 years (p-for-interaction 0.025 and 0.009 respectively), but not for other age groups. CONCLUSIONS: The study implies heterogeneity in the impact of T2DM on mortality of post-AMI patients, being greater among young patients, particularly females, and no significant impact in octogenarians. That implies that young women with T2DM should have advanced measures for early detection of coronary artery disease and tight control of cardiovascular risk factors to lower the propensity to develop AMI.

Changes over Time in Hemoglobin A1C (HbA1C) Levels Predict Long-Term Survival Following Acute Myocardial Infarction among Patients with Diabetes Mellitus.

Frequent fluctuations of hemoglobin A1c (HbA1C) values predict patient outcomes. However, data regarding prognoses depending on the long-term changes in HbA1C among patients after acute myocardial infarction (AMI) are scarce. We evaluated the prognostic significance of HbA1C levels and changes among diabetic patients (n = 4066) after non-fatal AMI. All the results of HbA1C tests up to the 10-year follow-up were obtained. The changes (∆) of HbA1C were calculated in each patient. The time intervals of ∆HbA1C values were classified as rapid (

Serum electrolyte/metabolite abnormalities among patients with acute myocardial infarction: comparison between patients with and without diabetes mellitus.

Background: Diabetes mellitus (DM) in a setting of acute myocardial infarction (AMI) is associated with significant metabolic changes and worse outcomes.Objective: To evaluate the prevalence and the prognostic significance of electrolyte/metabolite disturbances among AMI patients with vs. without DM.Methods: Patients admitted to a tertiary medical center with AMI throughout 2002-2012 were screened. Exclusion criteria were: dialysis, mechanical ventilation, and in-hospital coronary artery bypass graft (CABG) surgery. All the results of the following analyses were obtained: Glucose, Uric Acid, (UA) Calcium, Magnesium, Albumin, Potassium, and Sodium. The primary outcome was in-hospital all-cause mortality.Results: A total of 14,364 AMI patient admissions was evaluated, mean age 68.1 ± 14.4 years, 65.5% males, and 41.2% with DM. Following an adjustment to potential confounders, DM patients had increased risk for significant hyperglycemia, hyperuricemia, hypercalcemia, hypomagnesemia, hyperkalemia, and hyponatremia as well as significantly decreased risk for hypoglycemia, hypermagnesemia, and hypokalemia compared with nondiabetics. Overall, 681 (4.7%) patients died throughout the index admission. Deceased had an increased incidence of electrolyte/metabolite abnormalities versus hospital survivors. The prognostic significance of the different categories of the investigated variables is very similar among diabetics and nondiabetics, except increased and decreased uric acid levels [<4.5 (men); <4.0 (women) and ≥9.0 (men); ≥9.4 (women)] which are associated with worse outcomes among diabetics while hyperglycemia (Glucose ≥213 mg/dL) and increased Potassium levels (Potassium ≥4.4mEq/L) which comprise significantly worse prognosis among nondiabetics.Conclusions: Patients with DM admitted with AMI are at greater risk for electrolyte/metabolite abnormalities which are associated with increased risk for in-hospital mortality. The latter association is similar among patients with and without DM except for hyperglycemia and increased potassium levels (stronger among nondiabetics).

Potassium levels as a marker of imminent acute kidney injury among patients admitted with acute myocardial infarction. Soroka Acute Myocardial Infarction II (SAMI-II) Project.

BACKGROUND: Acute kidney injury (AKI) is a common complication following acute myocardial infarction (AMI) and associated with worse outcomes. Serum Potassium levels (K, mEq/L), which are regulated by the kidneys, are related with poor prognosis in patients with AMI. OBJECTIV: To evaluate whether K levels predict imminent AKI in patients with AMI. METHODS: This retrospective nested case-control study was based on medical records of hospitalized AMI patients, 2002-2012. The cases (AKI group) were defined as an increase of ≥1.5-fold in serum creatinine level or a decrease of ≥25% in the estimated glomerular filtration rate (eGFR) during the hospitalization. The control group comprised of matched randomly selected patients that did not develop AKI. For both groups, all creatinine and K levels were obtained for up-to 72 h prior to the AKI diagnosis (index time). RESULTS: A total of 12,498/17,678 admissions met the inclusion criteria. The AKI and the control groups consisted of 430 and 1345 matched admission respectively. K levels, prior AKI diagnosis seemed to be higher in the AKI group. Multivariate analysis showed that K ≥ 4.5 within 36-56 h prior to the index time was an independent predictor of the subsequent AKI, OR = 2.3, p < .001. The c-statistic of the model was 0.859, p < .001. Predictivity of K for AKI was stronger among ST-elevation (STEMI) vs. Non-ST-elevation AMI (NSTEMI) patients (OR = 4, p < .001 vs. 1.7, p = .025 respectively; p-for-interaction = 0.038). CONCLUSIONS: K ≥ 4.5 is an independent and incremental marker of imminent AKI in patients with AMI, predictivity is stronger in patients with STEMI than NSTEMI.

