PMID- 26077589
OWN - NLM
STAT- MEDLINE
DCOM- 20160408
LR  - 20181113
IS  - 2047-9980 (Electronic)
IS  - 2047-9980 (Print)
IS  - 2047-9980 (Linking)
VI  - 4
IP  - 6
DP  - 2015 Jun 15
TI  - Hospital variability in use of anticoagulant strategies during acute myocardial 
      infarction treated with an early invasive strategy.
PG  - e002009
LID - 10.1161/JAHA.115.002009 [doi]
LID - e002009
AB  - BACKGROUND: During a myocardial infarction, no single best approach of systemic 
      anticoagulation is recommended, likely due to a lack of comparative effectiveness 
      studies and trade-offs between treatments. METHODS AND RESULTS: We investigated 
      the patterns of use and site-level variability in anticoagulant strategies 
      (unfractionated heparin [UFH] only, low-molecular-weight heparin [LMWH] only, 
      UFH+LMWH, any bivalirudin) of 63 796 patients with a principal diagnosis of 
      myocardial infarction treated with an early invasive strategy with percutaneous 
      coronary intervention at 257 hospitals. About half (47%) of patients received UFH 
      only, 6% UFH+LMWH, 7% LMWH only, and 40% bivalirudin. Compared with UFH, the 
      median odds ratio was 2.90 for LMWH+UFH, 4.70 for LMWH only, and 3.09 for 
      bivalirudin, indicating that 2 "identical" patients would have a 3- to 4-fold 
      greater likelihood of being treated with anticoagulants other than UFH at one 
      hospital compared with another. We then categorized hospitals as low- or 
      high-users of LMWH and bivalirudin. Using hierarchical, multivariate regression 
      models, we found that low bivalirudin-using hospitals had higher unadjusted 
      bleeding rates, but the risk-adjusted and anticoagulant-adjusted bleeding rates 
      did not differ across the hospital anticoagulation phenotypes. Risk-standardized 
      mortality and risk-standardized length of stay also did not differ across 
      hospital phenotypes. CONCLUSIONS: We found substantial site-level variability in 
      the choice of anticoagulants for invasively managed acute myocardial infarction 
      patients, even after accounting for patient factors. No single hospital-use 
      pattern was found to be clinically superior. More studies are needed to determine 
      which patients would derive the greatest benefit from various anticoagulants and 
      to support consistent treatment of patients with the optimal anticoagulant 
      strategy.
CI  - (c) 2015 The Authors. Published on behalf of the American Heart Association, Inc., 
      by Wiley Blackwell.
FAU - Arnold, Suzanne V
AU  - Arnold SV
AD  - Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 
      Kansas City, MO (S.V.A., J.A.S., M.K.).
FAU - Li, Shu-Xia
AU  - Li SX
AD  - Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, 
      CT (S.X.L., J.P.C., K.D., K.M.S., H.M.K.).
FAU - Alexander, Karen P
AU  - Alexander KP
AD  - Duke Clinical Research Institute, Durham, NC (K.P.A., T.Y.W.).
FAU - Spertus, John A
AU  - Spertus JA
AD  - Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 
      Kansas City, MO (S.V.A., J.A.S., M.K.).
FAU - Nallamothu, Brahmajee K
AU  - Nallamothu BK
AD  - University of Michigan and the Ann Arbor VA Medical Center, Ann Arbor, MI 
      (B.K.N.).
FAU - Curtis, Jeptha P
AU  - Curtis JP
AD  - Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, 
      CT (S.X.L., J.P.C., K.D., K.M.S., H.M.K.) Section of Cardiovascular Medicine, 
      Department of Internal Medicine, Yale University School of Medicine, New Haven, 
      CT (J.P.C., K.D., H.M.K.).
FAU - Kosiborod, Mikhail
AU  - Kosiborod M
AD  - Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 
      Kansas City, MO (S.V.A., J.A.S., M.K.).
