Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA.
J Am Geriatr Soc. 2023 Oct;71(10):3179-3188. doi: 10.1111/jgs.18479. Epub 2023 Jun 24.
Among older adults, non-cardiovascular multimorbidity often coexists with cardiovascular disease (CVD) but their clinical significance is uncertain. We identified common non-cardiovascular comorbidity patterns and their association with clinical outcomes in Medicare fee-for-service beneficiaries with acute myocardial infarction (AMI), congestive heart failure (CHF), or atrial fibrillation (AF).
Using 2015-2016 Medicare data, we took 1% random sample to create 3 cohorts of beneficiaries diagnosed with AMI (n = 24,808), CHF (n = 57,285), and AF (n = 36,277) prior to 1/1/2016. Within each cohort, we applied latent class analysis to classify beneficiaries based on 9 non-cardiovascular comorbidities (anemia, cancer, chronic kidney disease, chronic lung disease, dementia, depression, diabetes, hypothyroidism, and musculoskeletal disease). Mortality, cardiovascular and non-cardiovascular hospitalizations, and home time lost over a 1-year follow-up period were compared across non-cardiovascular multimorbidity classes.
Similar non-cardiovascular multimorbidity classes emerged from the 3 CVD cohorts: (1) minimal, (2) depression-lung, (3) chronic kidney disease (CKD)-diabetes, and (4) multi-system class. Across CVD cohorts, multi-system class had the highest risk of mortality (hazard ratio [HR], 2.7-3.9), cardiovascular hospitalization (HR, 1.6-3.3), non-cardiovascular hospitalization (HR, 3.1-7.2), and home time lost (rate ratio, 2.7-5.4). Among those with AMI, the CKD-diabetes class was more strongly associated with all the adverse outcomes than the depression-lung class. In CHF and AF, differences in risk between the depression-lung and CKD-diabetes classes varied per outcome; and the depression-lung and multi-system classes had double the rates of non-cardiovascular hospitalizations than cardiovascular hospitalizations.
Four non-cardiovascular multimorbidity patterns were found among Medicare beneficiaries with CHF, AMI, or AF. Compared to the minimal class, the multi-system, CKD-diabetes, and depression-lung classes were associated with worse outcomes. Identification of these classes offers insight into specific segments of the population that may benefit from more than the usual cardiovascular care.
在老年人中，非心血管合并症常与心血管疾病（CVD）并存，但它们的临床意义尚不确定。我们确定了常见的非心血管合并症模式及其与 Medicare 按服务收费受益人的急性心肌梗死（AMI）、充血性心力衰竭（CHF）或心房颤动（AF）临床结局的关系。
使用 2015-2016 年 Medicare 数据，我们抽取了 1%的随机样本，创建了 3 个队列的受益人，这些受益人在 2016 年 1 月 1 日之前被诊断为 AMI（n=24808）、CHF（n=57285）和 AF（n=36277）。在每个队列中，我们应用潜在类别分析根据 9 种非心血管合并症（贫血、癌症、慢性肾脏病、慢性肺病、痴呆、抑郁、糖尿病、甲状腺功能减退和肌肉骨骼疾病）对受益人进行分类。在 1 年的随访期间，比较了非心血管合并症类别之间的死亡率、心血管和非心血管住院治疗以及丧失的家庭时间。
从 3 个 CVD 队列中出现了相似的非心血管合并症类别：（1）最低限度，（2）抑郁-肺，（3）慢性肾脏病（CKD）-糖尿病，和（4）多系统类别。在所有 CVD 队列中，多系统类别具有最高的死亡率风险（风险比[HR]，2.7-3.9）、心血管住院治疗（HR，1.6-3.3）、非心血管住院治疗（HR，3.1-7.2）和丧失的家庭时间（比率比，2.7-5.4）。在 AMI 患者中，CKD-糖尿病类别的所有不良结局的相关性均强于抑郁-肺类。在 CHF 和 AF 中，抑郁-肺和 CKD-糖尿病类之间的风险差异因结局而异；抑郁-肺和多系统类的非心血管住院率是心血管住院率的两倍。
在患有 CHF、AMI 或 AF 的 Medicare 受益人中发现了 4 种非心血管合并症模式。与最低限度类别相比，多系统、CKD-糖尿病和抑郁-肺类别与更差的结局相关。这些类别的确定为特定人群提供了更深入的了解，这些人群可能需要比通常的心血管护理更多的关注。
