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Weekend admissions for non-STEMI associated with higher rates of
inhospital mortality and lower rates of coronary angiography
Comment by Shaista Malik,
MD, PhD, MPH
T
he paper by Agarwal et al
comparing in-hospital mortal-
ity and frequency of coronary
angiography on weekend versus
weekday admissions in patients with
non-ST-segment elevation myocar-
dial infarction (NSTEMI) shows that
higher mortality on weekends may
be explained by decreased use of an
early invasive approach. Previous
papers have found that significant
differences in outcomes between
weekend and weekday admission
had largely dissipated, but many
did not look at contemporary or
large representative samples of the
national inpatient population, and
many didn’t examine NSTEMI and
STEMI separately. Previous studies
have shown that the day of the week
does not impact outcomes when it
comes to STEMI due to concerted
efforts to make medical care uniform
in time-sensitive acute illnesses.
Agarwal et al have shown in a large
representative sample (3,625,271)
that those admitted with NSTEMI
have 2% higher odds of mortality if
admitted over the weekend, and this
disparity dissipates when adjusted
for utilisation of early invasive strat-
egy. These results suggest that a
targeted approach to improving pro-
cesses of care in NSTEMI, as has
been done in the past for STEMI,
can have a significant impact on de-
creasing mortality in these patients
needing time-sensitive treatment.
Uniformity in use of an early in-
vasive approach and adherence to
guidelines, regardless of day of the
week, may ensure better quality
of care and improved outcomes in
patients admitted with NSTEMI.
Dr Malik is
Associate Professor
of Medicine,
Director, Susan
Samueli Center
of Integrative
Medicine, Medical Director,
Preventive Cardiology and Cardiac
Rehab Director, Women’s Heart
Program, University of California.
Benefits of omega-3 fatty acids from fish
oil after acute MI: an off and on affair?
Comment by
Paul Thompson,
MD
I
was pleasantly surprised by the
recently released results of the
Omega-3 Acid Ethyl Esters on
Left Ventricular Remodeling After
Acute Myocardial Infarction, or
OMEGA-REMODEL trial. The
study randomised patients with
documented acute myocardial in-
farction (AMI) treated by acute an-
gioplasty to either placebo (n=178)
or 4 gm daily of concentrated fish
oil using tablets containing
≈
465
mg of ethyl esters of eicosapentae-
noic acid (EPA) and
≈
375 mg of
docosahexaenoic acid (DHA). The
placebo contained corn oil with
≈
600 mg linoleic acid, no omega-3
fatty acids, and <0.05% of trans-fatty
acids. Participants started treatment
14 to 28 days after their AMI and
were treated for 6 months. Cardiac
magnetic resonance imaging (cMRI)
was performed at baseline and at 6
months to measure cardiac function
and structure. Studies were read by
blinded readers. There was high
adherence to guideline-based treat-
ment for AMI.
Patients treated with the concen-
trated fish oil had a 5.8% decrease
in their left ventricular systolic
volume index (LVSVI; P = 0.017)
and 5.6% less fibrosis in their non-
infarcted myocardium. Those with
the greatest increase in red blood
cell omega-3 fatty acid concentra-
tion had the greatest decrease in
LVSVI, demonstrating a dose effect
of treatment. Omega-3 treatment
was associated with decreases in
the inflammatory markers myelop-
eroxidase and lipoprotein-associated
phospholipase A2 (Lp-PLA2) as
well as decreases in ST2, a marker
of myocardial fibrosis. The decrease
in ST2 correlated directly with the
change in non-infarct myocardial
fibrosis (r = 0.65; P < 0.0001). The
authors speculated that the omega-3
fatty acids decreased inflammation
in the non-infarcted myocardium,
thereby preserving LV function.
Modern cardiology has had an
on/off affair with concentrated fish
oil. The GISSI, or Gruppo Italiano
per lo Studio della Sopravvivenza
nell’Infarto miocardico, study as-
signed 11,324 AMI patients to
1 gm daily of omega-3 fatty acids or
placebo in an open-label design. The
patients receiving fish oil had a 20%
reduction in mortality, which many
attributed to a reduction in sudden
death via a fish oil effect on cardiac
arrhythmia. Subsequent studies
were less supportive of a beneficial
effect of fish oil on cardiac arrhyth-
mias and on AMI treatment in
general. The OMEGA-REMODEL
trial suggests that concentrated fish
oil may have a beneficial effect on
cardiac remodelling, and it offers
a different possibility for GISSI’s
success. OMEGA-REMODEL is
a relatively small study, but well-
designed and well-performed and
suggests that cardiology’s affair with
fish oil may be on again.
