Role of Cardiologists in Evaluation of Type 2 Myocardial Infarction Unclear

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Patients with type 2 myocardial infarction (T2MI) have high rates of recurrent cardiovascular events. For MI in general, cardiologist evaluation is associated with mortality reduction, and outpatient follow-up is associated with increased adherence to secondary preventive therapies. However, it's unknown how often patients with T2MI are evaluated by a cardiologist during hospitalization or after discharge, and it's also been unclear whether cardiologist evaluations affect diagnostic testing and treatment.

Cian P. McCarthy, MD, cardiology fellow, and Jason H. Wasfy, MD, MPhil, medical director of the Massachusetts General Physicians Organization and director of Quality and Analytics at the Cardiology Division at Massachusetts General Hospital, and colleagues found that even at their own tertiary care center, only 57% of patients with T2MI were evaluated by a cardiologist during hospitalization and only 38% had outpatient cardiology follow-up. They report their findings in Circulation: Cardiovascular Quality of Care and Outcomes.

Study Cohort

The study subjects were 359 patients at Mass General who presented with T2MI between October 2017 and May 2018. Of those, 207 (57%) were evaluated by a cardiologist. 120 (33%) of those patients received a cardiology consultation and 87 (24%) were admitted or transferred to a cardiology service.

There were no significant differences in clinical presentation between patients who were or were not evaluated by cardiologists, including similar rates of chest pain, shortness of breath, ST-segment changes and ischemic T-wave abnormalities.

Diagnostic Testing

Patients evaluated by a cardiologist were more likely than the comparison group to undergo the following tests during hospitalization:

• Stress testing (14% vs. 3%; P=0.002; adjusted OR, 4.91; 95% CI, 1.95–15.05)
• Transthoracic echocardiography (80% vs. 51%; P<0.001; aOR, 4.68; 95% CI, 2.86–7.79)
• Coronary angiography (21% vs. 0%; P<0.001)

Treatment at Discharge

Patients evaluated by a cardiologist were significantly more likely than the comparison group to be discharged on:

• A statin (75% vs. 65%; P=0.04)
• Clopidogrel (14% vs. 6%; P=0.02)
• A beta-blocker (72% vs. 56%; P=0.002)

There were no differences between groups in rates of prescriptions of aspirin, prasugrel, ticagrelor, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers or angiotensin receptor–neprilysin inhibitor.

Follow-up

289 of the patients were discharged alive and had follow-up data available. Of those, 111 (38%) had an outpatient cardiology follow-up visit within six months. Patients who had a cardiologist evaluation during hospitalization were substantially more likely than others to have cardiology follow-up (53% vs. 19%; P<0.001).

Are the Gaps in Care Important?

This analysis documents gaps in care for patients with T2MI, but the implications of those gaps are uncertain. For example, there was no significant difference in all-cause mortality between those who did or did not receive a cardiologist evaluation (12% vs. 9%, P=NS).

Given the increasing frequency of T2MI and the high risk associated with it, clinical trials are needed to identify effective treatment strategies, which should include pinpointing the role of cardiovascular specialists.

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