Clinical Presentation and Outcome of Patients Experiencing Homelessness Presenting With ST-Segment Elevation
Samantha S L Liauw1, Linh Luong2, Shuangbo Liu3
1Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Insights
Patients experiencing homelessness (PEH) with ST elevation myocardial infarction (STEMI) face significantly higher in-hospital mortality. Targeted interventions are crucial to improve cardiovascular outcomes for this vulnerable population.
Area of Science:
- Cardiology
- Public Health
- Health Disparities
Background:
- Cardiovascular disease is a leading cause of death in homeless adults.
- Limited data exists on ST elevation myocardial infarction (STEMI) in patients experiencing homelessness (PEH).
Purpose of the Study:
- To investigate the clinical presentation, management, and outcomes of STEMI in PEH.
- To compare in-hospital mortality between PEH and nonhomeless individuals with STEMI.
Main Methods:
- Retrospective analysis of 2854 STEMI admissions (2008-2017).
- Comparison of baseline characteristics and clinical outcomes between PEH (n=75) and nonhomeless patients.
- Propensity score adjusted standardized mortality ratio weighting (SMRW) used to compare in-hospital mortality.
Main Results:
- PEH were younger, more likely male, and presented more often with cardiogenic shock or cardiac arrest.
- In-hospital mortality was significantly higher among PEH (Risk Ratio 3.83) after adjustment.
- PEH constituted 2.6% of STEMI admissions.
Conclusions:
- PEH with STEMI have a 4-fold higher in-hospital mortality despite contemporary care.
- Urgent need for targeted interventions to improve STEMI outcomes in homeless populations.
- Addressing health disparities in cardiovascular care for PEH is critical.
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.
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