December 10, 2019
By Will Boggs MD
NEW YORK (Reuters Health) - A new tool accurately predicts six-month mortality for older adults hospitalized with acute myocardial infarction (AMI), researchers report.
"Our risk calculator can be used as older patients are preparing to be discharged from the hospital for heart attack," said Dr. Sarwat I. Chaudhry of Yale School of Medicine, in New Haven, Connecticut.
By incorporating information about medical history, clinical status, and functional impairments, we can improve our ability to understand who is at low mortality risk and who has higher risk," she told Reuters Health by email. "Patients at high risk may warrant closer follow-up, more intensive medications for secondary prevention, or tailored guidance for cardiac rehabilitation."
While advanced age is a key contributor to post-AMI mortality, there is considerable heterogeneity among older adults, and some have exceptional outcomes. Current AMI mortality risk models, derived from younger cohorts, may have limited relevance in older adults.
Dr. Chaudhry and colleagues developed and validated their model for use in older adults (75 years and older) at the time of discharge from hospitalization for AMI. They used data from more than 3,000 participants in the SILVER-AMI observational study, 266 of whom had died by 180 days after discharge.
Among the 15 factors significantly associated with six-month mortality in a multivariable model, four of which were not in prior models, the strongest factors for increased odds of mortality included more advanced age, greater length of stay, self-reported worsening health status, and unintentional weight loss.
Meanwhile, receipt of in-hospital coronary-artery-bypass graft was most strongly associated with lower odds of mortality, the researchers report in Annals of Internal Medicine.
The resulting SILVER-AMI model discriminated between deceased individuals and survivors with 82% accuracy in the derivation cohort and 84% accuracy in the validation cohort, both of which were significantly better than the 76% accuracy of the GRACE mortality-risk score.
"Our study demonstrated the important contribution of functional impairments in driving risk of mortality after heart attack," Dr. Chaudhry said. "An important question is whether interventions to remediate these impairments can make a difference."
Dr. Kirsten Bibbins-Domingo of the University of California, San Francisco, who co-authored an accompanying editorial, told Reuters Health by email, "The real questions in clinical practice are these: How does knowing that a patient is at higher risk change what we do for that patient? What can we do to help assure that these high-risk patients have the best possible outcome after a heart attack? These are the questions that still need to be answered if we are to improve health for our patients."
"Physicians should be aware that older adults may not be well served by our standard approaches to assessing risk after a heart attack," she said. "Getting a few more pieces of information about older adults may help us to better identify those older adults we need to support better after a heart attack for them to achieve the best possible outcomes."
The researchers used the SILVER-AMI model to develop a web-based calculator of six-month mortality after discharge, which is available at www.silverscore.org.
SOURCE: https://bit.ly/2t4gbVk Annals of Internal Medicine, online December 10, 2019.
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