‘Comfort measures only’ status in acute MI often follows complications during treatment
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Patients with acute MI being treated with comfort measures only by discharge were found to have attained that status after in-hospital complications, often after aggressive initial management, according to a retrospective cohort study.
“A lot of effort is put into making these patients better, especially when they come in with acute issues, like a heart attack,” Leila Haghighat, MD, a cardiology fellow at the University California, San Francisco, told Healio. “But often, trying to do everything we can to save a life comes at the cost of putting these patients through invasive procedures that may not ultimately change the outcome. That begs the question, in which patients with heart attacks are these procedures futile? Which patients, assuming it is within their goals of care, would be better served having the focus of their hospitalization be on maximizing their comfort, rather than prolonging life?”
Patients with acute MI
The retrospective cohort study, published in Circulation: Cardiovascular Quality and Outcomes, used the National Cardiovascular Data Registry (NCDR) Chest Pain-MI registry to collect data on patients with acute MI, which the researchers then analyzed for temporal trends, patient- and hospital-level patterns and predictors in comfort measures only (CMO) rates in 6-month increments from January 2015 to June 2018. The primary outcome of the study was whether a patient was designated as CMO at the time of discharge. The final study population consisted of 483,696 patients with acute MI across 827 hospitals.
Within the cohort, 2.9% of the total patients had CMO status at discharge, with 2.6% of that number having non-STEMI and 3.4% having STEMI. There was a slight decline in CMO incidence over time, dropping from 3% in early 2015 to 2.8% in early 2018 (P < .007) overall. The CMO incidence decline was observed in patients with non-STEMI (from 2.9% to 2.4%; P < . 001) but not in patients with STEMI (from 3.2% to 3.4%; P = .22).
Notably, patients who were initially managed invasively but later achieved CMO status experienced high rates of procedural complications, including cardiogenic shock (38.3%), dialysis (10.1%) and bleeding (33.3%).
Role of invasive procedures
“One of the more interesting findings from our study was that invasive procedures were done in over half of patients with heart attacks who by the time of discharge chose to focus their hospitalization on comfort,” Haghighat told Healio. “This group of patients also had high rates of complications, including bleeding, dialysis and cardiogenic shock. This suggests that there may be some patients in whom upfront aggressive care does not provide much benefit and may perhaps be more harmful than beneficial.”
CMO rates ranged from 0% to 17.1% across hospitals, with a median OR to assess for hospital effect of 1.59 (95% CI, 1.56-1.62). Researchers also found that 58.3% of the 13,955 patients who were CMO by discharge underwent diagnostic catheterization, an invasive strategy, despite elevated risk predictions. According to the study, the prevalence of high in-hospital bleeding and mortality Acute Coronary Treatment and Intervention Outcomes Network (ACTION) risk scores among patients who were initially treated aggressively and achieved CMO status shows the significant role of hospital treatment on CMO status.
“Being able to better identify who are the patients hospitalized for heart attacks who may benefit from an early focus on comfort can better inform comprehensive and timely goals of care discussions,” Haghighat told Healio. “Among patients admitted with a heart attack, it behooves providers to assess their risk of morbidity and mortality upfront and incorporate this along with patients’ preferences into goals of care discussions to identify patients in whom a focus on comfort might be appropriate.”
For more information:
Leila Haghighat, MD, can be reached at leila.haghighat@ucsf.edu; Twitter: @leilahaghighat.
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Haghighat L, et al. Circ Cardiovasc Qual Outcomes. 2022;doi:10.1161/CIRCOUTCOMES.120.007610.
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