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Objectives: Little is known about sexual activity after an AMI and the extent to which physicians discuss this with their patients. We compared sexual activity, predictors of change in activity, and patterns of communication with physicians about sexual activity among men and women following an AMI. Methods: Between 2005-08, the TRIUMPH Study enrolled 4340 AMI patients and surveyed them at baseline, 1, 6, and 12 months. In 9/07, a sexual health module to assess pre- and post-MI sexual activity and communication was added and administered at months 1 and 12; a total of 1184 men and 576 women received the module at their one year follow-up. Multivariable hierarchical models (separate for men and women), within site, were used to predict loss of sexual activity 1 year after an AMI. Loss of sexual activity was defined as less frequent or no sexual activity in those who were sexually active prior to an MI. Item non-response for the sexuality module ranged from 4.4%-5.9%. Findings: Participants were 58.6 ± 11.0 years (males) and 61.0 ± 12.9 years (females) old. Women were less likely than men to be married (40.6% of 574 vs 64.6% of 1182, p Conclusions: Discussion with a physician about sex occurs much less often for women than men. Lack of physician-patient communication about sex prior to hospital discharge after an MI is independently associated with loss of sexual activity at one year.

Background: Recent evidence suggests that LDL levels alone may be an incomplete assessment of cardiovascular risk, given the emerging importance of LDL density. Specifically, an excess of low-density LDL (Pattern B vs. A/B or A) has been shown in primary prevention cohorts to be particularly atherogenic. To date, however, the prevalence of Pattern B profiles among patients presenting with an MI has not been described. Methods: The TRIUMPH registry enrolled acute MI patients from 24 US centers between 4/05 and 12/08. We excluded patients with prior MI or missing LDL levels; leaving 1,975 patients for analysis. Patients were stratified by LDL patterns, using the VAP method, to compare their demographic and clinical characteristics. As a secondary analysis, we examined changes in LDL pattern from baseline in patients newly on statins at 6 months. Results: Pattern B LDL profiles were present in 644 (32.6%) of patients. These patients were younger and more likely to be male, obese, have larger waist circumferences, higher triglycerides, and lower HDL levels ( Table ). Blood pressure, fasting glucose, and Lp-a levels did not differ across groups. Among 311 MI patients started on a statin, their LDL patterns became more atherogenic in 99 (31.8%) and less atherogenic in 43 (13.8%), suggesting little improvement with statins. Of the 113 patients with Pattern B at baseline, 84 (74.3%) patients did not improve, while the remaining 29 (25.7%) changed to a more favorable pattern. Conclusion: Patients with LDL Pattern B were younger and had more risk factors for metabolic syndrome. Statins did not markedly improve particle size patterns over time, suggesting that other approaches may be needed to further modify risk. Patient characteristics and 6-month LDL patterns according to LDL Density Pattern at baseline Patient characteristics and 6 month LDL patterns Variable Pattern A (n=777) Pattern A/B (n=554) Pattern B (n=644) p-value Age (yrs.) 59.9 ± 12.8 58.2 ± 12.1 55.3 ± 10.7 Male 473 (60.9%) 383 (69.1%) 482 (74.8%) Caucasian 475 (61.3%) 378 (68.2%) 495 (77.1%) MI type: STEMI 303 (39.0%) 275 (49.6%) 326 (50.6%) NSTEMI 468 (60.2%) 273 (49.3%) 315 (48.9%) DM 224 (28.8%) 175 (31.6%) 180 (28.0%) 0.359 LDL-C (mg/dL) 94.4 ± 32.2 95.8 ± 31.7 100.0 ± 31.9 0.004 Triglycerides (mg/dL) 132.4 ± 65.2 133.8 ± 60.3 200.1 ± 149.0 HDL (mg/dL) 42.6 ± 11.4 40.9 ± 10.3 36.6 ± 8.1 BMI (kg/m 2 ) 28.5 ± 6.1 29.9 ± 6.7 30.8 ± 6.6 < 0.001 Waist circumference (in) 37.6 ± 5.6 38.9 ± 5.7 39.3 ± 5.3 < 0.001 hsCRP (mg/L) 4.2 ± 6.0 3.7 ± 4.6 3.2 ± 4.0 Home statin use (%) 191(24.6%) 165(29.8%) 218(33.9%) Initial systolic BP (mmHg) 141.9 ± 31.7 143.1 ± 27.3 144.9 ± 29.1 0.171

