Intensive care use and mortality among patients with ST elevation myocardial infarction: retrospective cohort study

Abstract

ObjectiveTo evaluate the effect of intensive care unit (ICU) admission on mortality among patients with ST elevation myocardial infarction (STEMI).DesignRetrospective cohort study.Setting1727 acute care hospitals in the United States.ParticipantsMedicare beneficiaries (aged 65 years or older) admitted with STEMI to either an ICU or a non-ICU unit (general/telemetry ward or intermediate care) between January 2014 and October 2015.Main outcome measure30 day mortality. An instrumental variable analysis was done to account for confounding, using as an instrument the additional distance that a patient with STEMI would need to travel beyond the closest hospital to arrive at a hospital in the top quarter of ICU admission rates for STEMI.ResultsThe analysis included 109 375 patients admitted to hospital with STEMI. Hospitals in the top quarter of ICU admission rates admitted 85% or more of STEMI patients to an ICU. Among patients who received ICU care dependent on their proximity to a hospital in the top quarter of ICU admission rates, ICU admission was associated with lower 30 day mortality than non-ICU admission (absolute decrease 6.1 (95% confidence interval −11.9 to −0.3) percentage points). In a separate analysis among patients with non-STEMI, a group for whom evidence suggests that routine ICU care does not improve outcomes, ICU admission was not associated with differences in mortality (absolute increase 1.3 (−0.9 to 3.4) percentage points).ConclusionsICU care for STEMI is associated with improved mortality among patients who could be treated in an ICU or non-ICU unit. An urgent need exists to identify which patients with STEMI benefit from ICU admission and what about ICU care is beneficial.

Stent as a bridge to surgery or immediate colectomy for malignant right colonic obstruction: propensity-scored, national database study

“…IV analysis can adjust for both measured and unmeasured confounders when an appropriate IV is used. Differential distance was used as an IV, as in a previous study that determined the effect of using the ICU to reduce mortality associated with myocardial infarction. The differential distance was defined as the difference between the distance from a patient's residence to the nearest hospital where colectomies were performed in a year and the distance from a patient's residence to the nearest hospital where colonic stent insertions were performed in the year.…”

Feasibility of management of hemodynamically stable patients with acute myocardial infarction following primary percutaneous coronary intervention in the general ward settings

“…Two previous studies reported no impact of CCU use on clinical outcomes in patients with NSTEMI with low in-hospital mortality (1.3% vs. 1.2% in the CCU and GW groups) and STEMI patients with low APACHE III scores and a low likelihood of complications [15,16]. On the other hand, Valley et al showed that ICU admission was associated with improved survival at 30 days among patients with STEMI with high mortality (14.3% vs. 8.3% in the ICU and GW groups) [14]. This may explain the survival benefit of the ICU in high-risk cohorts, whereas low-risk patients (i.e., patients with low in-hospital mortality) may be managed appropriately in the GW.…”

“…In addition, we examined the length of stay and total hospitalization costs. The total duration of hospitalization was shorter (11 [9][10][11][12][13][14][15] vs. 12 [9][10][11][12][13][14][15][16] days, p<0.001), and total hospitalization cost was lower in the GW group than in the CCU group after PSM (1780000 [1480000-2150000] vs. 1830000 [1560000-2240000] JPY, p<0.001)…”

“…Recent observational studies also showed mixed findings. Valley et al reported that CCU rather than general ward (GW) admission for STEMI, but not NSTEMI, was associated with improved survival at 30 days [14]. Two studies indicated no impact of CCU use on clinical outcomes in patients with NSTEMI or low-risk patients with STEMI when compared to GW use [15,16].…”

A fork in the road after STEMI: Rapid recovery and discharge or cardiac arrest and high mortality

“…In addition, Valley et al identified patients without clear indication for the ICU and demonstrated an absolute mortality reduction of 6% in those patients admitted to the ICU on a discretionary basis. 9 Cardiac arrest is the most feared complication of STEMI, as it is the primary cause of short-term STEMI-associated mortality occurring in 5 À10% of STEMI patients. 3,4 The majority of these cardiac arrests are out-of-hospital.…”