Comparison of Inhospital Mortality and Frequency of Coronary Angiography on Weekend Versus Weekday Admissions in Patients With Non-ST-Segment Elevation Acute Myocardial Infarction.

Patients with myocardial infarction admitted on weekends have been reported to less frequently undergo invasive angiography and experience poorer outcomes. We used the Nationwide Inpatient Sample database (2003 to 2011) to compare differences in all-cause inhospital mortality between patients admitted on a weekend versus weekday for an acute non-ST-segment elevation myocardial infarction (NSTEMI) and to determine if rates and timing of coronary revascularization contributed to this difference. A total of 3,625,271 NSTEMI admissions were identified, of which 909,103 (25.1%) were weekend and 2,716,168 (74.9%) were weekday admissions. Admission on a weekend versus weekday was independently associated with lower rates of coronary angiography (odds ratio [OR] 0.88; 95% confidence interval [CI] 0.89 to 0.90; p <0.001) or utilization of an early invasive strategy (EIS) (OR 0.480; 95% CI 0.47 to 0.48; p <0.001). Unadjusted inhospital mortality was significantly higher for the cohort of patients admitted on weekends (adjusted OR 1.02; 95% CI 1.01 to 1.04; p <0.001). However, this disparity was no longer significant after adjustment for differences in rates of utilization of EIS (OR 1.01; 95% CI 0.99 to 1.03; p = 0.11). In conclusion, this study demonstrates that among patients admitted with a diagnosis of an acute NSTEMI, admission on a weekend was associated with higher inhospital mortality compared with admission on a weekday and that lower rates of utilization of EIS contributed significantly to this disparity.

Agrawal S ，Garg L ，Sharma A ，Mohananey D ，Bhatia N ，Singh A ，Shirani J ，Dixon S ... -  《-》

Early Invasive Versus Initial Conservative Strategies for Women with Non-ST-Elevation Acute Coronary Syndromes: A Nationwide Analysis.

Studies conducted largely in men have shown improved outcomes with an early invasive strategy with non-ST-elevation acute coronary syndrome. In contrast, data have been less conclusive in women, with some trials demonstrating potential harm. This study aims to assess whether an early invasive strategy in women is associated with better outcomes in real-world data. Women admitted with a primary diagnosis of non-ST-elevation myocardial infarction or unstable angina were identified from the National Inpatient Sample years 2012 and 2013. The incidence of in-hospital mortality in women with non-ST-elevation acute coronary syndrome undergoing an early invasive strategy versus an initial conservative strategy was compared using a propensity score-matched analysis. Among 372,080 women with non-ST-elevation acute coronary syndrome, 153,680 (41.3%) were managed with an early invasive strategy and 218,400 (58.7%) were managed with an initial conservative strategy. Propensity score-matched 19,965 women were treated with an early invasive strategy, and 20,009 women were treated with an initial conservative strategy. The risk of in-hospital mortality was lower with an early invasive strategy (2.1% vs 3.8%; odds ratio [OR], 0.55; 95% confidence interval [CI], 0.49-0.62). This benefit was noted in women presenting with non-ST-segment elevation myocardial infarction (OR, 0.52; 95% CI, 0.46-0.58) and was not observed in women with unstable angina (OR, 5.14; 95% CI, 0.47-56.9), Pinteraction = .06. A propensity-adjusted analysis yielded similar results (OR, 0.51; 95% CI, 0.45-0.57). In this large contemporary observational analysis of women with non-ST-elevation acute coronary syndrome, an early invasive strategy was associated with lower in-hospital mortality. This benefit was observed in women presenting with non-ST-elevation myocardial infarction but not with unstable angina. These findings provide evidence supporting the guideline recommendations for an early invasive strategy in women with non-ST-elevation acute coronary syndrome and high-risk features (eg, troponin positive).

Elgendy IY ，Mahmoud AN ，Mansoor H ，Bavry AA ... -  《-》

Use and timing of coronary angiography and associated in-hospital outcomes in Canadian non-ST-segment elevation myocardial infarction patients: insights from the Canadian Global Registry of Acute Coronary Events.

