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Author Interview: Adam C. Salisbury, MD, MSc
Saint Luke's Mid-America Heart Institute and University of Missouri-Kansas City
4401 Wornall Road, Kansas City, MO 64111
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Publication:
Author Interview: Adam C. Salisbury, MD, MSc
Recovery From Hospital-Acquired Anemia After Acute Myocardial Infarction and Effect on Outcomes.
Salisbury AC, Kosiborod M, Amin AP, Reid KJ, Alexander KP,
Spertus JA, Masoudi FA.
Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City School of Medicine, Kansas City, Missouri.
Am J Cardiol. 2011 Jul 22
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What are the main findings of the study?
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In previous work, we found that new-onset, hospital-acquired anemia (HAA) was common during hospitalization for acute myocardial infarction (AMI), developing in nearly 1 in 2 patients who were not anemic upon hospital arrival and were managed medically or with percutaneous coronary intervention (Circ Cardiovasc Qual Outcomes; 2010; 3(4): 337-346).
In that study, development of HAA was associated with greater mortality in follow-up after AMI. The present study addresses two key questions. First, is HAA frequently persistent in follow-up after AMI or is it a transient phenomenon? Second, is persistence of HAA associated with poorer physical functioning or greater mortality in recovery after AMI?
We leveraged data from the 24-center TRIUMPH registry of AMI, which included protocol driven follow-up hemoglobin assessment at 1 month after hospitalization with AMI for all patients who consented to participate with follow-up laboratory testing. We identified 530 patients who developed HAA during their index AMI hospitalization and also had hemoglobin assessment 1 month after AMI to describe the trajectories of hemoglobin recovery in recovery after AMI. Nearly 1 in 3 of these patients (165, 31%) remained anemic at the 1-month follow-up hemoglobin assessment.
Importantly, patients with persistent HAA at 1 month (versus patients whose HAA resolved) experienced significantly poorer health status in follow-up as assessed by the Short Form-12 Physical Component Summary score, particularly early in recovery at 1 and 6 months after AMI. Since patients may be most motivated to engage in a more active lifestyle early after AMI, the early impairment of physical functioning associated with persistent HAA could limit participation with cardiac rehabilitation, limit adoption of exercise routines or impair patients’ return to work. Patients with persistent HAA also had a greater risk of all-cause death over the 36 month follow-up period. Even after adjusting for potential confounders, these patients experienced a 2-fold greater mortality rate post-AMI (HR 2.08, 95% CI 1.02-4.21).
These findings are clinically important because HAA is potentially modifiable. Although causality cannot be determined from these observational data, it is possible that prevention and management of HAA could attenuate the adverse outcomes observed in this study. In particular, patients who develop HAA may benefit from early outpatient follow-up and additional evaluation for, and management of, treatable underlying causes of anemia.
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Were any of the findings unexpected?
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Persistent HAA is surprisingly common 1 month after hospitalization with acute myocardial infarction. This suggests that many patients do not promptly recover from acute hemoglobin declines during hospitalization (often resulting from recognized or unrecognized bleeding, diagnostic laboratory testing and acute inflammation in the setting of myocardial necrosis). Indeed, many of these patients may have poor hematopoietic reserve in the setting of underlying renal disease, iron deficiency or chronic inflammation.
It is likely that further diagnostic evaluation to diagnose and treat iron deficiency or anemia in the setting of chronic renal disease or heart failure may improve patients’ health status and other outcomes.
It is also important to note that our findings were robust after adjustment for key potential confounders. In particular, we adjusted for the severity of HAA at the time of discharge from the hospital. Patients with more significant anemia at discharge may be more likely to remain chronically anemic at 1 month. However, the relationship between persistent HAA and both physical functioning and mortality remained significant even after adjustment for severity of anemia at discharge.
Therefore, it is unlikely that persistence of HAA is simply a reflection of discharge HAA severity.
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What should clinicians and patients take away from this study?