Background: Little data are available regarding differences in prognosis and health status between new-onset and prior atrial fibrillation (AF) among patients with acute myocardial infarction (AMI). Methods: The TRIUMPH study enrolled 4340 AMI patients who received longitudinal follow-up including SF-12 health status assessments through 1 year post-AMI. We compared 1-year mortality, rehospitalization, and functional status according to AF type (none, prior, new) after adjusting for differences in baseline characteristics. Results: A total of 212 AMI patients (4.9%) had prior AF and 254 (5.9%) had new-onset AF. Compared with no AF, new AF was associated with older age, male sex, first MI, worse baseline physical function, home atrioventricular nodal blocker use, and worse ventricular function (c-index 0.77). Rates of 1-year mortality were 6.2%, 14.5%, and 13.0%, and 1-year rehospitalization rates were 29.1%, 44.2%, and 36.8% for no, prior, and new AF, respectively. After multivariable adjustment, neither prior nor new AF was associated with increased 1-year mortality, and only prior AF was associated with increased risk of 1-year rehospitalization (Figure). After adjusting for baseline SF-12 physical function scores, patients with prior AF had lower 1-year scores than those with no AF (40.6 vs. 43.7, p Conclusion: New-onset AF during AMI is associated with a number of comorbidities but, unlike prior AF, is not associated with adverse outcomes. These results raise the question of whether AF is itself a cause of or simply a marker of comorbidities leading to downstream adverse outcomes after AMI.

Background: Recognizing depression in acute myocardial infarction (AMI) offers an opportunity to treat this burdensome comorbidity, and could improve the risk stratification of AMI patients. Whether depression recognition is associated with health status after AMI is unknown. Methods: In the 24-center prospective TRIUMPH study, 4062 patients completed the Patient Health Questionnaire-9 (PHQ-9) during their index AMI admission and the Seattle Angina Questionnaire (SAQ) for quality of life (QOL) and angina frequency during the index admission and at 1-year. Patients were defined as depressed based on a PHQ-9 score ≥10, and depression was defined as recognized if the treating team documented any of the following in the patients' chart: depression diagnosis at discharge; anti-depressant medications administered at discharge; or referral for counseling. We examined the association between depression recognition and impaired quality of life (SAQ QOL score Results: Of 4062 patients, 3303 (81.3%) were not depressed, 528 (13.0%) had unrecognized depression, and 231 (5.7%) had recognized depression. Patients with unrecognized depression were just as likely to have increased risk of 1-year adverse QOL and angina, as compared to patients with recognized depression. (Table) Conclusion: Depression in AMI is a comorbidity that is frequently missed in routine care. Regardless of being recognized, however, depression is associated with adverse 1-year AMI-specific health status. Although depression recognition has the potential to identify patients at risk of persistent angina and poorer QOL that might benefit from more aggressive treatment of their coronary disease, recognition in itself will not be sufficient to optimize their outcomes. The Association Between Depression Recognition Groups and 1-Year Impaired Quality of Life/Angina 1-Year AMI-Specific Health Status Unadjusted Adjusted * N (%) RR (95% CI) P-Value RR (95% CI) P-Value Impaired SAQ QOL Non Depressed 369 (17.6%) Reference Reference Recognized Depression 51 (38.1%) 2.31 (1.81-2.93) 1.70 (1.31-2.20) Unrecognized Depression 103 (34.4%) 1.97 (1.64-2.36) 1.54 (1.32-1.80) Angina Non Depressed 436 (20.6%) Reference Reference Recognized Depression 53 (39.3%) 1.98 (1.57-2.49) 1.51 (1.18-1.95) 0.046 Unrecognized Depression 97 (32.3%) 1.54 (1.31-1.80) 1.32 (1.14-1.53) 0.074 Abbreviations: AMI, acute myocardial infarction; SAQ, Seattle Angina Questionnaire; QOL, quality of life. * Covariates in the multivariable model included: age, sex, race, education, marital status, insurance status, Killip class, left ventricular systolic function, chronic heart failure, diabetes mellitus, hypercholesterolemia, hypertension, prior PCI, prior CABG, prior MI, prior CVA/TIA, current smoking, BMI, family history of CAD, ST-elevation AMI, ischemic symptoms on arrival, cancer, chronic lung disease, renal failure, and peripheral arterial disease.