Although an early invasive approach has become standard strategy for the management of non-ST-segment elevation myocardial infarction (NSTEMI), the frequency and timing in Canada is uncertain. We examined the use and timing of coronary angiography, revascularization, and cardiovascular outcomes of NSTEMI patients: (1) admitted on weekdays vs weekends; and (2) stratified according to presentation risk level, in the Canadian Global Registry of Acute Coronary Events (GRACE)/Expanded GRACE (GRACE(2))/Canadian Registry of Acute Coronary Events (CANRACE) population. Of 6711 NSTEMI patients, 1956 (29.1%) were admitted on the weekend. The median (interquartile range) wait time for coronary angiography was 58 (32-106) and 70 (50-112) hours for weekday and weekend patients, respectively (P = 0.32). Compared with lower-intermediate risk, higher-risk patients were less likely to undergo angiography (44.7% vs 69.7% for weekdays and 45.2% vs 69.6% for weekends; both P < 0.0001) and waited longer for angiography (median 71 vs 61 hours; P < 0.0001). Weekend admission was independently associated with higher mortality (adjusted odds ratio [OR], 1.52; 95% confidence interval [CI], 1.15-2.01; P = 0.004), recurrent ischemia (adjusted OR, 1.16; 95% CI, 1.01-1.32; P = 0.03), and heart failure (adjusted OR, 1.28; 95% CI, 1.00-1.63; P = 0.048) but not with reinfarction. Median wait time for angiography in Canadian NSTEMI patients admitted on the weekend was not significantly longer than for those who presented on a weekday. Patients admitted on weekends had higher adjusted mortality and cardiovascular event rates. Higher-risk patients were less likely to undergo angiography and waited longer, with higher observed in-hospital event rates. Systematic, guideline-recommended risk stratification should be considered to ensure that optimal management strategies (eg, timely coronary angiography in higher-risk patients) are matched to level of risk.

Gyenes GT ，Yan AT ，Tan M ，Welsh RC ，Fox KA ，Grondin FR ，Deyoung JP ，Rose BF ，Gallo R ，Kornder JM ，Wong GC ，Goodman SG ，Canadian Global Registry of Acute Coronary Events (GRACE/GRACE(2)) ，Canadian Registry of Acute Coronary Events (CANRACE) Investigators ... -  《-》

Readmission and processes of care across weekend and weekday hospitalisation for acute myocardial infarction, heart failure or stroke: an observational study of the National Readmission Database.

Variation in hospital resource allocations across weekdays and weekends have led to studies of the 'weekend effect' for ST elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (NSTEMI), heart failure (HF) and stroke. However, few studies have explored the 'weekend effect' on unplanned readmission. We aimed to investigate 30-day unplanned readmissions and processes of care across weekend and weekday hospitalisations for STEMI, NSTEMI, HF and stroke. We grouped hospitalisations for STEMI, NSTEMI, HF or stroke into weekday or weekend admissions. Multivariable adjusted ORs for binary outcomes across weekend versus weekday (reference) groups were estimated using logistic regression. We included all non-elective hospitalisations for STEMI, NSTEMI, HF or stroke, which were recorded in the US Nationwide Readmissions Database between 2010 and 2014. The analysis sample included 659 906 hospitalisations for STEMI, 1 420 600 hospitalisations for NSTEMI, 3 027 699 hospitalisations for HF, and 2 574 168 hospitalisations for stroke. The primary outcome was unplanned 30-day readmission. As secondary outcomes, we considered length of stay and the following processes of care: coronary angiography, primary percutaneous coronary intervention, coronary artery bypass graft, thrombolysis, brain scan/imaging, thrombectomy, echocardiography and cardiac resynchronisation therapy/implantable cardioverter-defibrillator. Unplanned 30-day readmission rates were 11.0%, 15.1%, 23.0% and 10.9% for STEMI, NSTEMI, HF and stroke, respectively. Weekend hospitalisations for HF were associated with a statistically significant but modest increase in 30-day readmissions (OR of 1.045, 95% CI 1.033 to 1.058). Weekend hospitalisation for STEMI, NSTEMI or stroke was not associated with increased risk of 30-day readmission. There was no clinically meaningful evidence against the supposition that weekend and weekday hospitalisations have the same 30-day unplanned readmissions. Thirty-day readmission rates were high, especially for HF, which has implications for service provision. Strategies to reduce readmission rates should be explored, regardless of day of hospitalisation.

Martin GP ，Kwok CS ，Van Spall HGC ，Volgman AS ，Michos E ，Parwani P ，Alraies C ，Thamman R ，Kontopantelis E ，Mamas M ... -  《BMJ Open》

Higher in-hospital mortality during weekend admission for acute coronary syndrome: a large-scale cross-sectional Italian study.

Malanchini G ，Stefanini GG ，Malanchini M ，Lombardi F ... -  《-》