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June 17, 2019

Association Between Inpatient Echocardiography Use and Outcomes in Adult Patients With Acute Myocardial Infarction

Author Affiliations
  • 1Division of Cardiovascular Medicine, University of Massachusetts Medical School-Baystate, Springfield
  • 2Institute for Healthcare Delivery and Population Science, University of Massachusetts Medical School-Baystate, Springfield
  • 3Department of Medicine, University of Massachusetts Medical School-Baystate, Springfield
  • 4School of Public Health and Health Sciences, University of Massachusetts, Amherst
  • 5Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester
JAMA Intern Med. Published online June 17, 2019. doi:10.1001/jamainternmed.2019.1051
Key Points

Question  Is use of echocardiography associated with outcomes in acute myocardial infarction?

Findings  In this cohort study of 98 999 admissions from 397 US hospitals, higher hospital rates of echocardiography use were associated with longer length of stay and greater costs but not with differences in rates of mortality or 3-month readmission.

Meaning  Greater use of echocardiography did not appear to be associated with better patient outcomes in patients with acute myocardial infarction.


Importance  Guidelines recommend that patients with acute myocardial infarction (AMI) undergo echocardiography for assessment of cardiac structure and ejection fraction, but little is known about the association between echocardiography as used in routine clinical management of AMI and patient outcomes.

Objective  To examine the association between risk-standardized hospital rates of transthoracic echocardiography and outcomes.

Design, Setting, and Participants  This retrospective cohort study of data from 397 US hospitals that contributed to the Premier Healthcare Informatics inpatient database from January 1, 2014, to December 31, 2014, used International Classification of Diseases, Ninth Revision (ICD-9) codes to identify 98 999 hospital admissions for patients with AMI. Data were analyzed between October 2017 and January 2019.

Exposures  Rates of transthoracic echocardiography.

Main Outcomes and Measures  Inpatient mortality, length of stay, total inpatient costs, and 3-month readmission rate.

Results  Among the 397 hospitals with more than 25 admissions for AMI in 2014, a total of 98 999 hospital admissions for AMI were identified for analysis (38.2% women; mean [SD] age, 66.5 [13.6] years), of which 69 652 (70.4%) had at least 1 transthoracic echocardiogram performed. The median (IQR) hospital risk-standardized rate of echocardiography was 72.5% (62.6%-79.1%). In models that adjusted for hospital and patient characteristics, no difference was found in inpatient mortality (odds ratio [OR], 1.02; 95% CI, 0.88-1.19) or 3-month readmission (OR, 1.01; 95% CI, 0.93-1.10) between the highest and lowest quartiles of echocardiography use (median risk-standardized echocardiography use rates of 83% vs 54%, respectively). However, hospitals with the highest rates of echocardiography had modestly longer mean lengths of stay (0.23 days; 95% CI, 0.04-0.41; P = .01) and higher mean costs ($3164; 95% CI, $1843-$4485; P < .001) per admission compared with hospitals in the lowest quartile of use. Multiple sensitivity analyses yielded similar results.

Conclusions and Relevance  In patients with AMI, hospitals in the quartile with the highest rates of echocardiography showed greater hospital costs and length of stay but few differences in clinical outcomes compared with hospitals in the quartile with the lowest rates of echocardiography. These findings suggest that more selective use of echocardiography might be used without adversely affecting clinical outcomes, particularly in hospitals with high rates of echocardiography use.

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    1 Comment for this article
    2D and 3D Speckle tracking Echocardiography can change mortality in patients with ACS.
    Ram Singh, MD(Internist Cardiologist | Halberg Hospital and research Institute, Moradabad,India
    Dear Sir,
    We have read the article on echocadiography use in AMI with great interest but wish to share that it is 2D and 3D speckle tracking echocardiography that gives early information of remodeling in patients with acute coronary syndromes (ACS)[1-3]. This has become most important because empagliflozin and coenzyme q10(Tishcon Corp.NY) have been found to prevent remodeling[1,4].
    Despite great advancements, AMI and heart failure are major causes of mortality because of the delay in the diagnosis of myocardial dysfunction[2-5]. The International College of Cardiology emphasize that imaging via 2D and 3D echocardiography and if necessary via PET and MRI
    are important tools to confirm the presence of pathological remodeling for early diagnosis of remodeling which can be prevented by suitable therapies [4].

    Ram B Singh,Jan Fedacko, Galal Elkilany, Krasimira Hristova

    1.Santos-Gallego CG, Requena-Ibanez JA, San Antonio R, Ishikawa K, Watanabe S, Picatoste B, Flores E, Garcia-Ropero A, Sanz J, Hajjar RJ, Fuster V, Badimon JJ. Empagliflozin ameliorates adverse left ventricular remodeling in nondiabetic heart failure by enhancing myocardial energetics. J Am Coll Cardiol. 2019 Apr 23;73(15):1931-1944. doi: 10.1016/j.jacc.2019.01.056.
    2..Balligand JL. Remodeling the failing heart: the biology and future treatment options. https://www.escardio.org/static_file/Escardio/Education/Courses/Basic%20science%20summer%20school/Revised_JL%20Balligand.pdf; Jl.balligand@uclouvain.be,accessed may 2019.
    3.Causes and Prevention of Ventricular remodelling. https://www.acc.org/latest-in-cardiology/articles/2016/07/21/07/28/causes-and-prevention-of-ventricular-remodeling-after-mi, accessed may 2019.
    4.Singh RB, Elkilany GN, Hristova K, Fedacko J, Joshi P. Utility and necessity of cardiovascular imaging in a chest pain unit. World Heart J 2016; 8: 125-132.
    5. Muraru D, Niero A, Rodriguez-Zanella H, Cherata D, Badano L. Three-dimensional speckle-tracking echocardiography: benefits and limitations of integrating myocardial mechanics with three-dimensional imaging. Cardiovasc Diagn Ther 2018;8(1):101-117.