Considerable attention has been devoted to the effect of social support on patient outcomes after acute myocardial infarction (AMI). However, little is known about the relation between patient living arrangements and outcomes. Thus, we used data from PREMIER, a registry of patients hospitalized with AMI at 19 United States centers from 2003 through 2004, to assess the association of living alone with outcomes after AMI. Outcome measurements included 4-year mortality, 1-year readmission, and 1-year health status using the Seattle Angina Questionnaire (SAQ) and the Short Form-12 Physical Health Component scales. Patients who lived alone had higher crude 4-year mortality (21.8% vs 14.5%, p0.001) but comparable rates of 1-year readmission (41.6% vs 38.3%, p = 0.79). Living alone was associated with lower unadjusted quality of life (mean SAQ -2.40, 95% confidence interval [CI] -4.44 to -0.35, p = 0.02) but had no impact on Short Form-12 Physical Health Component (-0.45, 95% CI -1.65 to 0.76, p = 0.47) compared to patients who did not live alone. After multivariable adjustment, patients who lived alone had a comparable risk of mortality (hazard ratio 1.35, 95% CI 0.94 to 1.93) and readmission (hazard ratio 0.99, 95% CI 0.76 to 1.28) as patients who lived with others. Mean quality-of-life scores remained lower in patients who lived alone (SAQ -2.91, 95% CI -5.56 to -0.26, p = 0.03). In conclusion, living alone may be associated with poorer angina-related quality of life 1 year after MI but is not associated with mortality, readmission, or other health status measurements after adjusting for other patient and treatment characteristics.

Although fast food is affordable and convenient, it is also high in calories, saturated fat, and sodium. The frequency of fast food intake at the time of and after acute myocardial infarction (AMI) is modifiable. However, patterns of fast food intake and characteristics associated with its consumption in patients with AMI are unknown. The aim of this study was to study fast food consumption at the time of AMI and 6 months later in 2,481 patients from the prospective, 24-center Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status (TRIUMPH) study of patients with AMI. Fast food intake was categorized as frequent (weekly or more often) or infrequent (less than weekly). Multivariate log-binomial regression was used to identify patient characteristics associated with frequent fast food intake 6 months after AMI. At baseline, 884 patients (36%) reported frequent fast food intake, which decreased to 503 (20%) 6 months after discharge (p0.001). Male gender, white race, lack of college education, current employment, and dyslipidemia were independently associated with frequent fast food intake 6 months after AMI. In contrast, older patients and those who underwent coronary bypass surgery were less likely to eat fast food frequently. Documentation of discharge dietary counseling was not associated with 6-month fast food intake. In conclusion, fast food consumption by patients with AMI decreased 6 months after the index hospitalization, but certain populations, including younger patients, men, those currently working, and less educated patients were more likely to consume fast food, at least weekly, during follow-up. Novel interventions that go beyond traditional dietary counseling may be needed to address continued fast food consumption after AMI in these patients.