Associations between Subsequent Hospitalizations and Primary Ambulatory Services Utilization within the First Year after Acute Myocardial Infarction and Long-Term Mortality.

Healthcare resource utilization peaks throughout the first year following acute myocardial infarction (AMI). Data linking the former and outcomes are sparse. We evaluated the associations between subsequent length of in-hospital stay (SLOS) and primary ambulatory visits (PAV) within the first year after AMI and long-term mortality. This retrospective analysis included patients who were discharged following an AMI. Study groups: low (0-1 days), intermediate (2-7) and high (≥8 days) SLOS; low (<10) and high (≥10 visits) PAV, throughout the first post-AMI year. All-cause mortality was set as the primary outcome. Overall, 8112 patients were included: 55.2%, 23.4% and 21.4% in low, intermediate and high SLOS groups respectively; 26.0% and 74.0% in low and high-PAV groups. Throughout the follow-up period (up to 18 years), 49.6% patients died. Multivariable analysis showed that an increased SLOS (Hazard ratio (HR) = 1.313 and HR = 1.714 for intermediate and high vs. low groups respectively) and a reduced number of PAV (HR = 1.24 for low vs. high groups) were independently associated with an increased risk for mortality (p < 0.001 for each). Long-term mortality following AMI is associated with high hospital and low primary ambulatory services utilization throughout the first-year post-discharge. Measures focusing on patients with increased SLOS and reduced PAV should be considered to improve patient outcomes.

Mortality and healthcare resource utilization following acute myocardial infarction according to adherence to recommended medical therapy guidelines.

Guideline recommended medical therapy (GRMT) plays a pivotal role in improving long-term outcomes and healthcare burden of acute myocardial infarction (AMI) patients. We evaluated patients' adherence to GRMT following AMI and the association with long-term (up-to 10 years) mortality, healthcare resource utilization and costs. METHODS: AMI patients hospitalized in a tertiary medical center in Israel that survived at least a year following post-discharge and enrolled in the two largest health plans were analyzed. Data were obtained from computerized medical records. Patients were defined as adherent when ≥80 % of the GRMT prescriptions were issue during the first post-discharge year. Hospitalizations, emergency department (ED) visits, primary care utilization and outpatient consulting clinic and other ambulatory services expenditure were calculated annually. RESULTS: Overall 8287 patients qualified for the study (mean age 65.0 ± 13.6 years, 69.7 % males). Adherent patients (n = 1767, 21.3 %) were more likely to be younger, women and increased prevalence of most traditional cardiovascular risk factors. Throughout the follow-up, 2620 patients (31.6 %) died, 22.0 % versus 34.2 %, in the adherent vs. the non-adherent group (adjHR = 0.816, 95 % CI:0.730-0.913, p < 0.001). Reduced hospitalizations (adjOR = 0.783, p < 0.001), ED visits (adjOR = 0.895, p = 0.033), and costs (adjOR = 0.744, p < 0.001), yet increased primary clinics (adjOR = 2.173, p < 0.001) ambulatory (adjOR = 1.072, p = 0.018) and consultant (adjOR = 1.162, p < 0.001) visits, were observed. CONCLUSIONS: Adherence to GRMT following AMI is associated with decreased mortality, hospitalizations and costs.

Sex and Ethnic Disparities in Health-Related Outcomes Following Acute Myocardial Infarction in Israel.

