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. 2020 Jan 7;172(1):12-21.
doi: 10.7326/M19-0974. Epub 2019 Dec 10.

Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study

John A Dodson  1 , Alexandra M Hajduk  2 , Mary Geda  2 , Harlan M Krumholz  3 , Terrence E Murphy  2 , Sui Tsang  2 , Mary E Tinetti  2 , Michael G Nanna  4 , Richard McNamara  5 , Thomas M Gill  2 , Sarwat I Chaudhry  2
Affiliations

Predicting 6-Month Mortality for Older Adults Hospitalized With Acute Myocardial Infarction: A Cohort Study

John A Dodson et al. Ann Intern Med. .

Abstract

Background: Older adults with acute myocardial infarction (AMI) have higher prevalence of functional impairments, including deficits in cognition, strength, and sensory domains, than their younger counterparts.

Objective: To develop and evaluate the prognostic utility of a risk model for 6-month post-AMI mortality in older adults that incorporates information about functional impairments.

Design: Prospective cohort study. (ClinicalTrials.gov: NCT01755052).

Setting: 94 hospitals throughout the United States.

Participants: 3006 persons aged 75 years or older who were hospitalized with AMI and discharged alive.

Measurements: Functional impairments were assessed during hospitalization via direct measurement (cognition, mobility, muscle strength) or self-report (vision, hearing). Clinical variables associated with mortality in prior risk models were ascertained by chart review. Seventy-two candidate variables were selected for inclusion, and backward selection and Bayesian model averaging were used to derive (n = 2004 participants) and validate (n = 1002 participants) a model for 6-month mortality.

Results: Participants' mean age was 81.5 years, 44.4% were women, and 10.5% were nonwhite. There were 266 deaths (8.8%) within 6 months. The final risk model included 15 variables, 4 of which were not included in prior risk models: hearing impairment, mobility impairment, weight loss, and lower patient-reported health status. The model was well calibrated (Hosmer-Lemeshow P > 0.05) and showed good discrimination (area under the curve for the validation cohort = 0.84). Adding functional impairments significantly improved model performance, as evidenced by category-free net reclassification improvement indices of 0.21 (P = 0.008) for hearing impairment and 0.26 (P < 0.001) for mobility impairment.

Limitation: The model was not externally validated.

Conclusion: A newly developed model for 6-month post-AMI mortality in older adults was well calibrated and had good discriminatory ability. This model may be useful in decision making at hospital discharge.

Primary funding source: National Heart, Lung, and Blood Institute of the National Institutes of Health.

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Conflict of interest statement

Disclosures: Dr. Krumholz reports personal fees from UnitedHealth, IBM Watson Health, Element Science, Aetna, Arnold & Porter, Ben C. Martin Law Firm, Facebook, and the National Center for Cardiovascular Diseases, Beijing; ownership (with spouse) of Hugo; contracts from the Centers for Medicare & Medicaid Services; and grants from Medtronic, the U.S. Food and Drug Administration, Johnson & Johnson, and the Shenzhen Center for Health Information outside the submitted work. Dr. Chaudhry reports personal fees from the CVS Caremark Clinical Program for the state of Connecticut outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-0974.

Reproducible Research Statement: Study protocol: See Supplement 2 (available at Annals.org). Statistical code and data set: Available from Dr. Chaudhry (e-mail, Sarwat.chaudhry@yale.edu).

Disclaimer: The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Figures

Figure 1.
Figure 1.
Receiver-operating characteristic curves for the SILVER-AMI and GRACE mortality risk models. In our validation cohort, we compared the AUCs for the SILVER-AMI 6-month mortality risk model and the GRACE risk model (which was previously developed for post-AMI 6-month mortality). The GRACE risk model includes the following factors: age, development (or history) of heart failure, peripheral vascular disease, systolic blood pressure, Killip class, initial serum creatinine concentration, elevated initial cardiac markers, cardiac arrest on admission, and ST-segment deviation. The diagonal green line indicates 50% discrimination and is provided to show how much each model improves on purely random assignment of risk. As shown, the SILVER-AMI mortality risk model showed superior discrimination compared with the GRACE model (AUC = 0.84 vs. 0.76; P < 0.001). AMI = acute myocardial infarction; AUC = area under the curve; GRACE = Global Registry of Acute Coronary Events; SILVER-AMI = Comprehensive Evaluation of Risk in Older Adults with AMI.
Figure 2.
Figure 2.
Calibration plot for the SILVER-AMI mortality risk model. Shown are deciles of observed 6-month risk versus predicted 6-month mortality, with the GRACE model applied to the SILVER-AMI validation cohort (top) and the SILVER-AMI model applied to the SILVER-AMI validation cohort (bottom). Error bars represent 95% CIs. AMI = acute myocardial infarction; GRACE = Global Registry of Acute Coronary Events; SILVER-AMI = Comprehensive Evaluation of Risk in Older Adults with AMI.
See this image and copyright information in PMC

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