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For the Sickest Heart Attack Patients, Outlook is Poorest Within 60 Days After Discharge

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For the Sickest Heart Attack Patients, Outlook is Poorest Within 60 Days After Discharge

Feb 17, 2016

Medical advances have improved outcomes for heart attack patients, even for the sickest patients who undergo cardiogenic shock, a condition where the heart can’t pump enough blood to meet the body’s needs. Yet a new study published in the Journal of the American College of Cardiology reveals that over half of all heart attack patients either die or are rehospitalized within one year after being discharged. Among those who experienced cardiogenic shock the outlook is particularly poor within the first 60 days after initial treatment, with 34 percent of these patients either dying or returning to the hospital within that period. Study author Rashmee Shah, MD, assistant professor of cardiology at the University of Utah School of Medicine, talks about what these findings mean, and what needs to happen next.

Episode Transcript

Interviewer: Heart attack patients are not all the same and that's important to know. We'll talk about that next on The Scope.

Announcer: Examining the latest research and telling you about the latest breakthroughs. The Science and Research Show is on The Scope.

Interviewer: I'm talking to Dr. Rashmee Shah, Assistant Professor of Cardiovascular Medicine at the University of Utah. What did you find?

Dr. Shah: We looked at heart attack patients who had a specific complication called cardiogenic shock. Cardiogenic shock occurs in patients who have very big heart attacks, and the heart muscle becomes so weak that it can't pump blood to the rest of the body. These are the sickest of the heart attack patients. In the last decade, we've gotten a lot better at treating heart attacks using stents, interventions and stents, to open the blocked arteries.

A lot of these patients are now surviving the hospitalization. That means they get hospitalized, get treated for their heart attack and then make it out of the hospital. Since that's happening more frequently, we need to know what happens to these patients after they leave the hospital. Are they going home and resuming their usual life? Or are they disabled and still sick like they were when they were in the hospital?

Interviewer: What did you find amongst these patients? How are they doing when they leave the hospital?

Dr. Shah: In a publication that preceded this one, we found that two-thirds of patients like this will survive the hospitalization and get discharged. We took it up from there. So among these patients who survived the hospitalization, we found that, surprisingly, within a year over half . . . almost 60% of these patients will either die or be rehospitalized.

Interviewer: Oh gosh.

Dr. Shah: Yeah, so not great. The interesting finding was that this risk is really clustered in the immediate, post-hospital period. So within the first 60 days after discharge, this is when these cardiogenic shock patients are the most vulnerable to have an adverse outcome, meaning death or hospitalization.

One interesting finding was that actually all heart attack patients, over 50% die or were rehospitalized within a year. That's all heart attack patients. That was a bit surprising and I think we'll have to delve a little deeper to see what could be driving that and what we can do about it.

Interviewer: That's not common knowledge yet, right, until this paper?

Dr. Shah: Correct.

Interviewer: Do you have any ideas of what's happening within this 60-day period that might put these patients at risk for dying?

Dr. Shah: Yeah. So there are some theories out there about the post-hospital, discharge period. One interesting idea is there's so-called post-hospital syndrome, especially among critically ill patients. Patients with cardiogenic shock are often in intensive care units, they're very sick. What happens is they become debilitated because they don't have adequate nutrition during that period, they're lying in bed, their days and nights gets reversed.

Everything about their daily life has changed and they become really weak. Critically ill patients, not just limited to cardiogenic shock patients, when they get home or when they get discharged to wherever they go, they're still very debilitated. This post-hospital syndrome is one possibility and efforts related to rehabilitation, physical therapy, occupational therapy could address that issue.

The other issue is that cardiogenic shock is a condition in which there's not enough blood getting to other organs of the body so they might have renal failure. They might have had less blood going to their brain, some kind of neurological effect. All those things coming together make patients very debilitated so it could also be a multi-organ issue.

Interviewer: Among patients who have heart attacks, what percentage is represented by this population?

Dr. Shah: The dataset we used is called the Action Registry and it's from the American College of Cardiology. This is the largest registry of heart attack patients in the US. In this population, 5% of heart attack patients will have cardiogenic shock.

Interviewer: You would think that if they have those serious problems, that they would be under a close watch once they're discharged. Do we know if that's happening?

Dr. Shah: Yeah. There are guidelines that encourage one-week follow-up for patients after a heart attack. That happens fairly consistently and it's something we work on aggressively here at the University of Utah. Often, the patients . . . there are standard therapies following heart attacks and these patients might not be able to get some of those therapies because, for example, their kidneys aren't working as well so they can't have the drug that can sort of protect the heart. They could have a follow-up, but that doesn't necessarily mean they eligible or able to get those evidence-based therapies to help the heart heal.

Interviewer: What are the next steps? What do you think this information is telling you about what can be done or what should be done?

Dr. Shah: I think there are many things we can do from here. A couple of things I'm interested in are focusing on the so-called patient recorded outcomes. We measure these very quantitative metrics, "Did the patient die? Did they get hospitalized?" But there's much more to patient wellbeing than just that. We want to know, "Are they able to function? Do they feel like they're short of breath every day?" those sorts of symptoms.

We can only get that by asking the patients and asking every patient, every time. Especially in this population, it'll be interesting to know what their daily life is like because it could be very different than what these somewhat simple metrics imply. I think that's a really important part there for subsequent research.

The other issue I think is important is, "Can we find a way that, while these patients are in the hospital, that we could proactively identify them before they leave the hospital?" That's really useful information for planning subsequent treatments or helping the patients and families understand what to expect when they leave the hospital.

Announcer: Interesting, informative, and all in the name of better health. This is The Scope Health Sciences Radio.