FAU - Gupta, Aakriti
AU  - Gupta A
AD  - Department of Internal Medicine, Yale University School of Medicine, New Haven, 
      CT (A.G.).
FAU - Wang, Tracy Y
AU  - Wang TY
AD  - Duke Clinical Research Institute, Durham, NC (K.P.A., T.Y.W.).
FAU - Lin, Haiqun
AU  - Lin H
AD  - Department of Biostatistics, Yale School of Public Health, New Haven, CT (H.L.).
FAU - Dharmarajan, Kumar
AU  - Dharmarajan K
AD  - Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, 
      CT (S.X.L., J.P.C., K.D., K.M.S., H.M.K.) Section of Cardiovascular Medicine, 
      Department of Internal Medicine, Yale University School of Medicine, New Haven, 
      CT (J.P.C., K.D., H.M.K.).
FAU - Strait, Kelly M
AU  - Strait KM
AD  - Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, 
      CT (S.X.L., J.P.C., K.D., K.M.S., H.M.K.).
FAU - Lowe, Timothy J
AU  - Lowe TJ
AD  - Premier, Inc, Charlotte, NC (T.J.L., H.M.K.).
FAU - Krumholz, Harlan M
AU  - Krumholz HM
AD  - Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, 
      CT (S.X.L., J.P.C., K.D., K.M.S., H.M.K.) Section of Cardiovascular Medicine, 
      Department of Internal Medicine, Yale University School of Medicine, New Haven, 
      CT (J.P.C., K.D., H.M.K.) Department of Health Policy and Management, Yale School 
      of Public Health, Yale University School of Medicine, New Haven, CT (H.M.K.) 
      Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal 
      Medicine, Yale University School of Medicine, New Haven, CT (H.M.K.) Premier, 
      Inc, Charlotte, NC (T.J.L., H.M.K.).
LA  - eng
GR  - U01 HL105270-05/HL/NHLBI NIH HHS/United States
PT  - Journal Article
PT  - Research Support, N.I.H., Extramural
PT  - Research Support, Non-U.S. Gov't
DEP - 20150615
PL  - England
TA  - J Am Heart Assoc
JT  - Journal of the American Heart Association
JID - 101580524
RN  - 0 (Anticoagulants)
RN  - 0 (Heparin, Low-Molecular-Weight)
RN  - 0 (Hirudins)
RN  - 0 (Peptide Fragments)
RN  - 0 (Recombinant Proteins)
RN  - 9005-49-6 (Heparin)
RN  - TN9BEX005G (bivalirudin)
SB  - IM
MH  - Aged
MH  - Anticoagulants/*therapeutic use
MH  - Female
MH  - Heparin/therapeutic use
MH  - Heparin, Low-Molecular-Weight/therapeutic use
MH  - Hirudins
MH  - Hospitals/*statistics & numerical data
MH  - Humans
MH  - Length of Stay/statistics & numerical data
MH  - Male
MH  - Middle Aged
MH  - Myocardial Infarction/*drug therapy/mortality/therapy
MH  - Peptide Fragments/therapeutic use
MH  - Percutaneous Coronary Intervention/methods/statistics & numerical data
MH  - Recombinant Proteins/therapeutic use
MH  - Retrospective Studies
MH  - Treatment Outcome
PMC - PMC4599539
OTO - NOTNLM
OT  - anticoagulation
OT  - bleeding
OT  - myocardial infarction
OT  - variation
EDAT- 2015/06/17 06:00
MHDA- 2016/04/09 06:00
PMCR- 2015/06/01
CRDT- 2015/06/17 06:00
PHST- 2015/06/17 06:00 [entrez]
PHST- 2015/06/17 06:00 [pubmed]
PHST- 2016/04/09 06:00 [medline]
PHST- 2015/06/01 00:00 [pmc-release]
AID - JAHA.115.002009 [pii]
AID - 10.1161/JAHA.115.002009 [doi]
PST - epublish
SO  - J Am Heart Assoc. 2015 Jun 15;4(6):e002009. doi: 10.1161/JAHA.115.002009.