Perhaps 40% of hospitalized patients with type 2 myocardial infarction (MI) are not evaluated by a cardiologist at the same admission, suggests a study based on experience over several years at a major medical center.
Such patients may be short-changed on the number and kind of tests they undergo, their discharge prescriptions, and whether they are scheduled for a postdischarge cardiology follow-up, results further show.
Even with limitations, the study, based on charts and diagnostic codes, raises questions about how clinicians manage and how hospital processes serve patients who receive a diagnosis of type 2 MI. Type 2 MI can be triggered when myocardial oxygen demand outstrips supply, and often occurs secondary to acute noncardiac conditions, such as sepsis and pneumonia.
"These patients have a high risk of recurrent cardiovascular events, and I think we should probably be doing more as cardiologists to evaluate them, and evaluate their risk factors to see what we can modify in either the inpatient or outpatient setting," Cian P. McCarthy, MD, Massachusetts General Hospital, Boston, told theheart.org | Medscape Cardiology.
"These data really highlight the gap in that care," he said. "People are unsure how involved the cardiologist should be, what medications to put them on, what testing to perform. And I think that ultimately comes down to a lack of good data in the form of randomized controlled trials to truly define what treatments we should be giving these patients."
McCarthy is lead author on the analysis published November 9 in Circulation: Cardiovascular Quality and Outcomes and presented during the American Heart Association Scientific Sessions 2020 virtual meeting.
Of 359 patients seen with type 2 MI over a recent 8 months at his center, 57.7% were evaluated by a cardiologist during the admission. Of these, 33.4% received a cardiology consultation and 24.2% were admitted to a cardiology service, the group reports.
Those patients were more likely to undergo echocardiography and stress testing, and "were more likely to be discharged on a statin or a beta blocker" and be scheduled for a postdischarge cardiology follow-up visit, McCarthy said
Such follow-up "is super important, and you know, it wasn't terrific in the cardiologist-treated group, and it was worse in the non-cardiologist-treated groups," said L. Kristin Newby, MD, MHS, Duke University School of Medicine, Durham, North Carolina, commenting on the findings for theheart.org | Medscape Cardiology. "And whether it's type 1 or type 2 MI, they should have their ejection fraction assessed, usually by echocardiography."
About such measures, Newby said, "I think we could probably do a better job right now, even in type 1 MI, when we don't know for sure whether they should have the full guidelines-recommended therapy for acute coronary syndrome."
The current analysis "brings out probably all the issues that we have applying the universal definition of MI in practice with regard to type 2 MI, which is really a very broad group of diagnoses," she said.
Conditions that can promote the culprit oxygen demand–supply mismatch can include sepsis, pneumonia, anemia, hypoxia, hypertension, and bleeding, along with cardiac issues such as atrial fibrillation.
So patients with type 2 MI tend to be "a broadly heterogeneous group," and it helps to consider that when trying to arrive at a diagnosis, Newby said. It also means that they may well not be seen as primarily cardiac patients, perhaps making cardiologist involvement less likely.
"I think that's definitely a contributing factor," McCarthy agreed. "These patients could be very sick with sepsis or pneumonia, and the focus is predominantly on treating whatever that problem is, because it's causing the demand infarct."
The cardiologist-evaluated patients were more likely to have:
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hyperlipidemia, 67.1% vs 52.0% (P = .005)
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known coronary disease, 58.9% vs 38.8% (P < .001)
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previous MI, 27.1% vs 14.5% (P = .006)
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heart failure, 56.5% vs 44.1% (P = .03)
"I think there are some disparities in care," Newby said, but some of the differences in the current study may be related to their features at presentation. The patients with type 2 MI seem to be "the ones you might think would get triaged to a cardiologist, as opposed to admitted to an internist or another medical service. That in itself may explain some of the differences that they saw in use of drugs and procedures. But I don't think it explains it all."
Those evaluated by cardiologists were also more likely to:
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undergo stress testing, 13.5% vs 3.3% (P = .002)
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have transthoracic echocardiography, 80.2% vs 50.7% (P < .001)
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be sent to coronary angiography, 21.3% vs 0.0% (P < .001)
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be discharged on a statin (74.5% vs 64.5%, P = .04) or beta blocker (72.0% vs 55.9%, P = .002)
Whether cardiologists added to the number of tests the patients underwent or, rather, were more likely to evaluate those who had undergone such testing "was something that we couldn't definitively tease out from the charts, one way or another," McCarthy acknowledged.
"So all we can say is that those evaluated by cardiologists had more testing, and that association persisted even after adjustment for their baseline risk factors," he said.
"Both are probably true," Newby observed. "Cardiologists are into using more tests. But it may also be that who gets referred to a cardiologist drives the need for those tests."
Among the 90% of patients who survived to discharge, 38% had an outpatient cardiology follow-up visit within 6 months, at a median of 39 days. Of those who received a cardiologist evaluation, 53% had cardiology follow-up, compared with 19% of the other patients (P < .001).
"We lack prospective testing of strategies for managing type 2 MI," Newby observed. They can be difficult to design because "usually we call them type 2 only after figuring out they don't have atherosclerotic coronary disease. So it's kind of a conundrum."
Studies like the current one are hypothesis-generating, she said, "but are probably not how we're going to get answers. Whether it's from prospective registries or we develop hypotheses about treatment and test them in defined type 2 MI populations, ultimately I think that's what we're going to have to do."
McCarthy had no conflicts. Disclosures for the other authors are in the report. Newby has previously disclosed consulting fees from or serving on an advisory board for Ortho Clinical Diagnostics, Roche Diagnostics, and Metanomics.
Circ Cardiovasc Qual Outcomes. November 9, 2020. Full text
American Heart Association (AHA) Scientific Sessions 2020: Abstract P713.
Follow Steve Stiles on Twitter: @SteveStiles2. For more from theheart.org | Medscape Cardiology, follow us on Twitter and Facebook.
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