Advertisement
Canadian Journal of Cardiology
Clinical Research| Volume 37, ISSUE 10, P1555-1561, October 2021

Clinical Presentation and Outcome of Patients Experiencing Homelessness Presenting With ST-Segment Elevation Myocardial Infarction

      Abstract

      Background

      Cardiovascular disease remains a major cause of morbidity and mortality among homeless adults. Despite major advances in the management of ST elevation myocardial infarction (STEMI), limited information is available for the clinical presentation and management and outcome of STEMI among patients experiencing homelessness (PEH).

      Methods

      All patients presenting with STEMI between January 1, 2008 and December 31, 2017 at a PCI capable STEMI network inner city hospital comprised the study population. Baseline characteristics, homeless status and clinical outcomes were determined from hospital records. The primary outcome of in-hospital mortality was compared between PEH and nonhomeless patients using a log-binomial regression model with propensity score adjusted standardised mortality ratio weighting (SMRW).

      Results

      Among 2854 STEMI admissions during the study period, 75 patients (2.6%) were identified as PEH. The PEH group was younger (58 vs 63 years; P = 0.0002), predominantly male (96% vs 76%), and more likely to present with cardiogenic shock or cardiac arrest (17% vs 6%) compared with the nonhomeless group. The in-hospital mortality remained significantly higher among PEH (risk ratio 3.83, 95% confidence interval 1.27-11.60) after propensity score adjustment.

      Conclusions

      Despite universal health care and contemporary STEMI management, PEH presenting with STEMI experienced a 4-fold higher in-hospital mortality compared with the nonhomeless cohort. Targeted interventions are needed to improve STEMI outcomes in this high-risk group.

      Résumé

      Contexte

      La maladie cardiovasculaire demeure une cause majeure de morbidité et de mortalité chez les adultes sans-abri. Malgré des progrès importants dans la prise en charge de l'infarctus du myocarde avec élévation du segment ST (STEMI), on dispose de données limitées sur le tableau clinique, la prise en charge et l'issue du STEMI chez les patients sans-abri.

      Méthodologie

      Tous les patients présentant un STEMI entre le 1er janvier 2008 et le 31 décembre 2017 à un hôpital du centre-ville capable de réaliser une intervention coronarienne percutanée (ICP) constituaient la population de l’étude. Les caractéristiques initiales, le statut de sans-abri et les résultats cliniques ont été déterminés à partir des dossiers de l'hôpital. Le critère d’évaluation principal, la mortalité hospitalière, a été comparé entre des patients sans-abri et des patients qui n’étaient pas des sans-abri en utilisant un modèle de régression log-binomiale avec pondération du ratio normalisé de mortalité et ajustement du score de propension.

      Résultats

      Parmi les 2 854 patients admis en raison d'un STEMI pendant la période de l’étude, 75 patients (2,6 %) ont été identifiés comme étant des personnes sans-abri. Les patients sans-abri étaient plus jeunes (58 ans vs 63 ans; p = 0,0002), étaient principalement des hommes (96 % vs 76 %) et étaient plus susceptibles de se présenter à l'hôpital en raison d'un choc cardiogénique ou d'un arrêt cardiaque (17 % vs 6 %) comparativement aux patients qui n’étaient pas des sans-abri. Le taux de mortalité hospitalière est resté significativement plus élevé dans le groupe des patients sans-abri (rapport des risques de 3,83; intervalle de confiance à 95 %: 1,27 à 11,60) après ajustement du score de propension.

      Conclusions

      Malgré un système de soins de santé universel et la prise en charge contemporaine du STEMI, la mortalité hospitalière était quatre fois plus élevée chez les patients sans-abri se présentant à l'hôpital en raison d'un STEMI que chez les patients qui n’étaient pas des sans-abri. Des interventions ciblées sont nécessaires pour améliorer l'issue du STEMI dans ce groupe à risque élevé.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Hwang SW
        • Wilkins R
        • Tjepkema M
        • O'Campo PJ
        • Dunn JR
        Mortality among residents of shelters, rooming houses, and hotels in Canada: 11 year follow-up study.
        BMJ. 2009; 339: b4036
        • Henry M
        • Watt R
        • Mahathey A
        • et al.
        The 2019 Annual Homelessness Assessment Report (AHAR) to Congress.
        Part 1: point-in-time estimates of homelessness. January 2020; (Available at:) (Accessed December 29, 2020)
      1. Employment and Social Development Canada. Final report of the Advisory Committee on Homelessness. 2018. Available at: https://www.canada.ca/en/employment-social-development/programs/homelessness/publications-bulletins/advisory-committee-report.html. Accessed February 10, 2021.