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Development of HAA is a marker for poor recovery after AMI. This high risk subgroup is likely to benefit from earlier, and more frequent, outpatient monitoring. These findings also underscore the importance of hospital-based measures to prevent HAA, such as using bleeding avoidance strategies at the time of coronary angiography and limiting diagnostic phlebotomy, given mounting evidence that HAA is associated with poor outcomes after AMI.
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What recommendations do you have for nephrology health care providers as a result of your study?
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Further studies are needed to determine whether programs to prevent and manage HAA improve patients post-AMI outcomes. Pending additional studies, providers should be aware that patients who develop new-onset anemia during AMI hospitalization are at high risk for adverse events in recovery. These patients may benefit from further diagnostic testing to determine whether they have treatable risk factors for persistent anemia.
In some patients, HAA that develops in the setting of the acute stresses of AMI hospitalization may unmask previously undetected iron deficiency related to chronic gastrointestinal blood loss, nutritional deficiency, or relative iron deficiency in the setting of inflammatory disorders, renal disease or heart failure which may be amenable to treatment.
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Featured Angina| Acute Coronary Syndrome and Heart Disease Interviews
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Highlights of Article by Dr. Erik Hess et of Mayo Clinic ;CIRCOUTCOMES 2012
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Chest pain is the 2nd most common reason patients come to EDs across the United States
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Initial testing – including information obtained from the history, physical exam, electrocardiogram, and cardiac troponin – identifies > 98% of heart attacks
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To avoid missing a diagnosis of heart attack or pre-heart attack symptoms, emergency physicians often admit patients to observation units or to the hospital for extensive diagnostic testing, including stress testing
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This results in false positive test results, unnecessary exposure to radiation, and unnecessary downstream procedures such as stent placement in arteries of the heart
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Decision aids are evidence-based tools designed to educate and engage patients in decisions regarding their care
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We hypothesized that patients who were educated regarding their future risk for a heart attack and engaged in the decision of whether to be admitted to the observation unit for stress testing or to follow-up with a Mayo Clinic heart doctor in the next 72 hours would have greater knowledge about their short-term risk for heart attack, be more aware of the management options, and choose less intensive approaches to evaluation
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We randomly assigned 204 patients who came to the ED with chest pain and were being considered for observation unit admission to the decision aid or to usual care
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Decision aid patients:
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Had greater knowledge regarding their short-term risk for a heart attack
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Less frequently decided to be admitted to the observation unit for stress testing
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Had 4 times greater engagement in the decision making process
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Had no adverse events within 30 days of the ED visit
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Take home points
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Patients want to be educated and engaged in decisions regarding their care
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Once properly informed and engaged in treatment decisions, patients often choose less intensive treatment options
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Integrated health systems like the Mayo Clinic in which physicians collaboratively work together to provide ER patients ready access to outpatient follow-up have potential to improve the value of Emergency care
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Glucose, Insulin and Potassium (“GIK”) TO MINIMIZE IMPACT OF HEART ATTACKS BEFORE PATIENTS GET TO THE HOSPITAL
Study puts life-saving drugs in the hands of paramedics, decreasing rate of cardiac arrest and death from heart attacks
CHICAGO (March 27, 2012) — Paramedics can potentially reduce someone’s chances of having a cardiac arrest or dying by 50 percent by immediately administering a mixture of glucose, insulin and potassium (“GIK”) to people having a heart attack, according to research presented today at the American College of Cardiology’s 61st Annual Scientific Session. The Scientific Session, the premier cardiovascular medical meeting, brings cardiovascular professionals together to further advances in the field.
The study showed that patients who received GIK immediately after being diagnosed with acute coronary syndrome — which indicates a possible heart attack is either in progress or on the way — were 50 percent less likely to have cardiac arrest (a condition in which the heart suddenly stops beating) or die than those who received a placebo, although the treatment did not prevent the heart attack from occurring. The reduction in in-hospital cardiac arrest or death was a “secondary endpoint”, so statistically was not definitive, but was consistent with how GIK seems to work in experimental models of heart attack.