Residual angina is known to be strongly associated with health-related quality of life (HRQL) in patients with chronic coronary artery disease. As the age of myocardial infarction (MI) survivors increases, better insights into the relationship between angina frequency and HRQL in older as compared to younger patients are needed to efficiently target medical resources.We evaluated angina frequency and HRQL at 1 and 6 months after MI in 1,795 post-MI survivors using the Seattle Angina Questionnaire (SAQ). We compared changes in HRQL between older (age ≥70 years, n = 464) and younger (age70 years, n = 1,331) patients as a function of change in SAQ angina frequency scores using hierarchical linear modeling within site.After adjusting for baseline HRQL and 26 other covariates, older patients with similar or improved angina control at 6 months had significantly greater improvements in HRQL than younger patients (difference in SAQ quality-of-life scale 8.77 points [CI 4.00-13.54, P = .0003] and 2.56 points [CI 0.66-4.47, P = .0084], respectively). However, older patients with increased angina experienced similar declines in HRQL as compared to younger patients.In stable patients with coronary artery disease after a recent MI, changes in angina control were correlated with HRQL in both older and younger patients. However, improved angina control was associated with greater HRQL improvements in older than in younger adults, underscoring the importance of aggressive angina control in older patients.

Background While the process of informed consent is designed to transfer knowledge of the risks and benefits of treatment and to engage patients in shared medical decision-making, this is poorly done in routine clinical care. We assessed the impact of a novel informed consent form for percutaneous coronary intervention (PCI) that is more simply written, includes images of the procedure, and embeds individualized estimates of outcomes on multiple domains of successful informed consent and shared decision-making. Methods We interviewed 590 PCI patients receiving traditional consent documents and 527 patients receiving novel ePRISM consents at 9 US centers and compared patients’ perceptions, knowledge transfer, and engagement in medical decision-making. Heterogeneity across sites was assessed and adjusted for using hierarchical models. Results Site-adjusted analyses revealed more frequent review (72% for ePRISM vs 45% for original consents) and better understanding of the ePRISM consents (ORs = 1.8-3.0, depending upon the outcome) with marked heterogeneity across sites (median relative difference [MRD] in the ORs of ePRISM’s effect =2-3.2). Patients receiving ePRISM consents better understood the purposes and risks of the procedure (ORs = 1.9-3.9, MRDs = 1.1-6.2), engaged more in shared decision-making (proportional OR = 2.1 [95% CI = 1.02-4.4], MRD = 2.2) and discussed stent options with their physicians (58% vs. 31%; site-adjusted odds ratio = 2.7 [95% CI = 1.2, 6.3], MRD = 2.6) more often. Conclusions A personalized consent document improved the process of informed consent and shared decision-making. Marked heterogeneity across hospitals highlights that consent documents are but one aspect of engaging patients in understanding and participating in treatment.

Complementary and alternative medicine (CAM) use is common in patients with cardiovascular disease. While CAM has not been linked to lower cardiovascular morbidity or mortality, health status benefits could justify CAM use. Patients with MI from 24 US sites were assessed for CAM use and health

Background Elevated blood glucose is associated with higher mortality in patients with acute myocardial infarction (AMI). Although clinical guidelines recommend targeted glucose control in this group, clinical trials have yielded inconclusive results. Our objective was to understand how this lack of evidence impacts the management of severe hyperglycemia in routine practice. Methods We examined insulin use among 4,297 AMI admissions with a mean hospitalization blood glucose of ≥200 mg/dL across 55 US hospitals from 2000 to 2008. Temporal trends and interhospital variation in 2 measures of insulin use during hospitalization—any (subcutaneous, intravenous [IV], short acting, long acting) and IV insulin—were examined using hierarchical Poisson regression models. Results Of the 4,297 admissions, 2,618 (61%) received any insulin and 538 (13%) received IV insulin. After multivariable adjustment, a slight increase in insulin use was observed per admission year (relative risk [RR] 1.06, 95% CI 1.01-1.11). There was a modest (albeit nonsignificant) increase in IV insulin use seen before May 2004 (RR 1.18, 95% CI 0.96-1.47), with no significant change thereafter (RR 0.99, 95% CI 0.92-1.09). Marked variability in insulin use was observed across hospitals (median rate ratio 1.5 [any insulin] and 1.8 [IV insulin]), which did not change over time. Conclusions Insulin use among patients with AMI and severe hyperglycemia has remained low over the past decade, with substantial and persistent interhospital variation. These observations reflect marked clinical uncertainty with regard to glucose management in AMI, underscoring the imperative for a definitive clinical trial in this field.

