Association of Cognitive Impairment With Treatment and Outcomes in Older Myocardial Infarction Patients: A Report From the NCDR Chest Pain-MI Registry

• Type of Material: Article
• Authors: Akshay Bagai, University of Toronto; Anita Y. Chen, University of Rochester; Jacob A. Udell, University of Toronto; John A. Dodson, New York University; David D. McManus, University of Massachusetts; Mathew S. Maurer, Columbia University; Jonathan R. Enriquez, University of Missouri; Judith Hochman, New York University; Abhinav Goyal, Emory University; Timothy D. Henry, Cedars Sinai Heart Institute; Martha Gulati, University of Arizona; Kirk N. Garratt, Christiana Care Health System; Matthew T. Roe, Duke Clinical Research Institute; Karen P. Alexander, Duke Clinical Research Institute
• Language: English
• Date: 2019-09-03
• Publisher: Wiley Open Access: Creative Commons Attribution Non-Commercial
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: Copyright © 2019 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.
• License: Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1161/JAHA.119.012929
• Title of Journal or Parent Work: Journal of the American Heart Association
• ISSN: 2047-9980
• Volume: 8
• Issue: 17
• Start Page: e012929
• End Page: e012929
• Grant/Funding Information: This research was supported by the American College of Cardiology Foundation's National Cardiovascular Data Registry (NCDR).; Dr Udell is supported by a Heart and Stroke National New Investigator/Ontario Clinician Scientist Award; Government of Ontario Early Researcher Award; Women's College Research Institute and Department of Medicine, Women's College Hospital; Peter Munk Cardiac Centre, University Health Network; Department of Medicine and Heart and Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, University of Toronto.; Dr McManus is supported by R01HL126911, R01HL137734, R01HL137794, R01HL136660, U54HL143541 from the National Heart, Lung, and Blood Institute and National Center for Complementary and Integrative Health.; Dr Dodson is supported by a Patient Oriented Career Development Award (K23 AG052463) from the National Institute on Aging.
• Keywords: Science & Technology; health services research; Cardiovascular System & Cardiology; DEMENTIA; Cardiac & Cardiovascular Systems; RISK; percutaneous coronary intervention; cognitive impairment; Life Sciences & Biomedicine; myocardial infarction; INTERVENTION
• Research Categories: Health Sciences, Medicine and Surgery

Abstract

Background: Little is known regarding use of cardiac therapies and clinical outcomes among older myocardial infarction (MI) patients with cognitive impairment. Methods and Results: Patients ≥65 years old with MI in the NCDR (National Cardiovascular Data Registry) Chest Pain-MI Registry between January 2015 and December 2016 were categorized by presence and degree of chart-documented cognitive impairment. We evaluated whether cognitive impairment was associated with all-cause in-hospital mortality after adjusting for known prognosticators. Among 43 812 ST-segment-elevation myocardial infarction (STEMI) patients, 3.9% had mild and 2.0% had moderate/severe cognitive impairment; among 90 904 non-ST-segment-elevation myocardial infarction (NSTEMI patients, 5.7% had mild and 2.6% had moderate/severe cognitive impairment. A statistically significant but numerically small difference in the use of primary percutaneous coronary intervention was observed between patients with STEMI with and without cognitive impairment (none, 92.1% versus mild, 92.8% versus moderate/severe, 90.4%; P=0.03); use of fibrinolysis was lower among patients with cognitive impairment (none, 40.9% versus mild, 27.4% versus moderate/severe, 24.2%; P<0.001). Compared with NSTEMI patients without cognitive impairment, rates of angiography, percutaneous coronary intervention, and coronary artery bypass grafting were significantly lower among patients with NSTEMI with mild (41%, 45%, and 70% lower, respectively) and moderate/severe cognitive impairment (71%, 74%, and 93% lower, respectively). After adjustment, compared with no cognitive impairment, presence of moderate/severe (STEMI: odds ratio, 2.2, 95% CI, 1.8-2.7; NSTEMI: odds ratio, 1.7, 95% CI, 1.4-2.0) and mild cognitive impairment (STEMI: OR, 1.3, 95% CI, 1.1-1.5; NSTEMI: odds ratio, 1.3, 95% CI, 1.2-1.5) was associated with higher in-hospital mortality. Conclusions: Patients with NSTEMI with cognitive impairment are substantially less likely to receive invasive cardiac care, while patients with STEMI with cognitive impairment receive similar primary percutaneous coronary intervention but less fibrinolysis. Presence and degree of cognitive impairment was independently associated with increased in-hospital mortality. Approaching clinical decision making for older patients with MI with cognitive impairment requires further study.