BACKGROUND: Survivors of acute myocardial infarction (AMI) are at increased risk for recurrent cardiac events and tend to use excessive healthcare services, thus resulting in increased costs. OBJECTIVES: To evaluate the disparities in healthcare resource utilization and costs throughout a decade following a non-fatal AMI according to sex and ethnicity groups in Israel. METHODS: A retrospective study included AMI patients hospitalized at Soroka University Medical Center during 2002-2012. Data were obtained from electronic medical records. Post-AMI annual length of hospital stay (LOS); number of visits to the emergency department (ED), primary care facilities, and outpatient consulting clinics; and costs were evaluated and compared according sex and ethnicity groups. RESULTS: A total of 7685 patients (mean age 65.3 ± 13.6 years) were analyzed: 56.8% Jewish males (JM), 26.6% Jewish females (JF), 12.4% Bedouin males (BM), and 4.2% Bedouin females (BF). During the up-to 10-years follow-up (median 5.8 years), adjusted odds ratios [AdjOR] for utilizations of hospital-associated services were highest among BF (1.628 for LOS; 1.629 for ED visits), whereas AdjOR for utilization of community services was lowest in BF (0.722 for primary clinic, 0.782 for ambulatory, and 0.827 for consultant visits), compared with JM. The total cost of BF was highest among the study groups (AdjOR = 1.589, P < 0.01). CONCLUSIONS: Long-term use of hospital-associated healthcare services and total costs were higher among Bedouins (especially BF), whereas utilization of ambulatory services was lower in these groups. Culturally and economically sensitive programs optimizing healthcare resources utilization and costs is warranted.

Early Atrial Fibrillation During Acute Myocardial Infarction May Not Be an Indication for Long-Term Anticoagulation.

Patients with new-onset of atrial fibrillation (NOAF) during acute myocardial infarction (AMI) currently receive long-term oral anticoagulation. The risk for stroke of "early" versus "late" onset of atrial fibrillation (AF) has not been elucidated. Consecutively, AMI patients admitted to a tertiary medical center were analyzed. We excluded patients with preexisting AF, AMI onset ≥24 hours prior to admission, significant valvular disease, fever >38.5°C, in-hospital death, or coronary artery bypass graft. Atrial fibrillation was verified by electrocardiography and medical records. Overall 7061 patients were included, 1.4% developed "early-paroxysmal AF (PAF)" that resolved within 24 hours of admission and 2.5% had "late-AF" beyond the first 24 hours. Median follow-up was ≈6 years. Primary end points included ischemic stroke and all-cause mortality. Stroke rates were higher only in patients with late-AF versus no-AF but not in the early-PAF: 10.6% versus 4.2%, 5.3%, respectively (P < .001). Death rates were higher in patients with late-AF and early-PAF versus no-AF: 55.3%, 43.2%, and 29.2%, respectively (P < .001). Congestive heart failure, hypertension, age ≥75, diabetes mellitus, a stroke or transient ischemic attack, vascular disease, age 65-74, female (CHA2DS2-VASc) score underestimated stroke risk in the late-AF group. In conclusion, the study generates the hypothesis that patients with early-PAF may not have a high stroke risk questioning the indication for long-term anticoagulation.

Temporal trends in healthcare resource utilization and costs following acute myocardial infarction.

BACKGROUND: Acute myocardial infarction (AMI) is associated with greater utilization of healthcare resources and financial expenditure. OBJECTIVES: To evaluate temporal trends in healthcare resource utilization and costs following AMI throughout 2003-2015. METHODS: AMI patients who survived the first year following hospitalization in a tertiary medical center (Soroka University Medical Center) throughout 2002-2012 were included and followed until 2015. Length of the in-hospital stay (LOS), emergency department (ED), primary care, outpatient consulting clinic visits and other ambulatory services, and their costs, were evaluated and compared annually over time. RESULTS: Overall 8047 patients qualified for the current study; mean age 65.0 (SD = 13.6) years, 30.3% women. During follow-up, LOS and the number of primary care visits has decreased significantly. However, ED and consultant visits as well as ambulatory-services utilization has increased. Total costs have decreased throughout this period. Multivariate analysis, adjusted for potential confounders, showed as significant trend of decrease in LOS and ambulatory-services utilization, yet an increase in ED visits with no change in total costs. CONCLUSIONS: Despite a decline in utilization of most healthcare services throughout the investigated decade, healthcare expenditure has not changed. Further evaluation of the cost-effectiveness of long-term resource allocation following AMI is warranted. Nevertheless, we believe more intense ambulatory follow-up focusing on secondary prevention and early detection, as well as high-quality outpatient chest pain unit are warranted.

Translating clinical trial results into personalized recommendations by considering multiple outcomes and subjective views.