Background Acute kidney injury (AKI) is common in patients with acute myocardial infarction (AMI) and is associated with permanent renal impairment and death. Although guidelines increasingly emphasize AKI prevention, whether increased awareness has translated into reduced AKI rates is unclear. Methods Among 33 249 consecutive hospitalizations in 31 532 unselected patients with AMI across 56 US centers from Cerner Corporation's HealthFacts database, we examined the temporal trends in AKI incidence from 2000 to 2008. Acute kidney injury was defined as an absolute increase in creatinine level of at least 0.3 mg/dL or a relative increase of at least 50% during hospitalization. Results From 2000 to 2008, the mean age of patients increased (from 66.5 to 68.6 years), as did the known AKI risk factors, including chronic kidney disease, cardiogenic shock, diabetes mellitus, heart failure, coronary angiography, and percutaneous coronary intervention. Despite this, AKI incidence declined from 26.6% in 2000 to 19.7% in 2008 (P Conclusions In a large national study, AKI incidence in patients hospitalized with AMI declined significantly from 2000 to 2008 despite the aging population and rising prevalence of AKI risk factors. These findings may reflect increased clinician awareness, better risk stratification, or greater use of AKI prevention efforts during this time period.

Clinical practice guidelines recommend maintaining serum potassium levels between 4.0 and 5.0 mEq/L in patients with acute myocardial infarction (AMI). These guidelines are based on small studies that associated low potassium levels with ventricular arrhythmias in the pre-β-blocker and prereperfusion era. Current studies examining the relationship between potassium levels and mortality in AMI patients are lacking.To determine the relationship between serum potassium levels and in-hospital mortality in AMI patients in the era of β-blocker and reperfusion therapy.Retrospective cohort study using the Cerner Health Facts database, which included 38,689 patients with biomarker-confirmed AMI, admitted to 67 US hospitals between January 1, 2000, and December 31, 2008. All patients had in-hospital serum potassium measurements and were categorized by mean postadmission serum potassium level (3.0, 3.0-3.5, 3.5-4.0, 4.0-4.5, 4.5-5.0, 5.0-5.5, and ≥5.5 mEq/L). Hierarchical logistic regression was used to determine the association between potassium levels and outcomes after adjusting for patient- and hospital-level factors.All-cause in-hospital mortality and the composite of ventricular fibrillation or cardiac arrest.There was a U-shaped relationship between mean postadmission serum potassium level and in-hospital mortality that persisted after multivariable adjustment. Compared with the reference group of 3.5 to less than 4.0 mEq/L (mortality rate, 4.8%; 95% CI, 4.4%-5.2%), mortality was comparable for mean postadmission potassium of 4.0 to less than 4.5 mEq/L (5.0%; 95% CI, 4.7%-5.3%), multivariable-adjusted odds ratio (OR), 1.19 (95% CI, 1.04-1.36). Mortality was twice as great for potassium of 4.5 to less than 5.0 mEq/L (10.0%; 95% CI, 9.1%-10.9%; multivariable-adjusted OR, 1.99; 95% CI, 1.68-2.36), and even greater for higher potassium strata. Similarly, mortality rates were higher for potassium levels of less than 3.5 mEq/L. In contrast, rates of ventricular fibrillation or cardiac arrest were higher only among patients with potassium levels of less than 3.0 mEq/L and at levels of 5.0 mEq/L or greater.Among inpatients with AMI, the lowest mortality was observed in those with postadmission serum potassium levels between 3.5 and4.5 mEq/L compared with those who had higher or lower potassium levels.

The use of drug-eluting stents necessitates prolonged dual antiplatelet therapy after PCI, which increases patents' risk for bleeding complications. However, there are no models to predict long-term bleeding events in patients undergoing PCI. A total of 3,128 PCI procedures in the multicenter PRISM