So what are clinicians to do?
This study was well-done, but
it is premature to translate these
promising results directly into
patient care. We do not yet know
whether these putative improve-
ments in myocardial function and
fibrosis from concentrated fish
oil, 4 gm daily, will have clinical
significance. A larger, clinical out-
comes study will be required before
concentrated fish becomes standard
of care. Some patients may learn of
these results and start themselves
on fish oil. Clinicians and such pa-
tients should be aware that the fish
oil preparation used in this study
was highly concentrated, similar
to the brand compound Omacor.
Over-the-counter fish oil capsules
have approximately one-third of the
omega-3 fatty acids available in the
concentrated products; so, over-the-
counter fish oil would not provide
the dose used in this study without
taking 12 tablets daily.
Dr Thompson is Chief of
Cardiology, Hartford Hospital,
Connecticut.
Comparison of inhospital mortality and frequency of coronary angiography on weekend versus weekday
admissions in patients with non-ST-segment elevation acute myocardial infarction
Abstract
Patients withmyocardial infarction admitted onweekends
have been reported to less frequently undergo invasive
angiography and experience poorer outcomes. We used
theNationwide Inpatient Sample database (2003 to 2011)
to compare differences in all-cause inhospital mortality
between patients admitted on a weekend versus week-
day 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%) wereweekday admissions. Admission on aweek-
end versus weekday was independently associatedwith
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
admittedwith a diagnosis of an acute NSTEMI, admission
on aweekendwas associatedwith higher inhospital mor-
tality compared with admission on a weekday and that
lower rates of utilization of EIS contributed significantly
to this disparity.
Am J Cardiol
2016;118:632-634, Agrawal S, Garg L,
Sharma A, et al.
Effect of omega-3 acid ethyl esters on left ventricular remodeling after acute
myocardial infarction: the OMEGA-REMODEL randomised clinical trial
Circulation
Take-home message
•
In this multicentre, double-blind trial, patients who suffered an acute MI were randomly assigned to 6 months of
high-dose omega-3 fatty acids (n=180) or placebo (n=178). Significant reductions in left ventricular systolic volume
index (−5.8%l; P = 0.017), non-infarct myocardial fibrosis (−5.6%; P = 0.026), and serum biomarkers of inflammation and
myocardial fibrosis were observed in the omega-3 fatty acids group compared with the placebo group. In addition,
increases in red blood cell omega-3 fatty acid correlated with decreases in left ventricular systolic volume index.
•
Following acute MI, high-dose omega-3 fatty acids had a beneficial effect on left ventricular remodeling, non-infarct
myocardial fibrosis, and biomarkers of inflammation beyond standard-of-care therapy.
Abstract
BACKGROUND
Omega-3 fatty acids from fish oil have been
associated with beneficial cardiovascular effects, but their
role in modifying cardiac structures and tissue characteristics
in patients who have had an acute myocardial infarction while
receiving current guideline-based therapy remains unknown.
METHODS
In a multicenter, double-blind, placebo-controlled trial,
participants presentingwith an acutemyocardial infarction were
randomly assigned 1:1 to 6 months of high-dose omega-3 fatty
acids (n=180) or placebo (n=178). Cardiac magnetic resonance
imaging was used to assess cardiac structure and tissue char-
acteristics at baseline and after study therapy. The primary study
endpoint was change in left ventricular systolic volume index.
Secondary endpoints included change in noninfarct myocardial
fibrosis, left ventricular ejection fraction, and infarct size.
RESULTS
By intention-to-treat analysis, patients randomly assigned
to omega-3 fatty acids experienced a significant reduction of left
ventricular systolic volume index (–5.8%, P=0.017), and noninfarct
myocardial fibrosis (–5.6%, P=0.026) in comparisonwith placebo.
Per-protocol analysis revealed that those patients who achieved
the highest quartile increase in red blood cell omega-3 index
experienced a 13% reduction in left ventricular systolic volume
index in comparisonwith the lowest quartile. In addition, patients
in the omega-3 fatty acid arm underwent significant reductions
in serumbiomarkers of systemic and vascular inflammation and
myocardial fibrosis. There were no adverse events associated
with highdose omega-3 fatty acid therapy.
CONCLUSIONS
Treatment of patients with acute myocardial
infarction with high-dose omega-3 fatty acids was associated
with reduction of adverse left ventricular remodeling, noninfarct
myocardial fibrosis, and serum biomarkers of systemic inflam-
mation beyond current guidelinebased standard of care.
Circulation
2016;134:378-391, Heydari B, Abdullah S,
Pottala JV, et al.
CORONARY HEART DISEASE
VOL. 1 • No. 2 • 2016
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