Acute Myocardial Infarction in Severe Mental Illness: Prevalence, Clinical Outcomes, and Process of Care in U.S. Hospitalizations

Abstract

Background: Severe mental illness (SMI) is associated with increased cardiovascular mortality. We sought to examine the prevalence, clinical outcomes and management strategy of patients with SMI presenting with acute myocardial infarction (AMI). Methods: All AMI hospitalizations from the National Inpatient Sample were included, stratified by mental health status in to 5 groups: no-SMI, Schizophrenia, 'Other non-organic psychoses' (ONOP), Bipolar Disorder and Major Depression. Regression analyses were performed to assess the association (adjusted odds ratios, p≤0.001 for all outcomes) between SMI subtypes and clinical outcomes. Results: Out of 6,968,777 AMI hospitalizations between 2004 and 2014, 439,544 (6.5%) had an SMI diagnosis. Although patients with Schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared to those without SMI, only Schizophrenia patients were at increased odds of mortality (1.10[1.04,1.16]), while ONOP were the only group at increased odds of stroke (1.53[1.42,1.65]) following multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared to those without SMI (1.11[1.04,1.17]). All SMI subtypes were less likely to receive coronary angiography and PCI, with the Schizophrenia group being at least odds of either procedure (0.46[0.45,0.48] and 0.57[0.55,0.59], respectively). Conclusion: Schizophrenia and 'other non-organic psychoses' are the only SMI subtypes associated with adverse clinical outcomes after AMI. However, all patients with SMI were less likely to receive invasive management for AMI, with women and schizophrenia diagnosis being the strongest predictors of conservative management. A multidisciplinary approach between psychiatrists and cardiologists could improve outcomes of this high-risk population.

The Challenge of Myocardial Infarction in Patients With Mental Illness

“…These rates were also lower among women across all study groups. 4 These findings align with previously published work from the NIS, which showed a persistent gap in revascularization in patients with SMI (particularly schizophrenia) despite the increasing use of percutaneous revascularization over time. 7 authors to study an often-overlooked subgroup of patients who are rarely recruited into clinical trials.…”

“…[5][6][7] Most studies have investigated SMI subtypes of schizophrenia and bipolar disorder; however, the current study by Mohamed et al expanded on the previous literature by including additional diagnoses (especially major depression) within SMI and further stratifying according to sex. 4 Significantly, the highest rates of inhospital mortality were observed in men and women with schizophrenia. This troubling finding concurs with multiple previous studies in various cohorts, including the NIS.…”

“…In this issue of the Canadian Journal of Cardiology, Mohamed et al 4 observe that patients with SMI in the United States are at increased risk of adverse clinical outcomes after acute myocardial infarction (AMI). The study involved a retrospective observational analysis of the National Inpatient Sample (NIS) database to extract data on patients who were hospitalized with the discharge diagnosis of AMI, including ST-elevation myocardial infarction and non-ST elevation myocardial infarction, between 2004 and 2014.…”

“…Notably, Mohamed et al describe an increase in the prevalence of SMI among the AMI population over the period, primarily because of an increase in major depression and bipolar disorder. 4 The increase in coding of major depression might reflect an increasing population prevalence, a change in its recognition over time, or might be related to more nuanced billing. Alternatively, previous studies that used data from the NIS from 2003 to 2012 showed that the prevalence of ST-elevation myocardial infarction has decreased in patients without mental illness but remained stable in those with SMI and depression.…”

The effects of mental health on myocardial infarction

“…In addition to that, pre-existing mental health affects post MI recovery as these patients are less likely to receive interventions. In the United States between 2004 and 2014 Mohamed et al 4 found that in 6,968,777 acute myocardial infarction hospitalisations, 439,544 patients (6.5%) had a severe mental illness diagnosis. The rates of reported depression increased throughout this period with 3.4% reporting depression in 2004 to 8.1% in 2014.…”