The effect was also present for patients with ST-elevation heart attacks, which require immediate treatment. For those patients, immediate GIK was associated with a 60 percent reduction in in-hospital cardiac arrest or death.
“When started immediately in the home or on the way to the hospital — even before the diagnosis is completely established — GIK appears not completely prevent any heart attack from occurring, but appeared in this trial to reduce the size of heart attacks and to reduce by half the risk of having a cardiac arrest or dying,” said Harry P. Selker, MD, MSPH, executive director of the Institute for Clinical Research and Health Policy Studies at Tufts Medical Center, who led the study with Joni Beshansky, RN, MPH, co-principal investigator and project director. “Acute coronary syndromes represent the largest cause of death in this country. GIK is a very inexpensive treatment that appears to have promise in reducing those deaths and morbidity.”
The cost of the treatment is about $50.
“Because the trial is the first to show GIK could be effective when used by paramedics in real-world community settings, it could have important implications for the treatment of heart attacks,” Dr. Selker said. Previous clinical trials have shown no consistent effect, likely because the GIK was given too late to help. This study, the “IMMEDIATE Trial,” was the first to test the effectiveness of administering GIK at the very first signs of a threatening heart attack, in the community, rather than waiting hours until the diagnosis was well-established at a hospital, as done in previous clinical trials.
“We wanted to do something that is effective and can be used anywhere,” said Dr. Selker. “We’ve done a lot of studies of acute cardiac care in emergency departments and hospitals, but more people die of heart attacks outside the hospital than inside the hospital. Hundreds of thousands of people per year are dying out in the community; we wanted to direct our attention to those patients.”
The researchers trained paramedics in 36 Emergency Medical Services systems in 13 cities across the country to administer GIK after determining that a patient was likely having a threatened or already established heart attack using electrocardiograph-based ACI-TIPI (acute cardiac ischemia time-insensitive predictive instrument) and thrombolytic predictive instrument decision support that prints patient-specific predictions on the top of an electrocardiogram. The paramedics used these predictions to decide if a patient would likely benefit from treatment. There were 911 patients randomized to receive either the GIK treatment or a placebo.
Administering GIK immediately also reduced the severity of the damage to the heart tissue from the heart attack. On average, 2 percent of the heart tissue was destroyed by the heart attack in people receiving GIK, compared with 10 percent in those who received the placebo. Although a significant proportion of suspected heart attacks are later determined to be false alarms (23 percent in this study), administering GIK does not appear to cause any harmful effects in such patients.
The research team will follow up with study participants at six and 12 months to evaluate the longer-term benefit of the GIK treatment.
This study was funded by the NIH’s National Heart, Lung and Blood Institute.
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Angina | Heart Disease Resourses
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Amazon.com 's Editorial Reviews
Angina: New Ways to Treat
Chronic Chest Pain
Part of the award winning public television series Healthy head
/Healthy Mind. It's one of the scariest medical symptoms for people who are generally healthy: a tightening, painful feeling in the chest known as Angina. In some cases this chest pain can be a serious warning that requires immediate treatment. But for the millions of people with chronic, stable angina the discomfort is something that can be readily managed with a variety of treatments. In this program we take a look at what generally causes angina, what can be done to prevent it and how it can be effectively treated with lifestyle changes, innovative drug therapies and medical procedures.
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Amazon.com Editorial Review:
Philips HeartStart Home Defibrillator (AED)
Be prepared for the unexpected.
When sudden cardiac arrest (SCA) strikes, the electrical system of the heart short circuits, causing the heart to quiver rather than pump in a normal rhythm. It typically results in the abnormal heart rhythm know as ventricular fibrillation (VF). It usually happens without warning and the majority of people have no previously recognized symptoms of heart disease. And it most often happens at home. For the best chance of survival from SCA caused by VF, a defibrillator should be used within 5 minutes. Yet, less than 1 in 20 people survive largely because a defibrillator does not arrive in time.
Just as seat belts or airbags do not save every life in a traffic accident, a defibrillator will not save every person who suffers a sudden cardiac arrest. Yet many lives could be saved if more people could be reached more quickly.
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