Currently, clinicians rely mostly on population-level treatment effects from RCTs, usually considering the treatment's benefits. This study proposes a process, focused on practical usability, for translating RCT data into personalized treatment recommendations that weighs benefits against harms and integrates subjective perceptions of relative severity. Intensive blood pressure treatment (IBPT) was selected as the test case to demonstrate the suggested process, which was divided into three phases: (1) Prediction models were developed using the Systolic Blood-Pressure Intervention Trial (SPRINT) data for benefits and adverse events of IBPT. The models were externally validated using retrospective Clalit Health Services (CHS) data; (2) Predicted risk reductions and increases from these models were used to create a yes/no IBPT recommendation by calculating a severity-weighted benefit-to-harm ratio; (3) Analysis outputs were summarized in a decision support tool. Based on the individual benefit-to-harm ratios, 62 and 84% of the SPRINT and CHS populations, respectively, would theoretically be recommended IBPT. The original SPRINT trial results of significant decrease in cardiovascular outcomes following IBPT persisted only in the group that received a "yes-treatment" recommendation by the suggested process, while the rate of serious adverse events was slightly higher in the "no-treatment" recommendation group. This process can be used to translate RCT data into individualized recommendations by identifying patients for whom the treatment's benefits outweigh the harms, while considering subjective views of perceived severity of the different outcomes. The proposed approach emphasizes clinical practicality by mimicking physicians' clinical decision-making process and integrating all recommendation outputs into a usable decision support tool.

Early Versus Late New-Onset Atrial Fibrillation in Acute Myocardial Infarction: Differences in Clinical Characteristics and Predictors.

New-onset atrial fibrillation (NOAF) during acute myocardial infarction (AMI) has significant consequences but is often misdiagnosed. The aim of the study was to evaluate predictors of NOAF throughout different phases of AMI. Patients with AMI admitted to a tertiary medical center were analyzed. Exclusion criteria were preexisting AF, AMI onset ≥24 hours prior to admission, in-hospital death, significant valvular disease, and in-hospital coronary artery bypass graft. Study population were AMI without-NOAF, early-AF (AF terminated within 24 hours of admission), and late-AF (beyond the first 24 hours). Overall 5946 patients were included, age: 64.8 ±14.8 years; 30% women. The incidence of NOAF was 4.6%: 1.6% early-AF, and 3% late-AF. Patients with NOAF comprised greater rate of women, cardiovascular risk-factors burden, severe left ventricular-dysfunction, pulmonary hypertension, valvular disorders, and left atrial enlargement compared with patients without-NOAF. Non-ST-elevation myocardial infarction and inferior-ST-elevation myocardial infarction (STEMI) were significantly more prevalent among early-AF group, while anterior-STEMI, in late-AF. The final multivariate models showed c-statistics of 0.73 and 0.76 for the prediction of new-onset early-AF and late-AF, respectively. In conclusion, there are different clinical predictors of early- versus late-NOAF. The study points out "high risk" AMI population for more meticulous heart rate monitoring for NOAF.

Adherence to NSTEMI Guidelines in the Emergency Department: Regression to Reality.

BACKGROUND: Adherence to guidelines for the initial treatment of ST-Segment Elevation Myocardial Infarction has been thoroughly studied, whereas the study of emergency department (ED) adherence to guidelines for Non-ST-Segment Elevation Myocardial Infarction-Acute Coronary Syndrome (NSTEMI-ACS) has been much scarcer. The recommended guidelines for the initial prompt workup and treatment of NSTEMI-ACS remains a challenge. AIM: We studied adherence to guidelines for NSTEMI in the ED. METHODS: A single-center, retrospective study of consecutive patients with NSTEMI admitted to a tertiary hospital and discharged alive between March 2013 and March 2014. ED records were manually reviewed for adherence to prespecified parameters. Cases with sudden death, shock, or type-II NSTEMI were excluded. Canadian Triage and Acuity Scale score system was used for triage in the ED. RESULTS: Adherence rates were 33.3%/24.6% of 240 patients for ECG/troponin obtained within 10/60 minutes receptively and 31.3% for anticoagulation within 15 minutes from diagnosis of ACS. Females were less likely to undergo electrocardiography (P = 0.009) or troponin-level tests within the specified timeframe (P = 0.043). Many cardiovascular risk markers were missed. Global Registry of Acute Coronary Events score was not used to risk stratify patients. CONCLUSIONS: Prompt identification and early medical treatment of NSTEMI in the ED is lacking. Better computerized medical history assembly, attention to typical and atypical clinical presentation, and the employment of an appropriate cardiologic risk stratification method may unblind the treating teams at the point of care and improve adherence to NSTEMI guidelines.