Acute Myocardial Infarction in Severe Mental Illness: Prevalence, Clinical Outcomes, and Process of Care in U.S. Hospitalizations

Background: Severe mental illness (SMI) is associated with increased cardiovascular mortality. We sought to examine the prevalence, clinical outcomes, and management strategy of patients with SMI presenting with acute myocardial infarction (AMI). Methods: All AMI hospitalizations from the National Inpatient Sample were included, stratified by mental health status into 5 groups: no SMI, schizophrenia, other non-organic psychoses (ONOP), bipolar disorder, and major depression. Regression analyses were performed to assess the association (adjusted odds ratios [ORs], P ≤ 0.001 for all outcomes) between SMI subtypes and clinical outcomes. Results: Of 6,968,777 AMI hospitalizations between 2004 and 2014, 439,544 patients (6.5%) had an SMI diagnosis. Although patients with schizophrenia and ONOP experienced higher crude rates of in-hospital mortality and stroke compared with those without SMI, only schizophrenic patients were at increased odds of mortality (OR, 1.10; 95% confidence interval [CI], 1.04-1.16), whereas ONOP was the only group at increased odds of stroke (OR, 1.53; 95% CI, 1.42-1.65) after multivariate adjustment. Patients with ONOP were the only group associated with increased odds of in-hospital bleeding compared with those without SMI (OR, 1.11; 95% CI, 1.04-1.17). All those with SMI subtypes were less likely to receive coronary angiography and percutaneous coronary intervention, with the schizophrenia group being at least odds of either procedure (OR, 0.46; 95% CI, 0.45-0.48 and OR, 0.57; 95% CI, 0.55-0.59, respectively). Conclusion: Schizophrenia and ONOP are the only SMI subtypes associated with adverse clinical outcomes after AMI. However, all patients with SMI were less likely to receive invasive management for AMI, with female gender and schizophrenia diagnosis being the strongest predictors of conservative management. A multidisciplinary approach between psychiatrists and cardiologists could improve the outcomes of this high-risk population.