        • Baggett TP
        • Liauw SS
        • Hwang SW.
        Cardiovascular disease and homelessness.
        J Am Coll Cardiol. 2018; 71: 2585-2597
        • Baggett TP
        • O'Connell JJ
        • Singer DE
        • Rigotti NA
        The unmet health care needs of homeless adults: a national study.
        Am J Public Health. 2010; 100: 1326-1333
        • Hunter CE
        • Palepu A
        • Farrell S
        • et al.
        Barriers to prescription medication adherence among homeless and vulnerably housed adults in three Canadian cities.
        J Prim Care Community Health. 2015; 6: 154-161
        • Ferdinand KC
        • Senatore FF
        • Clayton-Jeter H
        • et al.
        Improving medication adherence in cardiometabolic disease.
        J Am Coll Cardiol. 2017; 69: 437-451
        • Kreatsoulas C
        • Anand SS.
        The impact of social determinants on cardiovascular disease.
        Can J Cardiol. 2010; 26: 8C-13C
        • Tran DT
        • Welsh RC
        • Ohinmaa A
        • et al.
        Quality of acute myocardial infarction care in Canada: a 10-year review of 30-day in-hospital mortality and 30-day hospital readmission.
        Can J Cardiol. 2017; 33: 1319-1326
        • O'Gara P
        • Kushner F
        • Casey D
        • et al.
        2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.
        Circulation. 2013; 127: 362-425
        • Brookhart MA
        • Wyss R
        • Layton JB
        • Stürmer T.
        Propensity score methods for confounding control in nonexperimental research.
        Circ Cardiovasc Qual Outcomes. 2013; 6: 604-611
        • Stürmer T
        • Wyss R
        • Glynn RJ
        • Brookhart MA.
        Propensity scores for confounder adjustment when assessing the effects of medical interventions using nonexperimental study designs.
        J Intern Med. 2014; 275: 570-580
        • Desai RJ
        • Franklin JM.
        Alternative approaches for confounding adjustment in observational studies using weighting based on the propensity score: a primer for practitioners.
        BMJ. 2019; 367: l5657
        • Austin PC.
        An introduction to propensity score methods for reducing the effects of confounding in observational studies.
        Multivariate Behav Res. 2011; 46: 399-424
        • Austin PC.
        Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples.
        Stat Med. 2009; 28: 3083-3107
        • Austin PC.
        Optimal caliper widths for propensity-score matching when estimating differences in means and differences in proportions in observational studies.
        Pharm Stat. 2011; 10: 150-161
        • Wadhera RK
        • Khatana SAM
        • Choi E
        • et al.
        Disparities in care and mortality among homeless adults hospitalized for cardiovascular conditions.
        JAMA Intern Med. 2020; 180: 357-366
        • Skosireva A
        • O'Campo P
        • Zerger S
        • et al.
        Different faces of discrimination: perceived discrimination among homeless adults with mental illness in healthcare settings.
        BMC Health Serv Res. 2014; 14: 376
        • Choi M
        • Kim H
        • Qian H
        • Palepu A.
        Readmission rates of patients discharged against medical advice: a matched cohort study.
        PLoS One. 2011; 6: e24459
        • McInnes DK
        • Petrakis BA
        • Gifford AL
        • et al.
        Retaining homeless veterans in outpatient care: a pilot study of mobile phone text message appointment reminders.
        Am J Public Health. 2014; 104: S588-S594
        • Schwarcz SK
        • Hsu LC
        • Vittinghoff E
        • et al.
        Impact of housing on the survival of persons with AIDS.
        BMC Public Health. 2009; 9: 220
        • Correll CU
        • Solmi M
        • Veronese N
        • et al.
        Prevalence, incidence and mortality from cardiovascular disease in patients with pooled and specific severe mental illness: a large-scale meta-analysis of 3,211,768 patients and 113,383,368 controls.
        World Psychiatry. 2017; 16: 163-180