NCDR Study Shows Presence of Cognitive Impairment in Older MI Patients Impacts Treatment Selection

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Among older patients presenting with a myocardial infarction (MI), those with an NSTEMI are less likely to receive invasive treatment and those with STEMI are less likely to receive fibrinolysis. The presence of cognitive impairment was also associated with increased in-hospital mortality. These are among the findings of a study conducted using data from ACC's Chest Pain – MI Registry and published in the Journal of the American Heart Association.

Akshay Bagai, MD, MHS, et al., examined data from 43,812 patients with STEMI and 90,904 patients with NSTEMI who were older than 65 years and enrolled in the Chest Pain – MI Registry between January 2015 and December 2016. For the study, chart-documented cognitive impairment was categorized as mild (3.9 percent of STEMI patients vs. 5.7 percent of NSTEMI patients) or moderate/severe (2.0 percent vs. 2.6 percent, respectively).

Patients with STEMI with cognitive impairment were less frequently treated with cardiac medical therapies, including aspirin or a P2Y12 receptor inhibitor, within 24 hours or parenteral anticoagulation in-hospital compared with patients without cognitive impairment. There was a numerically small difference in the use of PCI among STEMI patients without cognitive impairment, mild impairment and moderate/severe impairment, respectively: 92.1 percent, 92.8 percent and 90.4 percent (p=0.003). The use of thrombolytic therapy (excluding those treated with PCI or ineligible) was lower in STEMI patients with mild or moderate/severe cognitive impairment (27.4 percent and 24.3 percent) compared with those without (40.9 percent). The results also showed in STEMI patients a slightly longer time from first medical contact to device and a lower use of CABG, and a difference in discharge medications with a lower use of P2Y12 receptor inhibitors, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and statins.

Focusing on patients presenting with NSTEMI, patients with cognitive impairment, compared with those without, were less likely to receive cardiac medical therapy within 24 hours, cardiac catheterization, or PCI and CABG procedures. In patients without, mild or moderate/severe cognitive impairment, the rates of catheterization were 84.7 percent, 50.3 percent and 24.6 percent (p<0.001) and the rates of PCI were 49.4 percent, 27.3 percent and 12.7 percent. The use of all discharge medications was lower for those with cognitive impairment.

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Cognitive impairment was associated with higher in-hospital mortality for STEMI and NSTEMI patients. For patients with mild cognitive impairment, compared with those without, the adjusted odds ratio for in-hospital mortality was 2.2 for STEMI and 1.7 for NSTEMI. For those with moderate/severe cognitive impairment, the odds ratio was 1.3 for both STEMI and NSTEMI.

The authors note that one in 13 patients older than 65 years in the U.S. have cognitive impairment documented in their medical records. Cognitive impairment without dementia is more prevalent and varies from a spectrum of age-related cognitive issues to mild cognitive impairment. After MI, even mild cognitive impairment was associated with less invasive care and less referral to and participation in cardiac rehabilitation, with moderate to severe cognitive impairment associated with worse risk-adjusted one-year survival.

"Improving outcomes of this patient population requires understanding the MI presentation in context of other medical conditions and patient goals of care," researchers concluded. "It also requires addressing noncardiac risk for mortality during and after hospitalization. Additional studies are needed to determine an optimal approach to inform clinical decision-making for older patients with MI with cognitive impairment.

Keywords: Myocardial Infarction, Hospital Mortality, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Cognition Disorders, Cognitive Dysfunction, Aspirin, Cardiac Rehabilitation, Angiotensin-Converting Enzyme Inhibitors, Receptors, Angiotensin, Fibrinolysis, Decision Making, Chest Pain, Thrombolytic Therapy, Registries, Hospitalization, National Cardiovascular Data Registries, Medical Records, Cardiac Catheterization, Dementia, Percutaneous Coronary Intervention, Referral and Consultation, Angiotensin Receptor Antagonists, Patient Care Planning, Cognition, Chest Pain MI Registry, National Cardiovascular Data Registries

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