Disclosures: Krumholz reports receiving personal fees from Aetna, Arnold & Porter law firm, Element Science, F-Prime, Martin Baughman law firm, Reality Labs, Siegfried & Jensen law firm, Tesseract/4Catalyst and UnitedHealth, is a co-founder of HugoHealth and Refactor Health, and is associated with grants and/or contracts from CMS and Johnson & Johnson through Yale University. The other authors report no relevant financial disclosures.
May 04, 2022
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Medicare data: Long-term mortality, rehospitalization trends after acute MI improving

Disclosures: Krumholz reports receiving personal fees from Aetna, Arnold & Porter law firm, Element Science, F-Prime, Martin Baughman law firm, Reality Labs, Siegfried & Jensen law firm, Tesseract/4Catalyst and UnitedHealth, is a co-founder of HugoHealth and Refactor Health, and is associated with grants and/or contracts from CMS and Johnson & Johnson through Yale University. The other authors report no relevant financial disclosures.
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Rates for 10-year mortality and hospitalization for recurrence after an acute MI decreased steadily over more than 2 decades, though researchers observed marked inequities among subgroups.

In an analysis assessing 25 years of Medicare data, researchers also observed marked differences in outcomes and temporal trends across demographic subgroups in the 30 days after an acute MI, emphasizing the urgent need for prioritization of efforts to reduce inequities in long-term outcomes.

Alert on heart monitor
Source: Adobe Stock

“We have made great progress over the last 2 decades not just in improving short-term outcomes after heart attacks, but this study demonstrates that there are also long-term gains,” Harlan M. Krumholz, MD, SM, professor of medicine (cardiology), of investigative medicine, of public health and the Institute for Social and Policy Studies at Yale School of Medicine and director of the Center for Outcomes Research and Evaluation, told Healio. “This represents a remarkable improvement in long-term survival and is a great success in the treatment of heart attacks. This gain occurred largely with improvements in the quality of our CV care, including more timely treatments and most widespread use of treatments known to reduce risk. This is one of the areas where we have made the most progress in medicine.”

Assessing long-term data

Harlan M. Krumholz

Krumholz and colleagues analyzed data from 3,982,266 Medicare fee-for-service beneficiaries aged at least 66 years who were discharged alive after acute MI from an acute care hospital from 1995 to 2019 (49% women; mean age, 78 years). Subgroups were defined by age, sex, race, dual Medicare-Medicaid-eligible status and residence in health priority areas, defined as areas with persistently high adjusted mortality and hospitalization rates. Researchers assessed 10-year all-cause mortality and hospitalization for recurrent acute MI, beginning 30 days from the index acute MI admission. Mortality data were obtained from Medicare data.

The findings were published in JAMA Cardiology.

Within the cohort, 67.8% of patients were hospitalized from 1995 to 2009 and had potential for a full 10-year follow-up period.

During the 25-year period, 10-year mortality and recurrent acute MI rates were 72.7% (95% CI, 72.6-72.7) and 27.1% (95% CI, 27-27.2), respectively. Adjusted annual reductions were 1.5% (95% CI, 1.4-1.5) for mortality and 2.7% (95% CI, 2.6-2.7) for recurrence.

Inverse probability weight-adjusted HRs for mortality were 1.13 for men vs. women (95% CI, 1.12-1.13); 1.05 for Black vs. white patients (95% CI, 1.05-1.06); 1.24 for dual Medicare-Medicaid-eligible patients vs. noneligible patients (95% CI, 1.24-1.24) and 1.06 for patients living in health priority areas vs. other areas (95% CI, 1.06-1.07).

Patients who identified as American Indian and Alaskan Native, Asian, Hispanic or other race had a lower 10-year mortality risk compared white patients (HR = 0.96; 95% CI, 0.95-0.96).

Inverse probability weight-adjusted HRs for recurrence was 1.07 for men vs. women (95% CI, 1.06-1.07), 1.08 for Black vs. white patients (95% CI, 1.07-1.09) and 1.21 for dual Medicare-Medicare-eligible vs. noneligible patients (95% CI, 1.2-1.21). There were no differences by health priority area or for other race vs. white patients.

Rates improving over time

For patients hospitalized in 2007-2009, 10-year mortality risk was 13.9% lower than for those hospitalized in 1995-1997 (adjusted HR = 0.86; 95% CI, 0.85-0.87), whereas 10-year recurrence risk was 22.5% lower (aHR = 0.77; 95% CI, 0.76-0.78).

Mortality within 10 years after the initial acute MI was higher for patients with a recurrent acute MI (80.6%; 95% CI, 80.5-80.7) compared with those without recurrence (72.4%; 95% CI, 72.3-72.5).

“Among patients who died within 10 years, more than 30% died within the first year,” the researchers wrote. “This finding highlights the importance of high-quality post-acute care immediately after acute MI hospitalization for secondary prevention. The high rate of hospitalization for recurrence over 10 years and the 8 percentage point increase in the risk of 10-year mortality with a recurrent event further demonstrate the need for quality care to reduce recurrence and improve long-term mortality for acute MI survivors.”

Disparities ‘a call to action’

Krumholz said the findings show progress but also indicate there is work to be done.

“There are still far too many recurrent heart attacks among the heart attack survivors — we can decrease this risk more effectively,” Krumholz told Healio. “Importantly, the striking disparities are a call to action. We show that Black Americans and those with low incomes are at much greater risk and have low likelihood of long survival after a heart attack. We need to double down on eliminating these health inequities. We have powerful tools to reduce risk and we need to be sure that everyone has access to them.”

For more information:

Harlan M. Krumholz, MD, SM, can be reached at harlan.krumholz@yale.edu; Twitter: @hmkyale.